Latest / Becker’s Payer Issues Podcast / Dr. Ben Kornitzer on AI, Prior Authorization Reform, and the Future of Payer Provider Collaboration

Transcript

Dr. Ben Kornitzer on AI, Prior Authorization Reform, and the Future of Payer Provider Collaboration · Becker’s Payer Issues Podcast

• 0:01
  - The payer provider relationship has never been simple,
• 0:04
  - but what's happening now is something different.
• 0:07
  - Value based models are maturing unevenly,
• 0:10
  - prior authorization reform is reshaping workflows on both
• 0:13
  - sides, and affordability
• 0:15
  - pressure is intensifying.
• 0:17
  - The organizations that figure out how to collaborate
• 0:19
  - genuinely, not just contractually,
• 0:21
  - are the ones that will set the terms
• 0:23
  - for what comes next.
• 0:24
  - Becker's fifth annual fall payer issues roundtable brings
• 0:27
  - together more than 500 executive level attendees and
• 0:30
  - 70 plus speakers for two days of focused
• 0:33
  - senior level conversation on benefit design, network strategy,
• 0:37
  - transparency,
• 0:38
  - and the financial and regulatory dynamics that are
• 0:41
  - redefining how care gets paid for. Join us
• 0:44
  - November second and third at the Swiss Hotel
• 0:46
  - Chicago.
• 0:47
  - For the agenda and event details, visit beckerspayer.com
• 0:50
  - and click on the events tab in the
• 0:52
  - upper right.
• 0:54
  - Hello, everyone. This is Jacob Emerson with the
• 0:56
  - Becker's Payer Issues podcast.
• 0:58
  - Thrilled today to be joined by a special
• 1:00
  - guest. Doctor Ben Kornitzer serves as senior vice
• 1:04
  - president and chief medical officer at Aetna. Doctor
• 1:07
  - Kornitzer, thank you very much for taking the
• 1:09
  - time to be with me on the podcast
• 1:10
  - today. Yeah, Jacob. Thank you for having me.
• 1:13
  - Absolutely. I'm I'm glad, you could be with
• 1:16
  - us. And before we dive into everything we
• 1:18
  - wanna talk about today, Ben, some really pressing
• 1:21
  - issues going on across the industry, I was
• 1:23
  - hoping you could tell our audience a little
• 1:25
  - bit more about yourself,
• 1:27
  - your background in health care, and then a
• 1:29
  - little bit about your role today at Aetna.
• 1:32
  - Sure. Sure. I'm a primary care physician by
• 1:34
  - training. My own area of focus was in
• 1:37
  - high risk seniors, and so I was actually
• 1:39
  - doing house calls in New York City, going
• 1:42
  - to The Bronx, going to Harlem,
• 1:44
  - seeing homebound older adults.
• 1:47
  - And that interaction was deeply meaningful to me,
• 1:50
  - but I also realized that so many of
• 1:51
  - the challenges they faced
• 1:53
  - were systemic challenges. And so I spent the
• 1:56
  - majority of my career since
• 1:58
  - really working across the health ecosystem from health
• 2:00
  - systems to value based care providers and
• 2:03
  - joined CBS Aetna just over a year ago
• 2:06
  - because I think that we're in a very
• 2:07
  - special moment in health care,
• 2:09
  - both with the rapid advancement of technology, greater
• 2:13
  - clinical conviction around how to actually get better
• 2:16
  - outcomes for patients.
• 2:19
  - And the ability to do that for an
• 2:21
  - organization at scale
• 2:23
  - seemed, very special to me. And so my
• 2:25
  - role as chief medical officer at Aetna
• 2:28
  - is overseeing,
• 2:29
  - our Med Affairs team, including medical policy,
• 2:33
  - supporting each of our lines of business, so
• 2:35
  - commercial, Medicaid,
• 2:37
  - Medicare,
• 2:38
  - as well as our physician network.
