Health Insurer of The Future
Health Insurer of The Future
Health Insurer of The Future
insurer of
the future
A focus on Asia Pacific,
EMEA and India
April 2023
Introduction
Health insurance is among the fastest
growing industries globally, and the
COVID-19 pandemic further
accelerated its growth in the past two
years. The pandemic has also driven
health awareness among consumers
and accelerated digital adoption and
the evolution of healthcare
ecosystems. Health insurers need to
reinvent their business models to
adapt to the rapidly evolving industry.
In this publication, we identify the
major trends shaping the future of
health insurance and explore the
current state of insurer models across
regions with focus on Asia Pacific,
EMEA and India, outlining the
challenges and opportunities faced in
adopting these models. This report is
based on insights and market
knowledge from our internal network
of professionals who work closely
with health insurers across the world.
The health protection gap refers to the financial burden faced by households, including uninsured healthcare
costs and avoidance of costly medical treatments. The gap is expected to worsen with the trend of
increasing longevity and an ageing population. Based on PwC’s Insurance 2025 and Beyond,2 the global
protection gap of US$1.4tn in 2020 is estimated to widen to US$1.86tn by 2025, with almost half of the risk
attributed to the Asia-Pacific region.
Various healthcare stakeholders are working to bridge the gap by offering government health plans,
microinsurance and improving access to affordable healthcare. Specifically, health insurers play an important
part through their initiatives in targeted product offerings, digital distribution and raising health awareness
among their policyholders.
COVID-19 pandemic fast-tracked the adoption of telehealth support services such as virtual consultations,
remote monitoring and digital patient engagement tools following the disruption to in-person healthcare.
HealthDay news3 reported that compared to the pre-pandemic levels, the utilisation of telehealth increased by
more than three times during the beginning of the pandemic, and further increased by close to four times one
year later. Consumer willingness to use telehealth and investment in digital health have also increased. All in
all, telehealth services are here to stay.
Furthermore, value-added services included in health insurance policies expanded from providing support at
the point of claim (e.g. access to a second medical opinion) to providing lifestyle-related benefits such as early
health screening and mental health support.
Consumers also demand hyper-personalised clinical interventions through precision medicine and personalised
treatments. In response, there has been steady adoption of genomics among healthcare providers when
tailoring treatment plans and drug prescriptions. This helps improve clinical outcomes, reducing the cost of
treatment and overutilisation due to relapses.
Wearables have long been used in health insurance, capturing physical activities and health measurements
(blood oxygen saturation, breathing rate and heart ECGs). They provide ongoing insights into customers’ health
and lifestyle data. This allows for continuous risk assessment throughout a customer’s insurance policy for
insurers, in contrast to relying on medical records that are available only at the point of claim.
Pairing artificial intelligence (AI) with this new source of data, advanced data analytics can provide deeper
insights into the medical claim cost and employ these outcomes for management of provider networks, claims,
pricing and risk management. AI is also often used to improve customer service engagement through chatbots
and to improve operating efficiency through robotic process automation, claims adjudication and
predictive analytics.
1
https://www.pwc.com/gx/en/financial-services/fs-2025/pwc-insurance2025.pdf
2
Ibid.
3
https://consumer.healthday.com/telemedicine-2658609541.html
Recent years have seen increased awareness about value-based care that aims to prioritise preventive
services and benefits that are cost-effective in the long run. This ultimately avoids unnecessary and excessive
treatments and contributes to reducing the large carbon footprint of healthcare systems.
Aside from the environmental impact, insurers bear a large social responsibility to their stakeholders. To
strengthen the ‘S’ pillar, the key focus is caring for staff beyond employee benefits and wellness. Workplace
safety, employee engagement, diversity and inclusion are additional factors for management consideration.
Likewise, these aspects should be extended to agents and distributions.
