D2C Care Navigation: Healthcare's Missing Ally Emerges
The Promise of Action-Oriented, AI-Innate Platforms
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Executive Summary
- Navigating the U.S. healthcare system has become increasingly complex, with patients left largely on their own to figure it out. For patients with chronic or acute conditions, managing referrals, medical records, and insurance issues is a fragmented, high-friction experience. Poor care navigation can be costly, leading to redundant care, unresolved billing errors, and delayed treatments. Managing the administrative side of care can consume more than eight hours per month of a patient or caregiver’s time.
- Traditional care navigation from insurers, providers, or employers only reaches a subset of patients who need help. Only ~13% of eligible insurer members engage with their case management services; fewer than a quarter of providers offer navigation outside oncology; and employer programs reach mainly large self-insured populations. Compounding the issue is a growing lack of trust in all three channels, leaving most patients without reliable support.
- Filling the care navigation gap is an emerging class of direct-to-consumer (D2C) solutions. Solace Health has raised $74M for its telehealth patient advocate platform, which has supported over 200K patients. PocketHealth has enrolled more than 2M patients on its radiology image aggregator. Tempus has launched its Olivia AI care concierge app. Together, these examples highlight early proof points of consumer interest in D2C care navigation.
- There remains an opportunity to truly reinvent care navigation using new AI capabilities that can now take on many of the roles once handled only by high-touch services. These tools help patients understand their health information, schedule appointments, coordinate across providers, and resolve insurance disputes, while making high-quality navigation available at a fraction of today’s cost.
Market Overview: From Oncology Navigators to a Universal Need
Care navigation was formalized in the 1990s when Dr. Harold Freeman embedded the first patient navigators into Harlem Hospital’s oncology clinic. These navigators were charged with helping patients through their treatment by addressing social and logistical barriers to their care.
Since then, the impact of care navigation services when used effectively has been notable. In addition to improved outcomes, cancer navigation can reduce the total cost of cancer care by $4–$5 for every $1 spent. Chronic disease care management programs, though less commonly studied, have shown significant reductions in ER visits, hospitalizations, and improved disease outcomes. Patients personally enjoy working with care navigators, regularly reporting 80-90% satisfaction scores.
However, access to care navigation services remains underprovided. Legacy payer, provider, and employer care navigation delivery channels all have their own limitations:
- Payers: Health insurers offer case management services across disease areas, often dedicating over 10% of their administrative budget to them. But engagement is poor: only ~13% of eligible members use these services. Outreach is not well timed to patient needs, and patients often distrust insurer motives (“Are they cutting costs at my expense?”). Engagement and trust can be hard for payers to build with members, especially when close to half of all U.S. adults have received a bill in the past year they thought should have been covered by their insurance.
- Providers: ~50% of U.S. cancer centers offer navigation, and fewer than half of those provider groups / health systems offer navigation outside oncology. Of those that do, they typically only employ a handful of care navigators concentrated in pulmonology and cardiology. Even with evidence of success, providers rarely expand navigation programs beyond oncology. They generally view care navigation as a cost center, leaving many disease areas underserved.
- Employers: Employer care navigation services have developed the broadest reach with the likes of Transcarent, Included Health, and Quantum Health covering an estimated 30M+ lives. However, employer platforms tend to focus on large self-insured employers, limiting the number of patients who can access these services. Employer navigators are also increasingly steering patients toward their own virtual care services, which can be convenient but also reflects the broader primary imperative for these platforms to lower costs vs. solely supporting the patient
A growing lack of trust in existing care navigation channels only amplifies some of their current limitations. Only 4% of patients report "completely" trusting their insurer. Less than half of Americans under 65 fully trust information from doctors or hospitals, a sharp decline since 2020. Among Millennials and Gen Z, 50% say they’re uncomfortable even sharing their health data with providers. The latter likely reflects a generational preference to control personal health data and decisions.