• 2:41
  - And so it's been a great pleasure to
• 2:43
  - be part of this team now for over
• 2:45
  - a year and really try to redefine what
• 2:47
  - care could be,
• 2:49
  - for Americans.
• 2:51
  - Absolutely. And and let me just touch off
• 2:53
  - of that last point you made, redefining what
• 2:55
  - care could be for Americans,
• 2:57
  - because as you said, I mean, it's such
• 2:59
  - a transformative
• 3:00
  - time in health care right now as you
• 3:01
  - know.
• 3:02
  - The definition of health care almost seems to
• 3:05
  - be changing. We see headlines every day about,
• 3:08
  - companies like CVS, but the large companies all
• 3:11
  - over the country from health plans to health
• 3:13
  - systems and,
• 3:15
  - everything in between
• 3:16
  - adopting AI tools, rolling out
• 3:19
  - AI initiatives,
• 3:21
  - that directly interact with patients on the ground.
• 3:24
  - And so
• 3:26
  - despite all those industry funds that certainly we
• 3:28
  - are writing on a daily basis,
• 3:30
  - I wonder if you you strip away that
• 3:32
  - industry hype and you
• 3:34
  - you take a look at
• 3:36
  - where do you think AI is actually and
• 3:39
  - genuinely changing the clinical relationship between
• 3:42
  - a health plan like Aetna and then all
• 3:44
  - your provider partners out there.
• 3:47
  - Where is it still more of a promise
• 3:49
  - that's being put into press releases versus,
• 3:52
  - again, where it's where it's really
• 3:54
  - change that you've seen,
• 3:56
  - with even just physicians across the country?
• 4:00
  - Yeah. So so let me first start by
• 4:02
  - saying that I'm an optimist. I like to
• 4:03
  - think about what Winston Churchill said, which is
• 4:06
  - Americans always get it right after trying everything
• 4:08
  - else first.
• 4:10
  - You know, when it comes to AI,
• 4:12
  - you know, I think back on my time
• 4:14
  - as a house call physician.
• 4:16
  - And the things that I wasn't able to
• 4:18
  - do was look across a population,
• 4:20
  - get real time data,
• 4:23
  - communicate and engage people
• 4:25
  - throughout their care journey in ways whether it
• 4:28
  - was late at night or on the weekends.
• 4:30
  - You just can't do that at scale as
• 4:33
  - a single provider, even someone part of a
• 4:35
  - large multi specialty practice. But AI opens the
• 4:38
  - door
• 4:39
  - to move at a speed and with a
• 4:42
  - level of,
• 4:44
  - clinical,
• 4:45
  - engagement that's that that's really differentiated.
• 4:49
  - On the other hand, there's a risk that
• 4:51
  - AI will just industrialize
• 4:52
  - all those parts of health care that are
• 4:54
  - most inefficient,
• 4:56
  - most adversarial. And so where I think the
• 4:58
  - opportunity is is for payers and providers to
• 5:01
  - really stack hands
• 5:03
  - and turn,
• 5:05
  - the AI tools into something that makes a
• 5:07
  - difference for patients.
• 5:09
  - Some of the early data that's out there
• 5:11
  - taking a look at the impact of AI,
• 5:13
  - so far, it's been largely inflationary.
• 5:16
  - We see that with, coding intensity,
• 5:19
  - but, you know, no real strong evidence that
• 5:21
  - people are getting different clinical outcomes.
• 5:24
  - And so rather than think about this as,
• 5:27
  - you know, a,
• 5:29
  - agentic bot war, if you will, between,
• 5:31
  - you know, the inflationary
• 5:33
  - and deflationary,
• 5:35
  - influences on provider and and and payers, really
• 5:38
  - step back and say, how can we use
• 5:39
  - it to
• 5:40
  - improve
• 5:41
  - what clinicians are doing? So think about things
• 5:44
  - like the ability to go through thousands of
• 5:46
  - pages of documents
• 5:48
  - and actually figure out what conditions
• 5:50
  - a member has,
• 5:52
  - surface those risks to the providers, to others
• 5:55
  - that can make a difference, make sure that
• 5:57
  - patients are on the right medications.
