Latest / Becker’s Payer Issues Podcast / AI, Interoperability, and Member Experience in Modern Payer Operations with Cara Wahmann

Transcript

AI, Interoperability, and Member Experience in Modern Payer Operations with Cara Wahmann · Becker’s Payer Issues Podcast

• 0:02
  - Generative AI is driving the era of infinite
• 0:04
  - healthcare abundance
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  - At Hippocratic AI, we partner with more than
• 0:08
  - 60 innovative healthcare organizations
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  - across payers, providers, and life sciences
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  - to drive patient and member outcomes.
• 0:16
  - Offering the safest clinical AI voice agents, Hippocratic
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  - AI is the first company to define comprehensive
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  - voice AI benchmarks for healthcare.
• 0:24
  - Safety, clinical accuracy,
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  - empathy, consistency.
• 0:29
  - Learn more at hippocraticai.com.
• 0:32
  - This is Gracelyn Keller with the Becker's Healthcare
• 0:34
  - podcast, and we are recording live at the
• 0:36
  - fourth annual spring payer issues roundtable.
• 0:38
  - I'm currently joined by Kara Wayman, who is
• 0:41
  - the executive director of clinical oversight and ops
• 0:43
  - support at HCSC. HCSC.
• 0:45
  - Kara, thank you so much for joining me
• 0:47
  - today. I'd love to have you start off
• 0:49
  - by introducing yourself and sharing a little bit
• 0:51
  - more about your role and organization.
• 0:53
  - Yeah. Of course, Grace. Thanks for having me.
• 0:55
  - I'm so, yes, Kara Wehman. I am a
• 0:57
  - nurse by trade. I am with HCSC. I've
• 0:59
  - been with the company for a little over
• 1:01
  - ten years now.
• 1:03
  - I, like you said, am the executive director
• 1:05
  - for clinical oversight and operational support in our
• 1:08
  - Medicare,
• 1:09
  - book of business. I oversee multiple states, and
• 1:12
  - then also our HealthSpring national accounts.
• 1:15
  - My primary focuses at HCFC
• 1:17
  - are our legal regulatory compliance, quality
• 1:21
  - clinical experience,
• 1:23
  - and how that interacts with our provider and
• 1:25
  - our member experiences.
• 1:27
  - I have for the last year and a
• 1:29
  - half been also working as the business representative
• 1:33
  - for our,
• 1:34
  - HCFC interoperability
• 1:35
  - strategy across all Medicare, Medicaid, and commercial lines
• 1:38
  - of business.
• 1:40
  - Wonderful. Well, thank you for taking the time.
• 1:42
  - And let's start our conversation with from your
• 1:45
  - perspective,
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  - what is the most pressing operational challenge facing
• 1:48
  - payers right now, and how are you addressing
• 1:50
  - it?
• 1:51
  - So that's a great question.
• 1:54
  - I'm a lot of people have actually talked
• 1:56
  - about it in the last two days. But
• 1:58
  - I would have to say
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  - it's definitely the rapid changing
• 2:02
  - and,
• 2:03
  - increasingly complex environment that we're operating in today.
• 2:07
  - Expectations
• 2:08
  - are greater from our members, our providers, our
• 2:10
  - regulators, our employers.
• 2:12
  - There is an explosion
• 2:14
  - of digital transformation,
• 2:16
  - use of AI,
• 2:18
  - all while we're also seeing new risks for,
• 2:21
  - fraud, waste, and abuse in multiple different ways
• 2:24
  - that we're having to combat.
• 2:25
  - There's there's so much happening at once
• 2:29
  - that it's really taking us to a state
• 2:32
  - where we have to be
• 2:33
  - very cognizant
• 2:35
  - to make sure that there aren't key competing
• 2:37
  - priorities
• 2:38
  - between the member experience
• 2:40
  - and regulatory compliance.
• 2:42
  - That each decision that we're making every
• 2:46
  - interaction that we have is meaningful,
• 2:49
  - and that we're able to not just keep
• 2:51
  - up with the pace that everything is going
• 2:53
  - with being thoughtful
• 2:55
  - and understanding that we are at a a
• 2:57
  - moment of change. And so how to embrace
• 3:00
  - that and how to use that change to
• 3:02
  - be able to
• 3:03
  - influence
• 3:04
  - the industry, be able to influence it in
• 3:06
  - a in a better way to be able
• 3:08
  - to,
• 3:09
  - meet our members where they're at and to
• 3:10
  - be able to meet the provider's needs too.
• 3:13
  - And there's a constant tension between keeping costs
• 3:16
  - down and actually delivering a good member experience,
• 3:18
  - especially as it comes to care coordination.
• 3:21
  - So how is your organization balancing cost containment
• 3:23
  - with improving member experience and quality outcomes? And
• 3:27
  - where are you seeing the greatest opportunity for
• 3:29
  - impact?
• 3:30
  - So this is a question I've seen come
• 3:32
  - up a lot lately,
• 3:34
  - in different panels,
• 3:35
  - in different surveys. And I think,
• 3:38
  - we all need to take a step back
• 3:40
  - too.
• 3:41
  - ROI is a big thing, and affordability is
• 3:44
  - a conversation that everybody is having every day.
• 3:47
  - But foremost,
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  - when we think about the return of all
• 3:51
  - of the work that we're doing right now,
• 3:52
  - it's our members, the member experience, and the
• 3:54
  - quality of health that our population has. So
• 3:57
  - making sure that we're servicing the members,
• 4:00
  - our greatest achievement is gonna be our patient
• 4:02
  - outcomes and a healthier population overall.
• 4:05
  - And digital engagement and transformation
