Despite significant investment in AI and advanced technologies, many payers are seeing little improvement in growth, cost-efficiency, or customer satisfaction. At the heart of this challenge lies an inability to demonstrate how customer experience (CX) translates into commercial value.
The uncomfortable truth: The current customer experience isn’t working
Healthcare payers are facing a perfect storm:
- Rising medical and drug costs
- Increasing regulatory and interoperability pressure
- Declining member satisfaction and trust
At the same time, organizations are investing heavily in digital and AI yet failing to translate this into real-world commercially beneficial outcomes.
The core issue?
Some payers mistake technology for strategy, implementing solutions without anchoring them in real member needs.
A sector in decline, by the numbers
Customer satisfaction in healthcare continues to slide. Our research shows satisfaction fell 4% this year, following a 5% decline last year.
What’s contributing to this decline?
- Poor transparency and communication
- Slow, complex issue resolution
- Growing perception that plans don’t deliver value for money
For too long, customer experience has been treated as a “nice to have.” Our research shows the opposite. Customer experience is a primary driver of cost efficiency, retention, and profitability.
When experiences fail:
Contact volumes increase
Rework and manual processing rise
Complaints and escalations grow
Churn accelerates
Processes become simpler and cheaper
Issues are resolved faster
Member loyalty strengthens
Cost-to-serve falls dramatically
Where experience is breaking down
Across the payer ecosystem, the same friction points appear repeatedly:
- Fragmented journeys: Members repeat themselves across touchpoints
- Reactive claims processes: Errors fixed after the fact, at higher cost
- Ineffective digital channels: Driving escalation instead of deflection
- Poor benefit clarity: Avoidable calls and confusion
- Disconnected provider relationships: Delays, disputes, and rework
The result? A system that is both expensive to run and frustrating to navigate.
A more effective approach: Fix the system, not the symptoms
Our research report introduces a practical lens: Strategic Optimization Points (SOPs).
These are the specific points in the journey where:
- Member expectations break down
- Costs concentrate disproportionately
The Six Pillars that drive both CX and financial performance
At the heart of the journey to customer experience excellence is the KPMG Six Pillars of Experience. These aren’t just experience metrics, they are directly linked to cost, churn, and growth outcomes:
Integrity: Building trust through transparency
Resolution: Solving problems quickly and fairly
Expectations: Delivering consistently and clearly
Time & Effort: Making interactions simple
Personalization:Tailoring to real needs
Empathy: Understanding the human context
Where to start: Practical actions that deliver results
Leading payers are already shifting from broad transformation to targeted, evidence-based change:
- Use existing data to pinpoint friction and cost drivers
- Map end-to-end journeys to identify root causes
- Apply AI and automation selectively, where it reduces real inefficiencies
- Simplify communications to reduce avoidable demand
- Align incentives around resolution and member outcomes
This is how organizations move from reactive cost-cutting to proactive value creation.
A new approach to customer experience for US health insurance payers focused on what actually drives financial performance
You don’t have to choose between lowering costs and improving experience.
The most successful payers recognize they are the same challenge and solve them together.
Discover:
- Where cost and experience are most tightly linked
- The biggest drivers of declining trust
- A clear, step-by-step blueprint for improvement
- Practical examples of where to focus first
Insight
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J.D. Brewer
Principal, Advisory, C&O Health & Government, KPMG US
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Saurabh Goyal
Principal, Advisory, Health & Government Solutions, KPMG LLP
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J.D. Brewer
Principal, Advisory, C&O Health & Government, KPMG US
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Saurabh Goyal
Principal, Advisory, Health & Government Solutions, KPMG LLP
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