• 5:59
  - We see within Aetna, in our own workflows,
• 6:03
  - the ability to go and, you know, save
• 6:05
  - up to ninety minutes,
• 6:07
  - for each of our nurses every single day
• 6:09
  - for their clinical reviews. That's time they can
• 6:12
  - be spending with our highest risk members,
• 6:15
  - helping them navigate, getting them in touch with
• 6:17
  - the highest value specialists,
• 6:19
  - making sure they have the right DME at
• 6:21
  - home, making sure if they need transportation
• 6:23
  - or other resources,
• 6:25
  - those are available to them. So it's those
• 6:28
  - areas where we can really make a difference,
• 6:31
  - with AI. And like any other tool, it's
• 6:34
  - really how we
• 6:36
  - choose to use that tool that's gonna make,
• 6:38
  - you know, the difference for those individual patients.
• 6:41
  - Absolutely. And I and I really appreciate your
• 6:43
  - candidness there in terms of,
• 6:45
  - acknowledging the the inflationary pressures we're we're seeing
• 6:48
  - both in research. And then I can certainly
• 6:50
  - say anecdotally from leaders like yourself,
• 6:53
  - at health plans and and at health systems
• 6:55
  - around the country, talking about how the technology
• 6:57
  - is,
• 6:58
  - entrenching some of these deeper, structural issues within
• 7:01
  - the system.
• 7:02
  - But there there does seem to be bright
• 7:04
  - spots, like you mentioned, especially coming on the
• 7:06
  - horizon.
• 7:07
  - And one of those is around prior authorization.
• 7:10
  - I know earlier this year, Aetna said it's
• 7:12
  - standardized
• 7:13
  - 88%
• 7:15
  - of your overall prior auth volume.
• 7:17
  - You now approved more than 95% of eligible
• 7:20
  - requests within twenty four hours,
• 7:22
  - and you've moved into bundled condition specific reviews
• 7:25
  - for areas like musculoskeletal
• 7:27
  - care and cancer.
• 7:29
  - As you know, this is a this is
• 7:31
  - a area of headache for a lot of
• 7:33
  - physicians and providers
• 7:34
  - around the country still. And so
• 7:36
  - from that perspective,
• 7:38
  - what do you think the next phase
• 7:40
  - of prior auth reform
• 7:42
  - looks like, should look like,
• 7:45
  - and and what's the what's the hardest part
• 7:47
  - of that paperwork burden that, we continually hear
• 7:50
  - about that automation
• 7:52
  - still hasn't really seemed to solve?
• 7:54
  - Yeah. So, listen, I think that we're on
• 7:56
  - a journey right now, but we've been making
• 7:58
  - tremendous progress. And I actually think over the
• 8:00
  - past years you indicated,
• 8:02
  - that's certainly accelerated. It's particularly accelerated,
• 8:06
  - with the work that we're seeing at at
• 8:07
  - Aetna. So, you know, we've now standardized 88%
• 8:10
  - of those prior authorizations.
• 8:13
  - We're able to approve 95%
• 8:15
  - of eligible requests within
• 8:17
  - twenty four hours.
• 8:18
  - You know, members that are dealing with cancer
• 8:21
  - diagnoses, like lung cancer, prostate, breast cancer,
• 8:25
  - are able to get their approvals done,
• 8:28
  - in a bundle, meaning that rather than each
• 8:30
  - individual service getting approved one at a time,
• 8:34
  - they can be approved
• 8:35
  - as an entire package so that all of
• 8:37
  - your upcoming imaging, medications,
• 8:40
  - other therapies are done, and you can really
• 8:42
  - focus on the healing
• 8:44
  - process.
• 8:45
  - And your providers can focus on doing what
• 8:48
  - they do best, which is, caring for their
• 8:50
  - patients.
