Healthcare delivery in the U.S. is increasingly fragmented, with patient care spread across multiple clinicians and care settings. Rather than a cohesive, longitudinal experience, care is delivered episodically, with each encounter starting from scratch. This fragmentation drives inefficiencies, redundancies, and inconsistent outcomes, highlighting the urgent need for solutions that preserve context and connect the care journey across the ecosystem.
A single member’s clinical history is often stored across multiple sources, including primary or urgent care, specialist visits, imaging centers, pharmacy records, and Emergency Departments (EDs). None of these care settings are designed to facilitate bi-directional exchange of health data, and even while organizations have developed integrations with HIEs and EHRs, or adopted interoperability tools, a large portion of patient encounters begin with limited context.
A study published in the Health Informatics Journal found that 58% of patients whose laboratory results were not transferred to other care settings received duplicative laboratory testing at hospitals.
When missing information leads to unnecessary repeat services, it frustrates members and increases costs for payers. Health policy researchers estimate that duplicative care accounts for roughly 25% of healthcare services in the U.S., representing about $100 billion in annual spending.
The downstream effects extend beyond cost. Members find themselves repeating their histories for every new provider, leading to inconsistent care.
For decades, healthcare was designed around the assumption that demand would be episodic, predictable, and manageable by human workflows. Every visit asks for the same information, such as current medications, prior diagnoses, recent tests, and previous treatments. When the patient becomes the most reliable source of record keeping, responsible for documenting their health journey, it creates a care gap. As a result, clinical decision-making becomes less effective due to inherent blind spots.
Legacy care models, such as nurse advice lines or telehealth, assume that episodes of illness are discrete events that can be resolved in isolation. In reality, patients’ needs are continuous, context-dependent, and nonlinear. When care is deployed around standalone encounters, clinical context is lost, leading to repeated assessments, redundant diagnostics, and inconsistent clinical decisions. Patients are left bouncing between care settings, from urgent care to specialists to EDs.
Over time, members may disengage not because they lack the proper healthcare resources but because the entire experience feels disjointed. They may opt to delay follow-up, put off preventive care, or lose trust in their health plan entirely, turning instead to unreliable information sources, such as search engines and general-purpose LLMs.
Without complete clinical context, a payer’s network can develop inefficiencies. Each encounter that lacks reliable context requires additional verification, such as reviewing prior authorizations, confirming medication use, or validating prior services.
When clinicians lack context, they run the risk of over-escalating, placing greater pressure on already strained downstream services. The financial impact is one of great magnitude: payers see more diagnostic testing, additional consultations, and interventions that might have been easily avoided with appropriate upstream care. When compounded across populations, the economic case for a more effective front door becomes self-evident.
Fragmentation introduces clinical risk because care decisions depend on continuity of care. When clinicians lack access to a patient’s prior course of treatment, changes in condition may be interpreted as new problems rather than a progression of an existing one. Important signals can therefore be missed, particularly when information from separate encounters is never reviewed together.
Gaps in follow-up create secondary concerns as well. Recommendations from one visit may not be reinforced at the next, eroding trust as treatment plans vary across settings. Over time, members may perceive inconsistency, and confidence declines. For payers, reduced adherence and incomplete follow-through translate into higher-acuity episodes, avoidable utilization, and rising long-term cost exposure.
To effectively address this fragmentation, payers are turning to AI-enabled care models as their modern front door. These models enable continuous care by preserving member context across interactions.
Counsel, for example, is an AI-enabled, physician-supervised primary care platform designed for this purpose. Through a proprietary RAG pipeline, Counsel AI retrieves relevant context from a patient’s health history, prescriptions, labs, and more, to deliver hyper-personalized care. Over time, Counsel also builds health memories based on prior interactions, adding greater context to every future point of care.
Counsel also integrates into a health plan’s ecosystem, so when specialized care is needed, members can be routed to the appropriate in-network care settings. This results in increased network efficiencies and a reduction in the total cost of care by reducing unnecessary escalations to EDs.
Counsel has developed a proprietary, AI-powered EHR called the Clinician Cockpit. When a physician needs to step in to deliver care, Counsel’s medical AI surfaces relevant information they can review for accuracy and safety. This enables them to deliver high-quality, personalized care at scale.
To meet the highest payer governance standards and quality reviews, Counsel produces a defensible chain of evidence through transparent traceability of inputs, reasoning, and actions.
When the quality of care improves, health plans unlock network efficiencies. With Counsel, 96% of medical concerns are resolved without escalation or claim submission, and due to our effective escalation protocols, we help reduce ED visits by 24% compared to consumer-facing AI tools.
For members, access to high-quality care increases. Counsel AI delivers advice immediately, and physicians can be added to any chat in minutes. Improved clarity and a continuous care experience strengthen engagement with Counsel, making it the trusted front door for every plan member’s health journey.
Fragmented care often leads to reactive spending, often due to overutilization of healthcare resources. By proactively investing in an AI-enabled front door that delivers continuous, context-aware care, health plans can unlock strategic value.
Solutions like Counsel deliver timely care for plan members, lowering downstream utilization of care, decelerating disease progression, and decreasing total cost of care.
To learn about Counsel’s AI-enabled care model and how it can help reduce fragmentation across your network, request a demo today.
The Counsel Health editorial team is a multidisciplinary group of writers and editors dedicated to delivering clinically grounded, evidence-based health information. Their work is informed by real-world care delivery and guided by physician expertise, ensuring content is accurate, accessible, and trustworthy. By translating complex medical topics into clear, practical guidance, the team helps readers understand their health, explore care options, and make informed decisions in a rapidly evolving healthcare landscape.
Javier Monterrosa is a healthcare marketing leader who has spent his career driving growth across AI, metabolic health, interoperability, and EHR companies. He holds a Master’s in Analytics and has co-authored published research examining how strategic decisions shape business growth. Having grown up in Latin America, he is driven to partner with mission-driven teams committed to improving healthcare access and outcomes through responsible technology.
Our content is created for informational purposes and should not replace professional medical care. For personalized guidance, talk to a licensed physician. Learn more about our editorial standards and review process.
