About 85% of health plans have yet to centralize their data across systems, representing missed opportunities when it comes to artificial intelligence and data strategy, according to a new report from healthcare data platform Arcadia.
Analysts showed a widening gap between payers’ current data capabilities and what they still need in terms of tools and infrastructure. For example, without a unified data foundation built around complete member profiles, efforts to apply agentic or generative AI will fall short, missing the savings and experience improvements the technologies promise.
The report also reveals how leading health plans are making meaningful progress with data-driven strategies that improve outcomes, manage costs and strengthen provider performance.
WHAT’S THE IMPACT
While 66% of payers rated their ability to share data externally as “very good” or “excellent,” only 57% said the same about integrating data from external sources. Survey numbers showed 85% have yet to integrate all available data into a centralized analytics platform, which limits their ability to generate comprehensive and actionable insights.
Less than 20% of plans use AI to develop care plans, summarize records or drive member engagement – tools that could improve operational efficiency and accelerate performance gains, the report found.
Most payers prioritized cost-containment strategies, such as improving risk adjustment (54%) and optimizing network performance (50%), over revenue growth goals like expanding membership (45%).
While 96% of payers said they maintain longitudinal member profiles, many admit challenges with data aggregation and interoperability. For instance, 76% of payers surveyed aren’t fully realizing the value of social determinants of health data, 87% reported not using episodes of care data, and just 10% of payers said they are actively using pharmacy data.
“Too often, payers believe they have a complete picture of the member, but our research suggests there are significant gaps in what data they’re actually using – meaning missed opportunities to unlock better risk adjustment, personalized care, and cost efficiencies,” said Michael Meucci, president and CEO of Arcadia. “A true 360-degree member profile must include timely and complete information across claims, clinical encounters, SDoH, episodes of care, and pharmacy data. When payers integrate that data and apply it strategically, they can improve outcomes, reduce costs, and collaborate more effectively with providers.”
THE LARGER TREND
According to the report, bridging the gap between fragmented data and actionable insight requires more than surface-level integration. Leading health plans are prioritizing platforms that unify clinical, claims, behavioral and social data, which enables real-time intelligence that can be shared across care teams.
With the right infrastructure, data shifts from a static asset to a strategic driver of transformation, authors said.
“The findings from this report make it clear that the most successful payer organizations will be those that invest in centralized analytics platforms, empower providers with shared insights, and apply data to personalize care, reduce costs, and improve outcomes,” said Dr. Luke Hansen, chief medical officer of Arcadia. “When payers and providers work from a common data foundation, it becomes possible to manage risk, optimize utilization, and enhance physician performance more efficiently.”
Email: jlagasse@himss.org
Healthcare Finance News is a HIMSS Media publication.