Payers are putting artificial intelligence to work.
Google recently launched a new AI-powered cloud program for prior authorization and claims processing. Elevance Health is piloting AI-powered concierge care for members.
Becker's asked 18 payer executives how AI will transform the insurance industry. The executives featured in this article are all speaking at the Becker's Payer Issues Roundtable, which will take place Nov. 9-10 at the Swissotel in Chicago.
To learn more about this event, click here.
If you would like to join as a speaker, contact Randi Haseman at rhaseman@beckershealthcare.com.
As part of an ongoing series, Becker's is talking to healthcare leaders who will speak at our roundtable. The following are answers from our speakers at the event.
Question: How will artificial intelligence change the payer industry?
Jim Agnew. Vice President of Corporate Development at Vytalize Health (Boston): Many believe AI will revolutionize many industries, including healthcare. The adoption of AI advancement is predicted to occur at a blistering pace. The obvious question is, can we as providers, payers and consumers of health services adapt to that level of change? Because innovation is made available, will it always be in our best interest to follow the technology? Or do we need to consider many more downstream implications than ever before?
Arguably, AI has the promise to improve the health customer experience far beyond today's web-based and online technology. In addition, the management of "big data" such as claims management and population health analysis will be enhanced via predictive and machine learning and provide less errors.
The promise of AI will come at a cost both in terms of both actual IT infrastructure investment and the downside of possible staff elimination.
Faris Ahmad, MD. Medical Director of Clinical Partnerships and Commercial PPO Reimbursement at Blue Cross Blue Shield of Michigan (Detroit): I think AI can influence/change the payer industry in a few ways:
Administrative
- Chat bots to handle customer service inquiries
- Automated processing of claims
- Fraud detection that is much more accurate than our current technology allows
Clinical
- Predictive analytics: Use of AI to analyze data to predict members that are at risk for disease, enabling them to intervene to help prevent them from getting the disease
- Personalized medicine: Use AI to analyze data to create personalized treatment plans for patients/members based on their health histories, genetics and risk factors
Arta Bakshandeh, DO. Chief Medical Informatics Officer of Alignment Health (Orange, Calif.): As a payer, AI's ability to help members better manage their care, minimize health emergencies and avoid hospitalization is game-changing. AI can address the recurring pain points of healthcare to increase efficiencies, improve health outcomes and reduce burnout. Alignment Health has been proving this for nearly a decade, working at the forefront of the AI revolution in senior care with our own AI-powered technology that collects thousands of data points — from lab reports to whether a patient picked up their prescriptions on time — to get a holistic picture of a member's health. Our AVA technology operates on 170 machine-learning algorithms and hundreds of thousands of rules across 35 modules; there's nothing like it. But impressive amounts of data mean nothing if you don't use it to make a real impact. What makes any AI technology powerful for payers is what it empowers care teams to do. For example, we can stratify members based on health status and social needs so care teams can reach out proactively to the most vulnerable members with timely, coordinated care. We also can predict care alerts, such as the risk for hospitalization and disease propensity, before early warning signs turn into a true emergency. AI will increasingly streamline and improve personalized care, save providers and payers money and time, and enable payers to invest savings back into their members' benefits.
Paige Brogan. Principal CalAIM at Blue Shield of California (Oakland): Artificial intelligence offers the opportunity to seamlessly share patient and member data to reduce errors, process claims faster and reduce costs.
Ceci Connolly, President and CEO at Alliance of Community Health Plans and Michael Bagel, Associate Vice President of Public Policy at Alliance of Community Health Plans (Washington, D.C.): Increasing the use of AI in healthcare has the potential to reduce healthcare costs and streamline clinical care delivery. AI can improve efficiency and reduce manual decision-making, leading to more timely and consistent determinations. Payers can better engage in population health management, with additional tools to identify patients at risk for chronic diseases, permitting them to intervene to keep patients healthier longer. It's imperative these tools do not sacrifice quality and access or exacerbate inequities and bias.
Onyinyechi Daniel, PhD. Vice President of Data and Analytics Strategy at Highmark Health (Pittsburgh): Artificial Intelligence is transforming the payer industry, and the healthcare industry more broadly, in three key ways: It enables us to build and mature robust capabilities for clinical and care delivery that will result in better health outcomes. It also allows us to optimize our business processes and reduce administrative costs through enhanced automation and accuracy for things like claims processing. Finally, it enables us to provide a simpler, more streamlined and personalized healthcare experience.
Robert Groves, MD. Chief Medical Officer of Banner|Aetna (Phoenix):
The possibilities are many:
- Improved and ever-improving predictive analytics
- Improved engagement by learning what works parsed by population/individual
- Improved workforce efficiency
- Precision medicine (beyond genetics)
- Knowledge management (In 1950 medical knowledge took 50 years to double, now we measure in months)
- Elimination of prior authorization (via knowledge management and clinical decision support)
- Improved accuracy and reliability of diagnostic services (derm/path/high-tech imaging)
- Improved safety of home-based care and services (computer vision)
These are the areas that immediately come to mind. There are likely many others, some of which we have not even imagined yet.