• contributions towards the development of microinsurance, rural and social sector coverage, and
government-led programmes
• setting of terms and rates based on the insured’s or reinsured’s adherence to ESG
• implementation of strict discipline in the supply chain and sourcing policy for vendors, distribution partners
and bancassurance deals.
In today’s customer-centric business environment, insurers need to continuously create new value propositions
for customers. No longer driven by competition for market share and unhealthy price wars, insurers need to
identify and explore new avenues to reinvent themselves. This comes in the form of collaborations with other
insurers, InsureTechs and healthcare providers, creating a new ecosystem in the process.
Developing an ecosystem business model requires a new strategic approach. An insurer can choose to be the
orchestrator who leads and shapes the ecosystem, acting as the connecting hub facilitating and encouraging
customer interactions while managing the web of partner organisations. Or an insurer can be a partner who
provides a service or product to the customers of the ecosystem, integrating its service with the orchestrator
platform and with the services of the other partners to provide one seamless proposition.
Consumer Advocate
Current take and highlights
Health insurers initially adopted the Consumer Advocate model by setting up a direct distribution channel
through their own website. They focus on selling simplified plans with minimal underwriting, allowing for a
straight-through process without agent intervention. However, the additional cost and effort required to set up
integration with legacy systems, staff training and low product profitability have hindered larger traditional
insurers from growing this segment. Instead, it has attracted start-ups with strong digital capabilities to enter
the market.
Over time, many traditional health insurers embarked on a digital transformation journey to expand their digital
capabilities. Digitally enabled, health insurers’ roles shift from sellers of insurance products to active health
advisors. Customer mobile apps are elevated to a core digital platform that measures, maintains, and improves
quality of health throughout the lifespan of a customer journey. With ecosystems enabling control of patient
care quality, costs and information, health insurers are able to position themselves as fully integrated health
and wellness companies, creating an all-encompassing engagement beyond the risk cover.
AI-powered mobile apps allow for personalised product offerings and communication according to the
customer’s needs and behaviour pattern. Based on how customers proceed through the buying process, richer
benefits can be added on to the simplified base plan. Similarly, automated communications or offers can be
triggered based on certain event changes, segment changes, profile changes or behavioural changes. Tailoring
the traditional insurance experience of buying, policy servicing, claims and renewals for the individual customer
helps in increasing the level of customer engagements, as well as cross-sell opportunities.
On top of improving the core insurance experience, the super-app integrates with various service providers in
the ecosystem to provide all-rounded health solutions. A robust health ecosystem covers the customer journey
at various stages of pre-claim, point of claim and post-claim. Such solutions include nutrition monitoring, fitness
tracking, health check-up appointment booking, mental wellbeing, tele-consultation and second
medical opinion.
Success stories
We have seen successful digital health ecosystems globally, such as Pulse by Prudential in Asia and insurers
in China. Pulse by Prudential is an AI-powered mobile app to provide consumers with round-the-clock access
to healthcare services and real-time health information. It includes features such as a health assessment tool,
a symptom checker and health and wealth content. Pulse also offers in-app purchases for premium
content, features and subscriptions, as well as for services such as a video consultation with a doctor.
4
https://static1.squarespace.com/static/599cb1c76f4ca34c4160199f/t/5a80ec478165f5c700b891ed/1518398537812/pwc-hri-payer-of-
the-future.pdf
While personalisation is available, hyper-personalised healthcare is still limited in the current model. Health
data is highly sensitive – do customers trust insurers with their medical records and genetic data? To
strengthen trust and confidence among consumers, health insurers can provide guarantees that no penalties
will be imposed on people who are unhealthy. This creates an opportunity to tap into the impaired lives
segment by offering impaired-specific wellness such as disease management programmes. This is also
aligned with the industry’s ESG focus.
Bridge Connector
Current take and highlights
Facilitates the relationship between patients and care providers. Plays an active role in getting
consumers the right care. Uses technology to enhance the provider and patient experience.
Health is a sensitive topic and today’s consumers still rely heavily on professional medical advice for guidance.