• 8:51
  - So so I think that that's really, you
• 8:53
  - know, just the beginning of what we think
• 8:55
  - is a longer term journey
• 8:57
  - to make health care frictionless. I mean, in
• 8:58
  - a perfect world,
• 9:00
  - the prior authorization
• 9:02
  - process would be almost invisible. It'd be working
• 9:04
  - in the background.
• 9:06
  - There would be interoperable
• 9:07
  - bidirectional
• 9:08
  - data,
• 9:09
  - and we'd be able to think through what
• 9:11
  - are those outcomes are gonna really put our
• 9:13
  - members,
• 9:14
  - in the best position. And I recently had
• 9:17
  - a had a case where, one of our
• 9:19
  - members,
• 9:20
  - was prescribed a medication for a very serious
• 9:23
  - fatal heart disease.
• 9:25
  - In fact, the provider,
• 9:27
  - had not realized that that patient had a
• 9:29
  - different pathology,
• 9:31
  - and that medication would have had absolutely no
• 9:33
  - benefit whatsoever
• 9:34
  - for that member. And so our ability
• 9:36
  - to leverage technology to surface things in a
• 9:39
  - way that an individual provider at the point
• 9:41
  - of care won't,
• 9:42
  - I think is really unique and differentiated.
• 9:45
  - But if you step back and think about
• 9:46
  - it, right, providers have longitudinal data we see
• 9:50
  - across the entire population
• 9:52
  - and not just the individual patient being seen
• 9:54
  - at a health system or at a clinic,
• 9:56
  - but we actually see, were they in Florida
• 9:59
  - six months ago and what were the studies
• 10:00
  - that were done there? What medications do they
• 10:03
  - have filled two years ago? And so that
• 10:05
  - longitudinal data
• 10:06
  - is also really unique. And so being able
• 10:09
  - to combine that with what providers see by
• 10:11
  - being boots on the ground, having those trusted
• 10:14
  - relationships, and having the member right in front
• 10:16
  - of them in the moment.
• 10:18
  - You know, those are two very different angles.
• 10:20
  - And when you put those together,
• 10:22
  - you can really change the trajectory of a
• 10:25
  - patient's, health care course. I think, you know,
• 10:27
  - it's that type of collaboration
• 10:29
  - that I think speaks to what we can
• 10:31
  - be when we're at our best.
• 10:33
  - So and I and I know it seems
• 10:35
  - like from our perspective that, Aetna has really
• 10:37
  - been on the forefront of just from the
• 10:39
  - prior authorization perspective,
• 10:41
  - reducing volume as part of of course, there's,
• 10:43
  - you know, this broader industry commitment among insurers.
• 10:46
  - And like I mentioned, Aetna seems to have
• 10:48
  - really been,
• 10:49
  - some of the most one of the most
• 10:50
  - successful plans in the space so far.
• 10:53
  - I also wanted to ask you about something
• 10:55
  - that Aetna has really been,
• 10:57
  - lauded for publicly within the industry, and it's
• 11:00
  - your work on real time clinical data exchange
• 11:03
  - earlier this year to support value based care
• 11:05
  - workflows.
• 11:06
  - I know this is something also that you've
• 11:08
  - worked on very heavily in your, prior
• 11:11
  - career since then. And so can you break
• 11:14
  - down for us what has to be true
• 11:17
  - for for the health plan and for the
• 11:19
  - provider to actually trust
• 11:21
  - the same data,
• 11:22
  - and where in your career experience does that
• 11:25
  - often break down the most?
• 11:27
  - Yeah. And, again, I'll get back to my
• 11:29
  - own clinical practice days. You know, whenever I
• 11:32
  - had a question or something didn't make sense,
• 11:35
  - I would always ask myself what's best for
• 11:37
  - the patient.