Today, patients are looking for a new kind of ally, one they choose, who works solely in their interest. We’ve seen what’s possible when navigation is truly patient-centered: better adherence, lower costs, and higher satisfaction. These benefits don’t need to be confined to legacy channels that underserve a large market. All of this sets the stage for a new direct-to-consumer (D2C) solution that puts patients in control of their health.
Mind the Gaps
Over half of U.S. adults are living with at least one chronic condition, and 4 in 10 are managing two or more. 35% of Medicare patients see 5+ different physicians and often juggle 10+ prescriptions per year. Without navigation, the system expects them to act as their own project managers: coordinating care, seeking education on their condition, tracking referrals, and managing billing issues. 62% of consumers feel healthcare is intentionally confusing. 61% of patients skipped medical care in the past year because scheduling was too much of a hassle. One in four people also reported missed or delayed care due to time required for information-seeking and paperwork.The impact for patients isn’t just lost or delayed care, but also redundant tests and imaging studies, conflicting diagnoses, and treatment plans that add to the patient's confusion.
Consider a typical patient with multiple chronic conditions: they may have to coordinate care across a half-dozen providers, manage a list of medications and refills, chase down lab results, and repeatedly explain their history due to siloed records. Nearly 90% of U.S. adults struggle to understand medical information and insurance policies, so these tasks can be truly overwhelming. Patients often don’t know “Who do I call next?” or “Why was my claim denied?”, basic questions that go unanswered without extensive time and effort. Not surprisingly, important care falls through the cracks. The deck is further stacked against patients when a shocking 60-80% of medical bills contain errors. It’s typically on the patient to spend multiple hours on the phone to get any billing mistakes corrected. These burdens add tremendous stress at the worst possible times — during a new diagnosis or a worsening illness. Managing just the administrative side of care can consume more than eight hours per month of a patient’s or caregiver’s time.
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These painful, complex, and administratively cumbersome tasks persist despite decades of “patient engagement” efforts by incumbent players. The net result is that care gets delayed or skipped, instructions get misunderstood, bills go into collections, and patients switch providers out of frustration.
Existing Solutions & Tailwinds Signaling Patient Demand
While no current AI-native solution yet offers end-to-end navigation from understanding your medical record to taking action on your behalf, we are seeing momentum in the relatively nascent D2C market care navigation market via a wave of startups and tech-driven platforms addressing key pain points.
- Solace Health ($74M raised) offers concierge-style advocacy with human “health advocates” who assist with the traditional care navigation activities billing under new Principal Illness Navigation (PIN) CPT codes. The company’s recent raise will fuel their expansion nationally having already served over 200K patients. While its combination of private and insurance pay model isn't inexpensive, their fundraises showcase the appetite for care navigation services through D2C channels.
- Legacy EHR aggregation companies like Picnic Health ($95M raised) and Citizen ($44M raised, having recently closed a $30M round) have begun layering in capabilities that enable patients to ask questions about their medical records. Citizen Health has expanded their capabilities with the launch of their AI health advocate, allowing patients to ask about medication side effects, insurance appeals, and other issues. Their continued success further demonstrates patient willingness to engage D2C tools to regain control of their medical data.
- PocketHealth ($55M raised) focuses on medical imaging access and is used by over 2 million patients to store and share radiology reports. Its popularity underscores strong consumer demand for control over personal health data, even when it comes through paid third-party apps.
- Newer entrants like Tempus’s “Olivia” and Trellis Health ($1.8M raised) are among the latest pushing the frontiers of care navigation. Both help patients aggregate and interact with their health records, but each brings a distinct approach. Tempus has introduced a patient-facing visit recording feature that summarizes physician visits and stores them for easy reference, representing an expansion of the feature set of traditional care advocacy platforms. Trellis, by contrast, has moved away from general care navigation and purpose-built its platform to support patients specifically through the pregnancy care journey.
