Healthcare is Under Siege – And Insurers Are Still Playing Catch-Up

Healthcare systems worldwide are at a breaking point.

Take the UK. The 7.5 million NHS waitlist isn’t just a backlog – it’s a crisis. General practitioners (GPs) are stretched to their limits, emergency departments are at capacity and specialists are booked out for months. The lingering impact of COVID-19 has only exacerbated accessibility issues, pushing healthcare systems to the brink.

Meanwhile, private healthcare isn’t faring much better. PMI claim costs are skyrocketing, driven by record levels of utilization and rising provider prices.

At the same time, consumer expectations have irreversibly changed.

• They want convenience – instant access, seamless digital interactions and service at their fingertips
• They demand transparency – clear costs, predictable experiences and data-driven recommendations
• They expect personalization – care tailored to their history, needs and preferences

And yet, healthcare still operates like it’s stuck in the past—paternalistic, clunky, inefficient, and wildly disconnected from modern digital experiences.

And insurers? They remain passive payors, reacting to claims instead of actively shaping the patient journey. They’ve tried every cost-control lever: policy exclusions, narrowing provider networks, steering customers toward “cost-effective” providers, negotiating discounts and bundled pricing models, and commissioning value-based care and outcome-driven contracts.

Yet claims inflation continues to surge, patient satisfaction declines and insurers are still asking: Why isn’t this working?

Because they’re acting too late. These strategies tweak the cost per treatment, but they fail to address unnecessary utilization or ensure the clinical appropriateness of care.

The future belongs to insurers that take control—those that proactively step into the clinical conversation, guide patients, prevent unnecessary care, and integrate AI-driven decision-making at every stage of the healthcare journey.

To stay relevant, insurers must evolve from claims processors to healthcare partners—not just funding care but orchestrating it. And the way to do it? Own the front door.

From Gatekeeper to Guardian: Why Insurers Must Own the Intelligent Front Door

Every industry that has revolutionized customer experience has done so by controlling the first touchpoint.

Amazon doesn’t just ship products—it owns the entire retail journey, from search to delivery. Fintech disruptors don’t just process payments—they offer AI-driven financial advice, fraud prevention and personalized banking experiences. Tesla doesn’t just sell cars—it integrates software, diagnostics and predictive maintenance into every vehicle experience. Healthcare must follow suit.

Right now, the entry point to care is disjointed. Some patients self-diagnose online, leading to misinformation and unnecessary anxiety. Others wait weeks for a GP appointment, delaying essential care. Many bypass primary care entirely, going straight to costly specialists or unnecessary diagnostics. This waste drives up claims, frustrates patients and erodes trust in insurers and providers alike.

If insurers want to control costs, improve patient experience and drive better outcomes, they must own the front door—not just a digital one, but an intelligent, clinically integrated one.

The Case for Owning the Front Door: Lessons from Oona Health

Oona Health has already proven the business case for insurers owning the front door. Unlike traditional insurers that passively pay bills, Oona actively manages access to care through its ownership of Primacare, an integrated provider network.

By bringing clinical expertise in-house, Oona has controlled costs by directing members to high-value, cost-effective care. It has improved patient experience by reducing friction and uncertainty. It has prevented unnecessary care by setting clear pathways upfront. It has boosted NPS and trust by making care more seamless and intuitive.

By owning the front door, Oona has flipped the entire insurer model. But there’s a limit: Oona’s model still depends on human clinicians. It works—but it’s not infinitely scalable. This is where AI changes everything.

Scaling the Front Door with AI: The Next Leap Forward

Oona has proven that owning the front door works. But what happens when you remove the human bottleneck? Traditionally, scaling access to care required more doctors, more nurses, and more call centers. That approach drives up costs, introduces human error and creates inefficiencies.

Now, Generative AI has the potential to eliminate these constraints—and when deployed alongside a virtual care team, it makes them bionic.

The Bionic Front Door: AI-augmented Virtual Care Teams

This isn’t about replacing doctors with chatbots. The Bionic Front Door pairs AI with a virtual care team—where AI does the heavy lifting and human clinicians step in where judgment is needed.

AI triages symptoms, collects history and provides real-time clinical recommendations. Virtual care teams oversee complex cases, ensuring human oversight where necessary. The AI continuously learns, refining accuracy and improving with every interaction.

This system doesn’t just replace humans—it makes them bionic.

Multi-Agent AI: A Team of AI-Powered Experts, Always On

• A true Intelligent Front Door isn’t a chatbot—it’s a bionic healthcare ecosystem.
• A Generalist AI Agent – First touchpoint, triaging cases
• A Symptom Assessment Agent – Matches symptoms to evidence-based care pathways
• An EHR Integration Agent – Pulls patient history for context-aware decision-making
• A Cost Optimization Agent – Ensures care is clinically appropriate and cost-effective
• Specialist AI Agents (Cardiology, Orthopedics, Neurology etc) – Provide deep domain expertise
•  An Appointment Scheduling Agent – Finds providers, books appointments and syncs follow-ups in real time
• A Prevention & Monitoring Agent – Uses wearables, behavioural nudges and digital coaching to improve health outcomes
• Virtual care team – Healthcare professionals review AI recommendations, provide oversight and refine care pathways

This AI-driven ecosystem learns, optimizes and scales infinitely—unlike traditional human-led navigation.

The Call to Action: Insurers Must Act – Now

Oona has proven the business case for insurers owning the front door.

But the next generation of healthcare transformation will be AI-driven, infinitely scalable and precision-guided.

What’s the takeaway?

• Insurers who own the Intelligent Front Door will control the future of healthcare
• Those who don’t will be relegated to low-margin claims processing in an AI-driven world

It’s decision time.

Will you build the future of healthcare – or wait for disruptors to take it from you?