Insights from b.well’s Kristen Valdes and WellSense’s Raj Nair on navigating data quality, AI implementation, and the future of personalized healthcare
Member trust is built through personalization, as Kristen joked in a recent webinar, just ask social media, which can sometimes know you better than your spouse when it comes to shopping. It serves up exactly what you want, the right products, at the right time, with seamless delivery options. Yet in healthcare, we still make people navigate phone trees, create multiple portal logins, and repeat their medical history at every appointment.
These disconnects aren’t just about technology anymore. For the first time in healthcare history, the technology has actually leapfrogged the business practices. The question now is whether health plans are ready to catch up.
In a recent webinar, Kristen Valdes, Founder and CEO of b.well Connected Health, sat down with Raj Nair, Chief Information Officer at WellSense Health Plan, to explore what it takes to build member trust, modernize infrastructure, and transform engagement in an era of real-time data exchange and artificial intelligence. Here’s everything you need to know about how forward-thinking health plans are preparing for 2026 and beyond.
The Member Trust Deficit: Starting from Behind
Health plans are starting from a position of deep distrust. Between prior authorization denials, claims disputes, and general opacity around healthcare costs, payers have a reputation problem that can’t be solved overnight.
The path forward requires building trust incrementally through member-centric outcomes rather than pure automation or cost reduction. Following the path means focusing on tangible improvements to the member experience at every touchpoint—from seamless portal capabilities to transparent communication about how data is being used and why.
The fragmentation of healthcare only compounds these challenges. Patient information is spread across about 70 different, disparate locations, from vision and dental records to primary care, specialists, hospitals, wearables, and home sensors. A decade ago, payers had the best visibility into patient health through claims data. But with the rise of cash pay, high deductibles, and out-of-pocket negotiations, that visibility is eroding precisely when risk management demands more comprehensive data than ever.
Meeting Members Where They Are with Consent
Building member trust starts with respecting consent and control. The key is recognizing that different members have different comfort levels with data sharing. Some patients worry about their health plan having access to clinical data, unaware that significant data sharing already occurs behind the scenes. Others assume their data is already out there and would gladly trade access for convenience and value.
The best strategy is to start with willing members who see the benefit, demonstrate value through improved care coordination and reduced administrative burden, and then grow adoption organically. This requires showing members what’s in it for them: eliminating unnecessary duplicate tests, reducing administrative costs, and enabling better total care management.
The CMS Health Tech Framework’s voluntary pledge includes transparency commitments from over 60 organizations to share information with consumers every time their data is exchanged across the national network. This level of transparency could fundamentally shift the consent conversation from theoretical privacy concerns to practical visibility and control.
Infrastructure First by Getting Your House in Order
Before health plans can deliver personalized experiences, they need to acknowledge that their internal infrastructure is often a mess. Many organizations are dealing with multiple data warehouses, data marts, and source systems that don’t communicate with each other.
The first step toward transformation is data cloud modernization, creating one single version of the truth across the organization. But data quality is only part of the equation. Internal systems also need robust API layers to actually communicate with each other. While the industry discusses interoperability in terms of external connections, many health plans lack even basic internal system communication.
WellSense invested heavily in three foundational areas: data cloud modernization to eliminate fragmentation, a robust API layer to enable internal system communication, and member-facing portals and apps to create opportunities for engagement. WellSense invested heavily in three foundational areas: data cloud modernization to eliminate fragmentation, a robust API layer to enable internal system communication, and member-facing portals and apps to create engagement opportunities. This simple yet powerful trio gave WellSense a clear, fast path forward in an industry where infrastructure and practices are still catching up.
Real-Time Data for Value-Based Care
The CMS Health Tech Ecosystem has created a monumental opportunity that many health plans haven’t yet fully grasped. Historically, only two types of nationwide data exchange were permitted: treatment exchange between providers and individual access for patients themselves. The new framework adds a third category: data exchange for the purpose of value-based care.
This means health plans can now access real-time clinical data through FHIR APIs, including structured and unstructured clinical notes, encounter notifications across the care continuum, and comprehensive patient histories (using USCDI V3 as the minimum data standard). This will be a fundamental shift from retrospective to proactive care management for organizations operating under risk-based arrangements.
New members are no longer complete unknowns requiring a year of claims data to understand their health status. Care gaps can be identified immediately upon enrollment. Encounter notifications provide visibility into emergency room visits, hospital admissions, and even telemedicine appointments, whether with in-network providers or not.
Perhaps most significantly, this regulatory change disrupts the nine-figure chart-chasing industry. With near real-time data access, these retrospective processes can be transformed into proactive interventions.
AI at Scale
WellSense currently has 40 AI use cases in production, a remarkable achievement that reflects both strategic planning and disciplined execution. Their approach prioritizes administrative processes over clinical decision-making, building member trust and demonstrating value before expanding into more sensitive areas.
The philosophy is to only build AI solutions when there’s a clear business use case or problem statement to address. This focus on value realization has made the AI program self-funded, generating revenue rather than just consuming budget.
Successful implementations include chart extraction, achieving 5-6X ROI by automating processes that previously took weeks, document extraction from faxes handling the 40% of prior authorizations that still arrive via fax, payment integrity and claims operations identifying outliers and coordination of benefits opportunities, and denial letter simplification rewriting complex medical language at a fifth-grade reading level.
