The Future of Healthcare Is Member-Centric, Not Workflow-Centric

Prior auth approvals are getting faster. Call center hold times are dropping. Claims routing is smarter. But the member is still the one holding everything together.

It plays out the same way at every step: a member gets approved in hours instead of days and then calls to schedule a referral, only to learn the referral team has no record of the approval. The member explains the situation from the beginning.

This has always been the pattern. Healthcare software was built around departmental workflows, each run by separate teams on systems that were never designed to talk to each other. A record could move from one step to the next, but the thread connecting those steps often could not. No one system was built to hold that whole episode of care, so the member became the coordinator, carrying the thread across every handoff.

AI changes that. It can read across the messy record as it is, taking in approvals, referrals, claims, calls, notes, and scheduling, then carry the context across the handoffs that used to fall on the member. But this isn’t how most health systems are using AI today. Instead, they’re applying it within the same old workflow boundaries: making approvals faster, giving a call center agent a better summary, routing a claim more intelligently. Each step gets smarter, but the journey still breaks between them. The member is still the one carrying context from one step to the next.

The organizations that win will use AI differently, redesigning around the member journey. At Reuters Health last month, leaders from Elevance, AdventHealth, and Ascension made that case from different positions: a major payor and two health systems, faced with the same fragmentation at different points in the member experience.

The panel kept returning to the same point: software can now carry what it learns from authorization to referral to scheduling, catching exceptions before they become the member’s problem.

As Arjun Prakash, CEO of Distyl AI, put it: "Prior authorization, a claim, a referral, and site selection are all just different decision points in one continuous experience."

Ascension described rebuilding a seven-year-old data foundation. It wasn’t because it failed, but because it was designed to report on the past rather than act in the present. To act across a member's journey, AI needs infrastructure that can maintain context across steps in real time. AdventHealth identified a similar gap: infrastructure built to process information on a schedule, rather than pass it forward as decisions happen. And Elevance fields millions of member calls, most of which they aim to make unnecessary by resolving issues before the member picks up the phone.

Redesigning around the member journey demands more than making a call center faster. It requires infrastructure that carries context in real time, where knowledge moves across departments and decisions compound on each other instead of starting over. The system holds the thread, so the member doesn’t have to.

That shift is already underway. Rather than a layer on top of operations, the member journey becomes the operating model itself. The question for every other healthcare organization is whether they’re building toward that member-centric model, or still optimizing workflows the member will have to stitch together themselves.