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High-tech works when it enables high-touch: AI & the opportunity for health plans


Artificial intelligence can create tangible benefits when it helps facilitate better, more frequent support beyond the four walls of care delivery.

Artificial intelligence is a technology that involves learning associations of predictive power from examples in data and using these inferences to augment or even replace human decision making. As a result, artificial intelligence holds plenty of promise-and earns its fair share of hype-across the healthcare industry.

In the health plan market, AI presents uniquely powerful opportunities, as payers operate in data-rich environments and are both payers and clinicians are incentivized to improve the health of populations, particularly for those with chronic conditions. But how can organizations look beyond the buzzwords to determine where AI can deliver measurable value? 

We’ve observed that AI can create tangible benefits when it helps facilitate better, more frequent support beyond the four walls of care delivery. Simply put, high-tech works when it enables high-touch support. As part of a digital health management approach, innovative health plans and care managers today leverage AI in the following contexts to connect people to the support they need, when and where they need it.

Improving targeting

Patients with chronic conditions are often isolated outside the four walls of the health system. Low-touch support, such as with telephone calls, is simply not effective for people with complex needs-they require daily and personalized support to improve their health. But finding, enrolling, and engaging those members in digital health management programs often proves challenging. That’s where AI comes in. 

While health plans currently use established statistical techniques for risk profiling based on cost, there is untapped potential to utilize machine learning and new data sources including social determinant data and data generated from digital health platforms to uncover patients who are most likely to benefit from clinical interventions. Through this new approach, doctors and health plans can identify members based on clinical needs, as well as emerging and actual risk and cost, and then focus their clinical resources on where they can be most effective. 

Informing early interventions

When health plans deliver digital health management solutions to members, such as mobile apps, they can generate huge amounts of data on member activity, patient-reported outcomes, and more insights. Through machine learning, health plans can harness that data to prioritize members based on real-time needs, generate intervention alerts, and recommend follow-up actions with their providers. 

This technology ultimately creates a positive feedback loop: because members receive timely, personalized support, they engage with care managers more often. This generates more data, which in turn gives health plans the insights they need to provide the right clinical intervention to the right patient at the right time. 

Shifting to whole-health management

We know there are countless factors that contribute to health outcomes, such as behavioral health, social determinants, lifestyle, and comorbidity. So to meet the holistic needs of members outside the walls of care delivery, care teams must shift their focus from utilization management, contracting, and disease management, and instead take a whole-health management approach.

Through AI, health plans can better perform internal operations involving data analysis and inference in order to work with providers on health management versus disease management. Effectively, this technology helps open the door to digital transformation of member-facing services to build services that are scalable and responsive to the needs of members. 

AI and health outcomes 

It may seem challenging to cut through the hype, but when health plans leverage AI as part of their digital health management approach, they can achieve measurable results. Through improved targeting, they can recruit more members, more efficiently into their health management programs and generate more predictable return on investment from those programs. Machine learning can turn member activity into real-time insights that inform the care team’s workflow, so they can provide the right intervention at the right time. Additionally, AI can help plans drive increased engagement through digital transformation of all member-facing services.

When considering the benefits of AI, a simple principle emerges. High tech works when it enables high touch: technology is most effective when it can facilitate the health support people need, when and where they need. 

Trishan Panch, MD, MPH, is the chief medical officer of Wellframe. Wellframe helps healthcare organizations support patients beyond the walls of care delivery through its digital health management app, which frame translates evidence-based, peer-reviewed guidelines and literature into an interactive daily checklist delivered to patients.



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