A Bridge Connector health insurer aims to help patients understand the different treatment options and provide
guidance in selecting the best care solution.
Traditionally, health insurers form a network of preferred providers, in which patients are awarded with reduced
premium or richer benefits for visiting. By managing the provider network, insurers have control over the
doctors and hospitals recruited into the network, hence giving them control over the cost and quality of patient
care. Furthermore, health insurers leverage appointment booking services to steer patients to the right care.
However, patients may feel that insurers have a vested interest in their recommendations as these
relationships are usually bound through contracts – providers offer a lower consultation cost in exchange
for volumes.
Health insurers need to promote transparency when forming the preferred network, with careful consideration
of a wide range of clinical specialist areas, locations, reputations and options to better manage
customer expectations.
In response, health insurers set up data platforms to facilitate provider selection by integrating clinical, claims,
demographic and lifestyle data. The key challenges in building these analytical platforms include:
Non-traditional partnerships between health insurers and healthcare services are growing. Strategic
partnerships with providers of telemedicine, second medical opinion, chronic care management and
ageing care allow insurers to better serve complex healthcare needs. In China, some insurance
companies established a health management platform connecting insurers and medical service providers
seamlessly at low cost and high efficiency. The platform provides health advice, chronic disease
management, medical VIP and concierge services.
The health industry is shifting towards the population health management model. Consumers are proactively
managing their health by focusing on preventive care and investing in healthy activities such as exercise and
diets to avoid the need for medical treatment. While this may initially be seen as shifting the power away from
healthcare providers given the reduction in medical treatment, we have seen healthcare providers restructure
their approach towards providing preventive care by featuring proactivity and personalisation.
While many providers are already offering health-screening packages, the results are usually not included in
medical records or utilised for further intervention. With the restructuring, physicians now refer eligible patients
for community-based intervention, such as smoking cessation or physical activity programmes. These
preventive care visits can be enabled by a data platform that helps track, schedule and evaluate care activities.
Other structured programmes include those for patients and families at high risk of type 2 diabetes mellitus.
Preventive strategies can be initiated early by family physicians through lifestyle interventions such as changes
to diet and physical activity, medication and metabolic surgery.
Lean Operator
Current take and highlights
Prioritises gaining efficiencies with core health insurer functions (claims adjudication and payment,
utilisation review, etc.). May partner with companies specialising in consumer engagement or provider
enablement tools.
Reducing inefficiencies
Many health insurers are working to reduce cost by eliminating inefficiencies. The Lean Operator model tackles
inefficiencies such as legacy policy administration and claim fraud.
Administrative costs such as claim administration and premium collection are the main avenues through which
health insurers are cutting costs. Straight through processing for insurance allows the insurer to automatically
process transactions without manual steps taken by an agent or intermediary. Processes which can be
automated include background checks, medical screening and claim processing. Automation and algorithms
take care of the entire process, offering consistency, productivity, lower operational costs and additional data.
This automated approach eliminates back-and-forth communication which works well with millennials or
Generation Z consumers.
Legacy policy administration systems (PAS) continue to hamper insurance companies’ ability to grow. A PAS
transformation provides the digital core needed to facilitate an agile and innovative organisation, a platform to
improve customer and partner engagement, and to make advanced data analytics an integrated component of
the business process.
With information now being stored almost solely electronically, it is important insurers develop specific
competencies in line with developing technologies. Fraud is an ever-increasing threat to insurers. Applying
advanced data analysis techniques can help with the identification of fraudulent transaction patterns and fraud
networks. Cloud technology provides a further opportunity for digitisation – acting as a great enabler by helping
carriers to configure and integrate quickly for innovation. Carriers that can scale up effectively, reduce costs,
and offer competitive prices have a strong competitive advantage.