• 11:39
  - And I think that we can do the
• 11:40
  - same thing in health care,
• 11:43
  - which is, you know, we have data. The
• 11:45
  - data isn't always perfect,
• 11:47
  - but the way that you earn trust is
• 11:49
  - that you give trust. So how can we
• 11:51
  - make that data as accessible,
• 11:54
  - as real time,
• 11:56
  - as actionable
• 11:57
  - as possible?
• 11:58
  - And at the same time,
• 12:01
  - really demonstrate a commitment to getting those
• 12:03
  - better outcomes for our members. And so if
• 12:06
  - data is significantly lagged, if the data, you
• 12:09
  - know, doesn't have, you know, clear provenance, it's
• 12:11
  - not gonna be used in a way that's
• 12:13
  - effective
• 12:14
  - for providers.
• 12:15
  - One of the things, you know, that that
• 12:17
  - that we've begun to see, which is incredibly
• 12:20
  - useful is, you know, our ability to to
• 12:22
  - surface care gaps. And so not just seeing
• 12:24
  - what care gaps exist right now, but looking
• 12:27
  - actually into the medical chart, looking across,
• 12:30
  - multiple different data source, say,
• 12:32
  - who is at risk for missing a gap
• 12:34
  - and how can we go and close that?
• 12:36
  - And rather than these just being suspect gaps
• 12:39
  - or suspect conditions,
• 12:41
  - actually being able to point out, well, the
• 12:43
  - patient had a cardio echogram
• 12:45
  - three months ago. Here are the results of
• 12:48
  - that test. Here are the medications that they
• 12:50
  - were put on. Here are the follow-up steps.
• 12:53
  - We couldn't have done that before AI. Just
• 12:56
  - the the the manual workflow
• 12:58
  - would have been humanly impossible. And so our
• 13:01
  - ability to collaborate at that level on data,
• 13:04
  - is pretty unique,
• 13:06
  - and pretty, differentiated.
• 13:09
  - 100%. I I hear you loud and clear
• 13:11
  - that, yeah, you literally could not have done
• 13:13
  - that manually in the past. And so it
• 13:15
  - seems, clearly, this will be extremely, extremely helpful
• 13:19
  - technology from just the perspective of servicing care
• 13:22
  - gaps among patients and members.
• 13:25
  - We've also heard in the industry right now
• 13:26
  - about,
• 13:28
  - the use of AI to,
• 13:30
  - literally start booking appointments
• 13:32
  - for for patients,
• 13:34
  - on or members on behalf of the health
• 13:35
  - plan. And, you know, as we start to
• 13:38
  - see AI take on more of this navigation,
• 13:41
  - coordination, administrative work for the member,
• 13:44
  - how do you ultimately, at the end of
• 13:45
  - the day, keep that human clinical touchpoint central
• 13:48
  - for for those members who need it most,
• 13:51
  - who might need those care gaps surfaced,
• 13:55
  - rather than simply automating them away further from
• 13:59
  - from the people at Aetna?
• 14:02
  - Yeah. So,
• 14:03
  - you know, our aspiration,
• 14:06
  - at Aetna is to be more than just
• 14:08
  - a payer, to be a health solutions company.
• 14:11
  - And what we mean by that is when
• 14:12
  - people are in need, being able to navigate
• 14:15
  - them to the best possible solutions.
• 14:17
  - If that means making real time appointments, connecting
• 14:20
  - them with high value
• 14:22
  - providers, helping them access their medications or other
• 14:26
  - resources.
• 14:27
  - And there are gonna be a large percentage
• 14:28
  - of the population,
• 14:30
  - who's gonna uniquely benefit because of what we
• 14:33
  - can do with AI. And I think about,
• 14:35
  - you know, just last year, right, we had
• 14:37
  - 3,300,000
• 14:39
  - care management,
• 14:41
  - activities that were augmented by AI.
• 14:44
  - You know, we were able to review 2,000,000
• 14:47
  - records in in two weeks, and that's about
• 14:49
  - a two thirds reduction
• 14:51
  - in in manual effort.
