Transforming Health Care Payer Operations With AI

Driving Member Engagement and Improving Outcomes

Milosz (Milo) Wicinski, Head of Business Development at Infermedica

Health plans today face mounting pressure to enhance member engagement while improving health outcomes and control rising costs. As health care inflation continues to outpace general inflation across the United States, health plans are increasingly turning to artificial intelligence (AI) to transform their operations and better serve their members. By leveraging AI-powered solutions, payers can streamline processes, gain actionable insights, and ultimately drive financial, quality, and health performance improvements.

Engaging members in their health care journey has become essential for health plans, and for good reason. Traditionally, the relationship between payers and members has been primarily transactional, focused on claims processing and service arrangement. However, this limited approach fails to address the root causes of unnecessary health care utilization and escalating costs.

By proactively engaging members earlier in their healthcare journey, health plans can influence better health outcomes and more efficient use of resources. This shift towards preventive care and early intervention is crucial for promoting proactive health management, enhancing care coordination, and achieving better patient outcomes. Moreover, it allows payers to guide members to the right care at the right time, reducing unnecessary appointments and claims while ensuring members receive appropriate and timely treatment.

Challenges in Obtaining Actionable Data

Despite recognizing the importance of member engagement, plans often struggle to obtain the actionable data needed to connect members with appropriate care. Several key challenges hinder this process. Many payers lack robust digital platforms that members use regularly, making it difficult to gather consistent, real-time health data. This limited digital engagement creates a significant barrier to effective data collection and analysis.

Furthermore, traditional payer apps are often used only for claims submission or service requests, resulting in infrequent member interactions and limited data collection opportunities. These infrequent touchpoints mean that health plans miss out on valuable opportunities to gather ongoing health information from their members.

Another challenge stems from the fact that most payers are not medical companies and may lack the in-house knowledge and technology required for comprehensive health navigation and assessment. This lack of medical expertise can make it difficult for payers to develop and implement effective health management strategies.

Lastly, payers require solutions that can be tailored to their specific care pathways and member populations, which can be challenging to achieve with off-the-shelf products. These customization needs often necessitate significant investments in technology and expertise to create truly effective, personalized solutions.

AI: Streamlining Processes and Enhancing Data Exchange

AI offers powerful solutions to address these challenges and transform payer operations. By implementing AI-driven technologies, health plans can significantly improve their data collection and analysis capabilities. AI allows for more personalized and engaging health assessments, enabling dynamic triaging that increases completion rates and gathers more comprehensive data compared to traditional protocol-based systems.

Moreover, AI-powered solutions can collect up to five times more data points during health interviews than conventional methods, providing richer insights into member health status and concerns. This improved data collection capability allows payers to build a more complete picture of their members' health needs and risks.

By analyzing a member's unique risk profile and health history, AI can generate tailored care recommendations and identify potential undiagnosed conditions. This personalization of care suggestions helps ensure that members receive the most appropriate and timely interventions.

Additionally, AI can enhance care management program adoption by helping identify members who may benefit from specific programs. This targeted approach improves enrollment rates and overall program effectiveness, leading to better health outcomes and more efficient resource allocation.

Uncovering Care Patterns and Insights

One of the most significant advantages of AI in health plan operations is its ability to uncover care patterns and insights that might otherwise go unnoticed. By analyzing vast amounts of data from multiple sources, including symptom checks, claims history, and wellness program information, AI can:

• Identify population health trends: Plans can gain a deeper understanding of their member population's health status, common concerns, and emerging health risks.
• Predict future claims and risks: By combining data from various touchpoints, AI can help payers anticipate future healthcare needs and potential high-cost claims.
• Improve underwriting accuracy: The rich data collected through AI-powered assessments can inform more accurate risk assessments and underwriting decisions.
• Enhance care coordination: AI can help identify gaps in care and opportunities for better coordination among health care providers, leading to improved patient outcomes and reduced costs.

Broader Implications for Health Care

The adoption of AI-powered technologies in payer operations has far-reaching implications for the entire health care ecosystem:

• Cost reduction: By promoting preventive care, reducing unnecessary utilization, and improving care coordination, AI can help lower overall health care costs for both payers and members.
• Increased accessibility: AI-enabled solutions can provide members with 24/7 access to health information and guidance, improving healthcare accessibility.
• Improved affordability: As costs are better controlled, health care services may become more affordable for a broader population.
• Enhanced member experience: By positioning themselves as trusted health partners rather than just insurance providers, payers can improve member satisfaction and loyalty.
• Data-driven decision making: The wealth of data generated through AI solutions can inform better policy decisions, product development, and population health management strategies.

Although it is already impacting all facets of health care, AI will play an increasingly critical role in transforming health plan operations. By leveraging AI-powered solutions built on verified medical information and advanced probability models, payers can not only improve their own financial performance but also contribute to a more efficient, accessible, and patient-centered healthcare system. The future of health care lies in the intelligent, responsible application of AI, and forward-thinking payers are already embracing this transformative technology to drive positive change for their members and the industry at large.

About the Author

Milosz (Milo) Wicinski, Head of Business Development at Infermedica, is dedicated to advancing health care through AI-powered solutions. Passionate about health care innovation, Milosz supports partners in successfully adopting cutting-edge technologies to improve accessibility and efficiency in primary care.