3. Aim high.
Rising healthcare costs are a global problem, with constant pressure to reduce these costs. Increased costs
are driven by ageing populations, specialised treatments, overhead costs for digitalisation and inflation. Global
healthcare expenditure as a percentage of GDP increased over the past decades from 8.5% per year in 2000
to 9.8% in 2019, according to the World Health Organization. 6 COVID-19 brought about a spike in global health
expenditure, as resources were steered towards fighting the pandemic. Future healthcare costs are expected to
continue growing, but at a more stable rate. Moving forward, healthcare costs are likely to be due to prevention,
diagnostics and digital solutions, instead of treatment and care.
Inflation has reached a level not seen in decades due to rising energy costs following Russia’s invasion of
Ukraine and economies opening up again after long lockdowns resulting from the COVID-19 pandemic.
Healthcare costs have not yet risen at the same rate as other forms of consumption because costs of health
services, prices and labour are set two to three years in advance. However, when these contracts are due to be
renewed, the costs are expected to rise in line with inflation levels seen by general consumers. Healthcare
providers will seek compensation for higher costs of healthcare delivery systems from healthcare payers,
including health insurers. 7
The Lean Operator model plays a small role in reducing healthcare costs, such as claim adjudication. The key
solutions, for instance, provider management and product proposition, lie in the other four models. In the long
run, it is key to be fully technology enabled, ranging from client-facing services to business and internal
processes. This will help in creating an agile and innovative organisation that makes optimal use of data.
5
https://www.pwc.com/gx/en/insurance/publications/firing-on-all-cylinders-five-steps-to-strategic-cost-reduction.pdf
6
https://apps.who.int/iris/bitstream/handle/10665/350560/9789240041219-eng.pdf
7
https://www.mckinsey.com/industries/healthcare-systems-and-services/our-insights/consumer-prices-are-rising-fast-and-healthcare-
isnt-far-behind
Uses data analytics to give providers insight into the health of populations and provides solutions to
help manage them. Pushes providers to value-based models to encourage keeping patients healthy.
Big data and health insurance analytics are a norm in the industry. They allow deeper understanding of
customers, what they value, what challenges they face and their lifetime value – enabling personalised
experiences and anticipation of needs. Investing in data analytics technology enables health insurers to be both
an Analytic Sensor and Consumer Advocate.
Many insurers offer incentive-based health and wellness programmes, aiming to encourage a healthier lifestyle
by incentivising customers through rewards. These are usually monetary rewards through reduced premium or
an indirect reward through coaching for well-being. For example, in India, Aditya Birla Health Insurance offers
up to 100% return of premium if a policyholder remains active for an adequate period. Yet, do these
programmes actually improve health and reduce claims? The early detection and preventive approach helps a
health insurer manage medical costs. From a life insurer perspective, maintaining a healthy lifestyle is
expected to improve longevity which may act as a double-edged sword.
There has been a general global increase in the adoption of electronic health records (EHRs). EHRs digitally
capture every source of information on a patient into one database, including medical history, data from
treatments, diagnoses, prescriptions and immunisation records. This massive volume of data enables EHR
analytics, mining data for insights to improve quality of care. It also helps reduce medical errors, provide more
accurate treatment and preventive care, and predict the cost of treatment.
The sharing of insights between insurers and providers may reshape the health insurance value chain. Sharing
healthcare information helps both parties increase administrative efficiency, improve care coordination and
patient outcomes, hence reducing costs and enabling value-based care.
However, there remain significant barriers to data sharing – concerns about data security, patient privacy and
fear of giving up a competitive edge. Insurers and providers must work together to overcome the challenges, in
particular for value-based care models where providers and payers must collaborate deeply to improve care
quality and reduce costs. It is important to advocate for regulatory mandates, implement strong privacy policies
and data encryption, and use health information technology to ensure secure data sharing.
Value based-care
Value-based care aims to provide cost-effective care that links to better clinical outcome and patient’s reported
perspective post-treatment. COVID-19 has caused a major disruption in the healthcare system, specifically in
elective and chronic care services. It eliminated the overuse and abuse of unnecessary medical treatment, to
focus resources on the most important cases. It is expected to accelerate the adoption of value-based care.