• 4:07
  - continues to accelerate across health care. So what
• 4:10
  - technologies and AI are you prioritizing
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  - right now, and where do you see meaningful
• 4:15
  - ROI as well as better engagement with members?
• 4:19
  - So I I think digital engagement
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  - and digital transformation, right, are kind of two
• 4:24
  - different things. And so there is definitely
• 4:27
  - a
• 4:28
  - new need to meet members and personalize their
• 4:32
  - experience and be more transparent
• 4:34
  - and make it easier to access information, how
• 4:37
  - they want
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  - to access their information.
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  - In a way, an app or a single
• 4:42
  - source
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  - that we're definitely seeing driving a lot of
• 4:45
  - our decisions.
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  - But then I think also,
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  - you know,
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  - digital transformation
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  - from the health plan and thinking about interoperability.
• 4:55
  - So again, embracing that change,
• 4:58
  - being intentional about where we're starting, thinking about
• 5:02
  - this moment that we're at right now is
• 5:04
  - foundational work. We talk a lot about interoperability
• 5:07
  - being the chassis
• 5:08
  - for what we're building or where we're driving
• 5:10
  - in the future for our
• 5:12
  - our prior authorization, for our member experiences,
• 5:15
  - for
• 5:16
  - all of our provider interactions, making sure that
• 5:18
  - we're getting them the tools that they need
• 5:21
  - within their workflow. So that way we can
• 5:23
  - improve that seamless experience for the members, make
• 5:25
  - sure that they have the access to all
• 5:27
  - of the data that they want in the
• 5:28
  - way that they want it.
• 5:30
  - And final question to wrap up our conversation.
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  - I'd love to know where you see the
• 5:35
  - greatest opportunity
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  - for
• 5:37
  - AI to reduce friction in member communications and
• 5:40
  - administrative workflows while maintaining personalization.
• 5:44
  - So
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  - for me
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  - as a nurse,
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  - I am really, really excited
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  - about how we are able to start using
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  - AI and deploying it in ways to maintain
• 5:57
  - clinical rigor.
• 5:58
  - So the digitization of our medical policies, that's
• 6:01
  - an area that,
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  - we're starting to see the opportunity to use
• 6:06
  - AI to digitize that and put it into
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  - a format, which our providers can use it
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  - within their workflow, within the EHR, within the
• 6:13
  - order set.
• 6:14
  - So taking AI and taking what used to
• 6:16
  - be, you know, a flat PDF
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  - and turning it into that digitized format, but
• 6:20
  - then also being able to support
• 6:23
  - the clinical rigor around it to be able
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  - to identify
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  - in other medical policies, you know, where we're
• 6:29
  - using like or similar similar values
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  - to make sure that we have that consistency
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  - in the clinical decision making.
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  - Those are some things that I think that
• 6:37
  - are happening right now that are very excited.
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  - We still have the human in the loop.
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  - So you still have a nurse. You have
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  - a doctor who's reading it, who's really understanding
• 6:44
  - is, yeah, interpreting it, but there are administrative
• 6:47
  - functions to that. And as you can imagine,
• 6:49
  - a health plan has a massive set of
• 6:52
  - clinical policies. There are clinical content vendors out
• 6:55
  - there that are doing this. And so being
• 6:57
  - able to digitize it at scale, but then
• 6:59
  - being able to use tools and technology to
• 7:01
  - make sure that we're consistent and we're identifying
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  - quickly any areas where we're potentially
• 7:06
  - deviating from how we had previously defined something,
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  - I think are ways in which AI can
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  - really help to maintain that clinical rigor and
• 7:14
  - experience.
• 7:16
  - Wonderful. Well, Cara, thanks so much for joining
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  - me today on the Becker's Healthcare
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  - and sharing these thoughts and insights. Again, we
• 7:22
  - are recording live at the fourth annual spring
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  - payer issues roundtable.
• 7:26
  - Thank you.