- Although not a D2C company, it is worth noting Epic’s announcement “Emmie”, their new patient-facing advocate that will be visible in MyChart. Once released, Emmie is expected to help with scheduling, reminders, patient education, and navigation through natural-language conversations. It is unclear whether patients will, at least initially, be limited to querying records local to their provider or whether Emmie will also access records available through Care Everywhere. Emmie will likely be oriented toward helping patients navigate within health systems rather than offering neutral navigation across the broader healthcare ecosystem. However, Emmie’s launch is another significant example of a company responding to patients’ desire to engage more deeply, autonomously, and easily in their healthcare journey.
Together, these early players show that many patients are seeking new solutions to better understand and navigate their health. Solace’s rapid patient acquisition points to strong pent-up demand, while Citizen Health’s continued traction highlights patients’ growing desire to better understand and take ownership of their care. However, there is still a big opportunity to broaden access to care navigation even further with an AI-native platform that can act on your behalf, fueled by key market tailwinds:
Regulatory & Reimbursement
In 2024, Medicare introduced Principal Illness Navigation (PIN) codes, allowing reimbursement for certain navigation services under physician supervision. While reimbursement is still modest, it reflects official recognition that navigation is a valuable healthcare function. Ongoing efforts to improve data interoperability (e.g., FHIR APIs, TEFCA, July’s recent CMS Interoperability Framework announcement) are also making it easier for navigation platforms to plug into health systems and support patients directly.
Patients Turning to AI Chatbots for Health Advice
By late 2024, one in six U.S. adults and 25% of adults under 30 now use an AI health chatbot monthly, indicating a generational shift in comfort with AI-driven support. As of early 2025, 34% of U.S. adults have used ChatGPT or similar AI systems for health or other queries, about double the share in 2023. Patients are increasingly comfortable moving away from Google and WebMD to using LLMs to research health conditions, check symptoms, and even receive mental health support.
Technology (AI) Advancements
Until recently, care navigation was only possible as a high-touch, expensive service commanding hundreds of dollars per interaction through D2C channels. The best care navigators wear many hats, acting as clinical advocates who help patients interpret medical information and lab results; personal administrators who manage appointments; and insurance counselors who handle bills, appeals, and benefits, among other roles.
Building a software system aligned to these expert tasks was not possible until recently. In the last year, high-quality models with the ability to invoke powerful external tools have emerged, with best practices solidifying around model evaluation, guardrails, and human escalation points. Multimodality has unlocked complex workflow automations: individual agents can place calls and handle phone trees, navigate UIs via safe computer use, and call tools to enable the automated push and pull of patient data via voice, patient portals, and SMS/email. On the clinical side, LLMs pair with EHR knowledge graphs and expert guidelines to structure health data in a way that enables natural language conversation with a patient's longitudinal health record.
Taken together, these advances open the door to a new kind of AI-powered care navigation experience that is built on a multimodal, agentic core and delivers the same support as any high-touch platform at a fraction of the cost.
Opportunity for Innovation
Despite promising developments, today’s solutions still don’t comprehensively address patients’ core frustrations with an AI-innate approach. Concierge services are too expensive, point solutions like those for insurance billing analysis are too narrow, and incumbent players aren’t serving large swaths of the market. New players are gaining momentum, but still don’t offer everything a patient is looking for. As a result, patients with complex needs have no single, accessible, and reliable care companion.
We see a compelling opportunity to build an AI-native care navigation platform that can reach patients directly (D2C) and empower them to take control of their health outside of normal channels.
- Comprehensive scope: A one-stop platform for managing a patient’s entire journey that can aggregate and interpret medical records, coordinate referrals, schedule appointments, manage insurance disputes, and connect patients with social support. Today’s offerings only address fragments of this; the opportunity is a unified, seamless experience that handles it all.
- Impartial guidance: To earn trust, the platform must be independent of insurers, providers, or employers. Acting as a “healthcare fiduciary,” it should prioritize only the patient’s best interest even if that means recommending out-of-network specialists or supporting second opinions. Neutrality is a core differentiator, enabling trust that is difficult for incumbents to replicate.