The key to achieving exponential returns is to reimagine the business processes themselves. Simply automating bad processes delivers marginal improvements. True transformation requires stepping back and asking whether the process should exist at all, or whether it could be fundamentally improved.
The AI at Scale approach also includes strong governance through a responsible AI group that includes compliance, legal, security, and key clinical and business leaders. This ensures thoughtful implementation with appropriate human oversight, particularly as use cases expand into clinical areas.
The Member Experience Gap
Member portal adoption at many health plans is abysmal, and for good reasons. Most portals were built as compliance checkboxes rather than valuable health tools. They require account creation before showing any value, offer limited functionality, and often add friction.
The solution starts with understanding consumer behavior in other industries. Nobody gives their credit card information before knowing a store has something worth buying. The same principle applies to healthcare portals, they need to show the value before demanding authentication.
Guest access allows members to see what capabilities are available before requiring login credentials. The capabilities that drive adoption are straightforward:
- digital member ID cards accessible anytime
- real-time prior authorization status
- claims status tracking with transparent explanations
- provider directories with cost transparency
- easy access to telemedicine and program enrollment
The demographic shift also works in favor of digital adoption. While Medicaid and Medicare populations were historically considered less tech-savvy, younger members are increasingly comfortable with mobile-first experiences. The key is making the app valuable enough that members choose it to manage their healthcare over any other option.
Going Beyond Digitizing Bad Processes
The most powerful transformation will be fundamentally rethinking how work gets done. The question isn’t whether AI can automate a process, but whether that process should exist in its current form at all.
This reimagination requires willing business partners because technology leaders can’t drive transformation alone. The most successful implementations start with business leaders who are open-minded and question the value of current processes vs. defending the status quo. The best strategy is to start with progressive leaders who are ready for change, demonstrate success with their transformation work, and momentum will build from there.
The lens matters too. Rather than approaching business process transformation purely from a cost reduction perspective, focus on simplifying processes and removing friction. When friction disappears and processes become simpler, administrative costs naturally decline as a byproduct.
Ecosystems Over Apps to Build Member Trust
The future of member engagement isn’t about forcing everyone to download your app or visit your portal. It’s about embedding your services into the experiences members already use.
With 78% of Americans having a smart TV, and mobile phones being the primary way to reach Medicaid populations, successful health plans must think beyond their own four walls to design personalized digital front doors people will actually open.
Ecosystems enable this through modernized API gateways that allow services to show up natively in other experiences. Digital health cards can appear in provider portals and apps, eliminating the need to bring physical insurance cards to appointments. Benefits information can integrate with Apple Health or Google Fit. Prior authorization status can be accessible via text message.
All of this requires robust API infrastructure, not just for compliance, but as a strategic capability. The goal is to make health plan services accessible and adaptable to the way people actually live.
How to Accelerate with Strategic Partnerships
One theme that consistently emerged throughout the conversation between Kristen and Raj was the critical importance of strategic partnerships over traditional vendor relationships. In an environment where the pace of change exceeds anything healthcare has seen before, no organization can go it alone.
The distinction matters. Strategic partners bring thought leadership, not just products. They provide access to innovation labs and R&D capabilities that safety net health systems and smaller plans can’t build internally. They share best practices across their client base, accelerating learning and implementation.
For organizations running on limited resources while trying to keep operations running, strategic partners become essential for lifting heads up to see what’s happening across the industry. Being singularly focused on keeping the lights on can make transformation nearly impossible.
The Path Forward
Despite the challenges, there’s genuine optimism about what’s ahead. Throughout decades in healthcare, there has been a lot of talk about reducing costs, but also few meaningful or lasting achievements. Now, something fundamental has shifted.
Technology has finally reached a point where it can meaningfully address healthcare’s most intractable problems. Three strategic areas are converging at the right moment: investments in healthcare innovation, the emergence of niche players solving specific problems, and the regulatory framework supporting data exchange. For the first time, technology leaders feel confident that if there’s a problem to be solved, technology can come to the table with a solution. As a result, the bottleneck shifts from technological capability to organizational readiness for change.
Healthcare personalization requires building member trust through transparency, securing consent by demonstrating value, modernizing infrastructure, reimagining ineffective processes, responsibly leveraging AI, and meeting members where they are through integrated ecosystems and strategic partnerships.
Your social media feed may know you better than your spouse because it has access to your data, uses it to deliver personalized value, and makes the experience seamless. Healthcare can do the same, but with the added responsibility of protecting sensitive information and maintaining human oversight where it matters most.
The future of healthcare isn’t about forcing members to come to us. It’s about meeting them where they are, with the information they need, when they need it, in ways that build trust. And for the first time in healthcare history, we have all the tools necessary to make that vision a reality.
The technology is here. The regulatory framework is evolving. For organizations willing to invest in infrastructure, reimagine processes, and put member experience at the center of everything they do, 2026 represents an unprecedented opportunity to transform healthcare delivery.
b.well Connected Health partners with health plans to navigate this transformation through our comprehensive platform for data integration, member engagement, and personalized care delivery. From modernizing API infrastructure and enabling real-time interoperability to creating seamless member experiences and implementing responsible AI, we help organizations turn strategy into action. Ready to explore how your health plan can build trust, improve outcomes, and transform member engagement in 2026? Contact us to start the conversation.