Introduction to AI in Healthcare
LAS VEGAS – As AI is transforming all aspects of healthcare, it’s affecting the care model for payers. Health insurers have end-to-end visibility into individual care needs and utilization patterns across providers and settings. Virtual care, technology, and AI have helped payers define a more active role in care delivery.
Barriers to Innovation
Barriers include resistance to change and lack of better payer and provider alignment, panelists said during the first Emerge Innovation Experience at HIMSS25. Edward Marx, CEO of Marx Advisory and a former global chief information officer at Cleveland Clinic, moderated the panel of experts from Clover Health, SCAN Health Plan, and Horizon Blue Cross Blue Shield of New Jersey and Humana.
The Role of AI in Payer-Driven Healthcare
The session "Voices of Innovation: Transforming Healthcare in a Payer-Driven World," mirrors the title of the book "Voices of Innovation – Payers," co-edited by Marx and Sakshika Dhingra, medical strategy director for Humana. Clover Health has developed AI-powered technology which enables it to harness big data and run algorithms to help with early diagnoses and better outcomes, said Aric Sharp, CEO of Value-Based Care at Clover Health.
AI-Powered Solutions
"Culturally we encourage everyone to use AI," Sharp said. "The core of our focus is at the point of care." Point-of-care solutions for most payers now include AI assistants and Chatbox, which can streamline member interactions. Members want information quickly, said Heather Lavoie, chief information officer and executive vice president of Enterprise Operations for Blue Cross Blue Shield New Jersey. One of the pain points for patients is calling their insurer, she said.
Benefits of AI in Healthcare
A more automated approach is helping with staff turnover, said Khin-Kyemon Aung, senior director of Healthcare Services, medical director, and primary care physician for SCAN. It’s difficult to find people to work in a call center, Lavoie said. AI can be used to do a summary of information for what’s covered. This makes it easier for people to work at a higher level. AI is also helping with the bigger aims such as allowing outbound calls to be labeled correctly so case managers can implement stratification and nurses can rout cases appropriately by disease state, according to Lavoie.
Real-World Applications of AI
SCAN has started working with Cresta, Aung said. The AI-powered contact center platform provides real-time automation and guidance to chat agents as they navigate complex care conversations. "It’s listening in the background," she said. Direct to consumer AI is making it easier for members, though there’s real root causes that AI can’t Band-aid over, Aung said. "AI is an accelerator to all of these other technologies," Lavoie said. "We’re excited about technology."
Challenges and Future Directions
Right now, AI is being used to make the way healthcare runs more efficiently, according to Sharp. "We have to think about breaking the way the system works in its entirety," Sharp said, even suggesting that "revenue cycle could go by the wayside if we look at entirely different models." Sharp said one of the biggest barriers to innovation is culture and people wanting to stay entrenched. Aung mentioned the challenge of payer and provider alignment.
Conclusion
In conclusion, AI is transforming the healthcare industry, particularly in the payer sector. While there are benefits to AI-powered solutions, there are also challenges that need to be addressed, such as resistance to change and lack of alignment between payers and providers. As the industry continues to evolve, it’s likely that we’ll see more innovative solutions that leverage AI to improve healthcare outcomes.
FAQs
Q: What is the role of AI in payer-driven healthcare?
A: AI is being used to help payers define a more active role in care delivery, including early diagnoses and better outcomes.
Q: What are some benefits of AI in healthcare?
A: AI can help with staff turnover, streamline member interactions, and provide real-time automation and guidance to chat agents.
Q: What are some challenges to implementing AI in healthcare?
A: Resistance to change, lack of alignment between payers and providers, and cultural barriers are some of the challenges to implementing AI in healthcare.
Q: How is AI being used in real-world applications?
A: AI is being used in point-of-care solutions, chat agents, and contact center platforms to provide real-time automation and guidance.
Q: What does the future hold for AI in healthcare?
A: The future of AI in healthcare is likely to involve more innovative solutions that leverage AI to improve healthcare outcomes, such as entirely different models of care delivery.
