Payer-provider dynamics have been a persistent struggle in healthcare, particularly evident in heated contract negotiations. AI — such as clinicians using scribes associated with greater coding intensity and insurers harnessing AI platforms to authenticate claims and assist with prior authorization — has only exacerbated these tensions.
But these tensions can sometimes overshadow the bottom line: patient care. To maintain this priority — and if AI is the crux of recent finger-pointing — do both sides of the equation need to use the same platform to achieve true alignment? The question becomes even more pressing as bigger AI players, such as Anthropic’s Claude, expand into healthcare, offering services to both payers and providers.
Becker’s asked three payer leaders about the feasibility of coming together with providers to leverage a shared AI platform and promote synergy across the aisle. They said the idea holds merit, but it probably will not happen any time soon.
“It’s too idealistic right now because we are not even able to share clinical data efficiently and effectively,” BCBS Nebraska CIO Rama Kolli said. “[The] healthcare ecosystem in general is so fragmented that some consolidation — not the system level, but the technology level — needs to happen to bring that uniform nature.”
Mr. Kolli said he understands the inclination, adding that he has heard of a payer working on a pilot with Epic to consolidate onto the same platform as providers and reduce the need for another claims system.
He hopes interoperability mandates coming down the pipeline can help, but he said larger hospitals are not the problem. Smaller facilities may not be able to invest in data exchange. Federal and local mandates will both have to come into play to realize unified AI platforms, he added.
“This is a huge lift with the kind of cooperation that would be required that I don’t think we’ve ever really seen before,” Magellan Health CEO Caroline Carney, MD, said.
Maggie Helms, senior vice president and chief data, AI and digital officer at Bloomington, Minn.-based HealthPartners, agreed the process would not happen overnight, but said she is passionate about the concept.
HealthPartners has an integrated health plan, sharing an innovation lab with the care-delivery branch. The team merged insurance plan information and clinical reminders within a consumer-facing app. Even with payer-provider AI collaboration on front-end initiatives, building a shared infrastructure is not always the primary issue.
“When you’re shoving apples and oranges into the same frame, you really aren’t solving the main problem,” she said. “I think it’s not only bringing together everything into a single platform, but it’s creating coherence in this mess of confusion that we call healthcare, and it’s speaking the same language.”
While she echoed that interoperability has the potential to push organizations toward unity, incentives are not so obvious.
“I think until there’s a real, ‘What’s in it for me?’ for organizations that have a lot of inertia to change, it will be difficult to see the kind of change at scale we will need,” she said.
