New tools are available today that can help providers and health plans work better – and together – and that’s a much more exciting future of health care than perpetuating the provider/payer arms race.
The exasperation among doctors frustrated by prior authorization battles with health insurance providers is not unique. Prior authorization frustrates everyone in the healthcare industry — to say nothing of patients. For every doctor tired of submitting more information to justify warranted care, a payer is feeling the same frustration, requesting a third fax to support their criteria as well.
The idea of “an AI arms race” between payers and providers toward a more efficient future is troubling in its own right. It adds to the perception of the future of artificial intelligence in healthcare as a zero-sum game, with health insurance companies on one side and clinicians on the other.
These sentiments perpetuate a false paradigm. Trading blows isn’t the solution — it perpetuates the problem. It’s time to end the arms race, especially since we now have the digital tools available to do exactly that.
A recent piece in the New York Times cites a warning from Dr. Jeff Levin-Scherz, a health policy expert at the Harvard T.H. Chan School of Public Health, that “ill-intended players” could create scenarios where “their AI will deny our AI and we’ll go back and forth.” That mindset is not pervasive among the health plan leaders we speak with, nor is it a path toward efficiency. Using AI and related tools to simply get quicker at fighting the other side isn’t a solution, and it certainly doesn’t take advantage of the true opportunities AI presents for health care organizations, both in terms of realizing new administrative efficiencies and improving the manner in which healthcare organizations each conduct their necessary business functions.
Rather than embrace a strategy that relies on arcane tools of the past to torment one another, health care organizations today – health systems and health plans – are using AI in much more meaningful ways. These include avoiding unnecessary fights altogether and working more collaboratively in their shared clinical decision-making processes. As Chris Bond of America’s Health Insurance Plans notes in the Times, insurance companies aren’t sitting still.
For example, a national health plan began working with a regional health system six years ago to use predictive analytics that consider the clinical documentation of individual patients while receiving care in acute care hospitals to help determine inpatient care vs. observation (outpatient) status. The hospital and health insurer compared the final status of the patients they had agreed on historically against what status the AI-based tool would have predicted for those same patients. As a result, the two organizations were able to identify about 20% of cases where they had agreed on inpatient or observation, and thus did not warrant the significant resources required to review and reach status determination.
Applying AI in this manner reduced the time to reach inpatient or observation status from 55 minutes per case to nine minutes.
AI is becoming more pervasive and accessible within all professions. Healthcare is an early example of two parties in the same professional space (payers and providers) using shared instances of AI to resolve their competing interests. While hospitals and insurance companies have greater resources to experiment and implement these tools compared to physician practices, the days of creating and maintaining processes and procedures that unnecessarily drive up the administrative cost of delivering and paying for care are nearing an end.
When there was no better way of doing things, staying the course made sense. But new tools are available today that can help providers and health plans work better – and together – and that’s a much more exciting future of health care than perpetuating the provider/payer arms race.
