Repost: Envisioning AI’s Role in the Next Era of Health Care Payments: Digitizing Provider-Payer Collaboration

Bajjali, Tawfiq. “Envisioning AI’s Role in the Next Era of Health Care Payments: Digitizing Provider-Payer Collaboration”, NEJM AI, 5/23/2024,https://ai.nejm.org/doi/full/10.1056/AI-S2400394?query=ai_toc

The journey of health care through the lens of artificial intelligence (AI) is one of profound transformation and boundless potential. As we collectively stand at the crossroads of digital innovation and traditional health care paradigms, the narrative is not just about technological advancement but a reimagined approach to provider-payer collaboration within true payment transformation; one that improves transparency and efficiency, while also reducing costs, improving outcomes, and retaining human centricity.

The essence of AI in health care encompasses and transcends data and insights-driven automation — harnessing technology to enhance human and human expertise, while making health care more personalized and proactive. In my prior roles at Amazon Web Services, Elevance Health, and Optum, I developed payer-based analytics that extended from payers to providers, empowering greater bidirectional sharing of data for improved value-based care and population health insights. The continual year-over-year growth of analytic and AI technology is paramount to solving ongoing challenges and opportunities, involving all stakeholders — including patients.

One challenge for health care consumers is pricing and affordability. More than 60% of all Americans live paycheck-to-paycheck,¹ and nearly 7 in 10 feel stress over their personal finances and rising prices.² A recent survey shows nearly 40% of individuals who are insured have delayed care due to cost.³ Also of note was that 38% reported their health worsening, and nearly 20% reported the treatment for the condition becomes more expensive due to the delay. Such delays create gaps, poor long-term outcomes, and higher levels of chronic disease, which compound the cost of care. Moreover, the most recent J.D. Power health plans survey⁴ shows select decreases in overall satisfaction from plan members — including customer service, provider choice, as well as information and communication.

Organizations from the provider and payer segments recognize that while improvements in the clinical environment play a key role in successful outcomes, health care payments and simplification of administrative tasks are drivers in need of transformation as well. It begins with the understanding that key stakeholders, including patients, can collectively benefit in this environment. AI has tremendous potential in this transformation, which can be further increased through improved data sharing across all parties.

In my current role at Lyric, a 30-year technology organization helping improve payment accuracy for health plans, AI is driving new thinking and possibilities. We’re moving from a widely adopted payer-based point solution to a next-generation platform with capabilities around data, predictive analytics, and AI — specifically to lower costs, improve transparency, and reduce complexity in health care payments.

Some examples of where AI is being used include selection of deterministic payment accuracy functions to invoke during claims processing; assisting in the identification of over and underpayments; automating the creation of prior authorizations and aggregating all the necessary information from valid data sources needed for efficient clinical review; calculating member risk by disease; and identifying recommended actions for providers, care teams, and members.

These examples also include the use of generative AI, which enables greater ease of explainability and understanding of complex decisions, and useful summarization of information. For both providers and payers, these capabilities reduce claim cost, discrepancies, denials, and complex case reviews. In turn, this ensures that providers are reimbursed accurately and efficiently, and plan members have higher levels of engagement and satisfaction.

Moreover, increased interoperability, coupled with AI and predictive analytics for valuable insights, will allow for scaling digital solutions to increase efficiency, quality, access, and equity through personalized care plans and effective predictive interventions.

As just one of many focused on the unfolding digital transformation in health care, my philosophy is grounded in three core principles: innovation, collaboration, and responsibility.

Innovation is the cornerstone of progress, driving us to explore new frontiers and push the boundaries of what is possible with AI in health care.

Collaboration is essential, as the convergence of technology and health care demands a multidisciplinary approach, bringing together experts from diverse fields to create holistic and impactful solutions.

Lastly, this is a pivotal time for how all of us who are in the pursuit of transformation will shoulder the use of ethical practices and responsibility in the use of AI. Benchmarks must be followed, biases reduced, and humans kept in the loop. Always remembering the role of AI is not to replace human expertise and judgment, but to enhance it. By automating routine tasks and analyzing vast datasets, AI can free up health care professionals to focus on what they do best in caring for patients, and administration professionals, from both the payer and provider segments, to spend more time on higher priority tasks and processes.

As we look to the future, the possibilities of AI in health care are only limited by our imagination. The journey ahead is fraught with challenges, but it is also ripe with opportunities to make a lasting impact on the health and well-being of individuals and communities around the world. It is a journey that requires vision, leadership, and a collective commitment to transforming health care for the better.

REFERENCES

1. Dickler J. 62% of Americans are still living paycheck to paycheck, making it ‘the main financial lifestyle,’ report finds. CNBC, October 31, 2023 (https://www.cnbc.com/2023/10/31/62percent-of-americans-still-live-paycheck-to-paycheck-amid-inflation.html).
2. Dhue S, Epperson E. 70% of Americans are feeling financially stressed, new CNBC survey finds. CNBC, April 11, 2023 (https://www.cnbc.com/2023/04/11/70percent-of-americans-feel-financially-stressed-new-cnbc-survey-finds.html).
3. Healthcare Dive. New study reveals 40% of workplace-insured Americans delay care due to cost, adversely impacting workplace culture and productivity. March 14, 2019 (https://www.healthcaredive.com/press-release/20240314-new-study-reveals-40-of-workplace-insured-americans-delay-care-due-to-cost-1/).
4. Commercial health plan member satisfaction declines in key areas, J.D. Power finds. JD Power, May 31, 2023 (https://www.jdpower.com/business/press-releases/2023-us-commercial-member-health-plan-study).