Dennis Hillen. Senior Vice President and Market Leader of Oscar Health (New York City): Healthcare is a unique mix of highly structured systems, colliding with often unstructured data. Language models have proven surprisingly good at bidirectionally generating structure from language, and language from structure. In our view, any place in healthcare where translation direction creates chaos is ripe for complete automation. For example, our claims system can now use understandable prose to explain why it paid a claim, or didn't.
Gregg Kimmer. President and CEO of Atrio Health Plans (Salem, Ore.): The biggest short-term impact I see is the enablement of payers to make member-facing decisions more quickly. For example, today we know quite a bit about members, such as their provider visit totals, age, how long they've been with our plan, etc. But, synthesizing all that we know about a member to quickly support a decision is a challenge. If AI can accelerate that process and give recommendations, it makes for a more efficient decision-making process. Additionally, it would be a game changer if AI was applied to data integrity within a payer's world. Provider directories, member roster information … there are many applications.
Ria Paul, MD. Chief Medical Officer of Stanford Healthcare Alliance (Palo Alto, Calif.): Utilization of AI has come to the forefront as healthcare costs are increasing and there is a need to find cost-effective strategies to assist with healthcare delivery. As AI can delve into administrative claims data, it can help payers connect patients to resources and appropriate care; for example, connecting patients with diabetes with chronic care management. Payers can also partner with healthcare delivery organizations with the know-how that they get from the claims data that will assist in also identifying high-risk patients and deliver care accordingly. At this time there is worry of HIPAA around data-sharing among various entities. Payers are also being cautious at this time; however, the future of AI is promising.
Krystal Revai, MD. Associate Chief Medical Officer of Health Alliance (Champaign, Ill.): Artificial intelligence will profoundly affect the payer industry. AI is already being used to facilitate prior authorization. I believe the next application for AI would be to improve communication with our members. Enhancing AI so that it can produce meaningful member friend language in our documentation — from plan documents to explanation of benefits is the next step towards transparency within the payer industry.
Bruce Rogen, MD. Chief Medical Officer of Cleveland Clinic Employee Health Plan (Ohio): AI might, maybe, help gather the information needed for improved payer-provider collaboration; for example, around prior authorizations, quality initiatives, to provide additional data and speed up processes that rely on chart reviews and people now.
John Snyder. President and CEO of Sanford Health Plan (Sioux Falls, S.D.): We think there will start to be greater uses and more opportunities for payers to use solutions based on AI-technology, particularly in core admin functions like claims processing that still have heavy manual components involved.
We have seen chatbots being utilized for customer service functions to help answer members' questions and give them answers on their policies. These can be successful for some interactions, but it is important for us to be sure to provide a top-notch experience to our members. There will have to be trust-established from both the payer and the member that the information our AI tools are serving up is accurate and meets their needs where they are at.
Praveen Thadani. President of Priority Health (Grand Rapids, Mich.): The payer industry has a wide range of opportunities to be positively impacted by artificial intelligence. AI can advance the value of automation by not only improving the efficiency of getting work done, but by significantly improving underlying core processes through machine learning. Also, analytical models today are used to underwrite products to reduce risk through fine-tuning premiums to match medical loss ratios. AI provides for the ability to more accurately price products by continuously fine tuning the projected loss ratio based on the continuous feed of claims and clinical data into the pricing model. Additionally, AI will allow member segmentation to become significantly more accurate in predicting who will benefit from (and participate in) expensive chronic disease prevention and management programs, allowing the health plan to fund more expensive treatments for the fewer targeted members and ensuring the best usage of premium dollars.
Michael Todaro, PharmD. Chief Operating Officer of Magnolia Health (Ridgeland, Miss.): I think AI will have a massive impact on payers. We will be able to customize healthcare models and better use data to predict individualized management. I think AI will play a very large role in expanding how we focus our resources on population health initiatives.
Chanin Wendling. Senior Director of Clinical Operations at Contigo Health (Charlotte, N.C.): We look forward to seeing artificial intelligence handle tasks that divert resources from member care. This can be in the form of using artificial intelligence to automate prior authorization functions on both the provider and payer side and answer common member inquiries regarding the member's plan. We want our team members to be able to spend their time resolving unique member questions and issues to improve member health outcomes and experiences within the healthcare system. We believe artificial intelligence will help us do that.
Darren Wethers, MD. Chief Medical Officer of Atrio Health Plans (Salem, Ore.): Artificial intelligence will change the payer industry in at least four ways. First, it will aid in identifying members with rising risk for hospitalization and emergency department use. Through application of analytics, plans will be able to recommend changes to member's drug regime (reducing risk for side effects and complications, which elevate cost). Plans will benefit from use of AI in identifying fraud, waste and abuse. Tools such as Chat GPT may help plans create member-friendly health education materials.