The demand for value-based care has grown in recent years, with the growth of the ageing population
challenging healthcare resources, along with a shift towards population health management and an integrated
care delivery model, and rising demand for personalised experience, choice and informed shared
decision making.
• Shared savings: Incentivise healthcare providers by giving them a proportion of the actual savings
achieved, based on accomplished pre-defined outcomes.
• Capitation-based funding: Payment is based on the performance of healthcare providers in terms of quality,
costs, coordination and prevention.
A successful implementation of value-based care should prioritise a patient’s perceived state and feeling post
treatment and be engaged to collect information on what outcomes matter to them.
Care Integrator
Current take and highlights
Integrates vertically to align incentives, improve care coordination, tackle utilisation and keep medical
costs low
Conflict between payer and provider has always been an issue in the health insurance industry. Health insurers
attempt to interfere with medical treatments by implementing pre-authorisation and step therapy. While these
initiatives help insurers control overcharging and over-treatment, it restricts providers in recommending the best
treatment to patients due to cost constraints.
The care integrator health insurer combines both health coverage and care delivery under one roof, aligning
KPIs of both parties and sharing the risk of insurance and provider performance. Unlike the Bridge Connector,
health insurers are repositioning themselves from merely a payer to a payer-provider. Health insurers can
better manage costs with transparency of health protocols and actual medical costs incurred. They are well
positioned to align and coordinate members’ health coverage with appropriate treatment plans and hence have
control over customer satisfaction with better care. Tapping into the value pool of providers enables
diversification for long-term success and sustainability.
With the industry’s push towards value-based care in the United States, there are many successful case
studies to leverage. In particular, a well-known integrated managed care consortium offers both insurance and
healthcare. Its success is driven by a few overarching principles:
• All parties share the same goal to deliver extensive and synergetic healthcare services to keep patients as
healthy as possible
• Close coordination between primary, secondary and tertiary care. It provides seamless care delivery for
members and improves quality of care with communication across healthcare providers.
• A good IT system that allows data integration across the entities. In particular, data integration challenges
would be easier to overcome under one roof. It stores all medical information of the patient, including past
treatments, tests results and appointment bookings.
• Work closely with hospitals that are not owned by the group, deeply integrating with the hospital operations
and proactively tracking medical costs to facilitate rate negotiation.
• Extensive use of care pathways that outlines the roles and responsibilities of each healthcare staff member,
i.e. physicians, nurses and pharmacists, to support clinical decisions.
High Low
Model adoption
APAC
EMEA
India
Expected outcome
Customer satisfaction
Medical cost
Quality of care
Investment
Digital transformation
Health ecosystem
In-house medical
professionals
EHR
Hyper-personalisation
Core PAS
transformation
Internal cost
transformation
Challenges
Data privacy
Data integration
High implementation
cost
Long-term commitment
Regulatory constraint
Note: The information above is based on insights and market knowledge from our internal network of professionals who work closely with
health insurers across the world.
It is amply clear that the health insurance industry is seeing a shift. Whether it is migration to one of the models
described in the paper or developing new models of pay and care, insurers are moving forward, and standing
still is no longer an alternative. The significant trends being observed are as follows:
• choice of being a bystander payer or adopting a clinically involved customer interface model
• alliances with ecosystem players on clinical and non-clinical customer engagement programmes
• focus on ESG
• product innovation
• regulatory compliance.
Health insurance is a primary societal tool for equalising access to healthcare for all – and as such it is as
important a pillar of modern life as banking or transportation. A higher level of focus by governments is needed
to make insurance a primary consideration across all demographic segments.
We are in a pivotal phase following the heightened awareness arising out of the pandemic. Collective human
memory of unpleasant incidents can be shortlived at times. It is imperative that the new-found awareness
continues and that availability of health insurance along with healthcare and health maintenance services
reach all levels of society.