The Future of Care Management: from Fragmentation to AI Orchestration

Healthcare enterprises face mounting pressure to improve Star/HEDIS performance, reduce Medical Loss Ratios (MLR), lower avoidable utilization, and enhance operational efficiency. Although digital tools and program expansion have increased over the past decade, most care management models have evolved incrementally, resulting in fragmented data, siloed workflows, and heavy manual coordination.

This Viewpoint introduces a care management paradigm centered on AI orchestration rather than isolated automation. It outlines an AI-ready architecture composed of four layers and emphasizes that enterprise impact depends on a governed execution layer. This centralized control plane sequences domain-specific agents, enforces guardrails, manages workflow handoffs, and continuously measures outcomes across programs.

The report also examines the barriers preventing AI from scaling beyond pilot initiatives and identifies strategic enablers required to overcome them. It defines the non-negotiable capabilities of a best-in-class care management platform and illustrates how this unified platform model adapts across payers, providers, and government agencies to deliver measurable improvements in cost, quality, efficiency, and engagement.