- AI-powered personalization: AI should proactively surface insights based on a patient’s history, identify overdue follow-ups, flag abnormal lab results, and detect potential drug interactions. It should read clinical notes, detect care gaps, and send reminders. Legacy care navigation services have fallen short when they can’t deliver timely and personalized services to their patients, something AI is poised to help overcome.
- Automation of routine tasks: The platform shouldn’t just advise patients, it should act on their behalf. It should automatically request records, pre-fill prior auth forms, draft and submit insurance appeals, and schedule appointments. Today’s tools stop short of execution, leaving patients to handle the burden. A platform that actually gets things done across the continuum of care delivers significant time and stress savings.
- Affordability and accessibility: D2C Concierge navigation is priced at a premium. A scalable D2C platform must offer modest subscriptions or usage-based pricing to reach middle-class consumers. With AI and operational efficiency, it can serve a large base. It must also meet patients where they are, with a mobile-first experience, 24/7 availability, and asynchronous messaging that fits into the lives of caregivers, workers, and digitally engaged adults..
- “Patients-Like-Me” community insights: A built-in, anonymous peer insights feature would allow users to benefit from seeing the questions asked and decisions made by patients like them. For example, a lupus patient could see what others on the same medication have said about managing fatigue. This structured “wisdom of the crowd” approach fills a gap left by traditional care. No current navigation tool offers this natively.
- Caregiver Access: Family caregivers represent a massive underserved population. More than 43.5 million Americans provide unpaid care while facing significant administrative burdens and lacking training to navigate complex health systems. A comprehensive D2C platform could enable caregivers to act seamlessly on behalf of patients, providing the emotional and informational support this vulnerable population desperately needs.
In sum, the market lacks a digital, AI-powered navigation platform that combines personalization, trust, execution, and affordability. The D2C navigator that truly partners with patients to advocate for them, coordinate their care, and remove their administrative burden hasn’t been built yet.
Risks & Execution Challenges
No D2C care navigation venture is without hurdles. We see four key risks, each with some potential mitigation strategies:
- Consumer Adoption & Monetization: Willingness to pay for a novel D2C healthcare platform is always a risk given patient preference for paying for healthcare through their payer. There’s a related risk for retention, developing a sticky platform patients will pay for month over month
Mitigation: Start with high-need early adopters and show clear ROI by saving money, time, and hassle. Leverage new option to pay for digital health subscriptions with HSA / FSA funds - Trust & Clinical Credibility: Patients may question the authority of any new platform. Providers may see it as interfering with care they’re recommending
Mitigation: Anchor credibility with a strong clinical team, medical advisors, evidence-based guidance, and early studies / proof points - Regulatory & Scope Constraints: Some navigation tasks risk crossing into medical advice, running afoul of Software as a Medical Device (SaMD) regulations
Mitigation: Ensure we have strict guardrails for any agents assessing and then communicating health information. Could consider using a “clinical wrapper” for telehealth edge cases - Scalability & Unit Economics: Balancing high-touch support with venture-scale efficiency is hard
Mitigation: Build AI-first workflows that triage and resolve most issues automatically, routing only complex needs to humans while optimizing UX for self-service
Conclusion
Healthcare’s next frontier is usability, access, and seamless action. Today, patients are left to navigate an opaque, fragmented system on their own, despite the availability of life-saving treatments. A D2C care navigation platform can change that, serving as the connective tissue of a more transparent, responsive, and patient-centered system.
The core frustrations of navigating a fragmented healthcare system that lacks a full picture of the patient are solvable. Advances in AI, chatbot adoption, and shifting patient expectations have created the conditions for a breakthrough. The D2C model ensures patient loyalty and trust, while automation and personalization can deliver better outcomes at scale.
Build With Us
At Redesign Health, we are eager to be part of this journey. We firmly believe a breakthrough D2C care navigation solution will not only be a great business, but a profound social good. Are you interested in building the future of healthcare navigation? We’re looking for visionary founders and partners who are passionate about lifting the burden from patients’ shoulders.
If you share this vision, reach out to us at buildwithus@redesignhealth.com.
DATA INSIGHTS
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