• 14:53
  - But there will always be a need for
• 14:55
  - that human touch and that human connection. You
• 14:58
  - know, I remember my first day of medical
• 15:00
  - school, someone wrote up on the board a
• 15:02
  - famous quote by by Francis Weld Peabody,
• 15:05
  - which is
• 15:06
  - the secret to the art of caring for
• 15:08
  - the patient is to care for the patient.
• 15:11
  - People feel that.
• 15:12
  - AI will never replace clinical judgment.
• 15:16
  - You need to have the ability to listen,
• 15:18
  - to empathize,
• 15:20
  - And every single case is unique, and I
• 15:21
  - think that's what drew me to medicine. That's
• 15:23
  - what,
• 15:24
  - drew my colleagues to medicine. I think we
• 15:26
  - need to continue
• 15:28
  - to make sure that we cherish and we
• 15:29
  - cultivate that. You know, we are committed at
• 15:32
  - at CVS and Aetna that clinical decisions will
• 15:35
  - always be made,
• 15:37
  - by a physician or, you know, another advanced,
• 15:41
  - clinician.
• 15:42
  - Responsible AI
• 15:44
  - has to be central to what we do
• 15:47
  - as a trusted organization.
• 15:49
  - And a big part of health care, it's
• 15:51
  - more than just getting the answer right on
• 15:53
  - a multiple choice test.
• 15:55
  - It's trust. Trust is the most valuable thing
• 15:57
  - in health care. It's the most powerful tool
• 15:59
  - we have. It's more powerful than a proton
• 16:02
  - beam, than a PET scan.
• 16:04
  - And so every single day, we have to
• 16:07
  - wake up and ask ourselves,
• 16:08
  - how can we leverage the tools that we
• 16:10
  - have
• 16:11
  - but also earn the trust of our members.
• 16:14
  - Because if we lose that, then we've lost
• 16:16
  - the ability to really have the impact that
• 16:18
  - we all believe in.
• 16:19
  - Well, I really love the historical quotes from
• 16:22
  - you today, Ben. And I, I'd love to
• 16:24
  - get one more insight from you for our
• 16:26
  - audience.
• 16:27
  - You're you're talking to health plan leaders from
• 16:29
  - all over the country right now, health systems
• 16:31
  - as well. What do you wanna share with
• 16:33
  - them while you have their ears or any
• 16:36
  - bits of advice you'd offer as they also
• 16:38
  - continue to navigate this transformational time for the
• 16:41
  - industry, but a very critical time as well
• 16:44
  - for for all the people that you serve.
• 16:47
  - Yeah. You know, what I would say is
• 16:49
  - we all find ourselves
• 16:51
  - in a unique moment, and health care has
• 16:53
  - often been called a wicked problem. And what
• 16:56
  - I mean by that, and it's not because
• 16:57
  - I'm from Boston,
• 16:59
  - is that it's a problem with multiple stakeholders
• 17:02
  - and no one controls all the levers. Think
• 17:04
  - about other problems like,
• 17:06
  - climate change or urban poverty.
• 17:10
  - So to solve these problems, what's gonna take
• 17:12
  - is teamwork. It's gonna take true partnership.
• 17:15
  - And AI is, you know, the most powerful
• 17:18
  - tool we've had so far
• 17:20
  - in health care to to really
• 17:22
  - change the dynamic between payers, providers.
• 17:26
  - And And it it can be used as
• 17:28
  - a tool to industrialize,
• 17:30
  - as I said before,
• 17:31
  - those parts of health care that are most
• 17:33
  - sort of acrimonious,
• 17:35
  - and it would put the member in the
• 17:36
  - middle. And I think that we have an
• 17:38
  - opportunity to step back
• 17:40
  - and look at value and value based care
• 17:41
  - and say, are there opportunities
• 17:43
  - to do things differently? Can we align on
• 17:46
  - ways to identify patients with heart failure earlier?
• 17:49
  - Can we align on ways to make sure
• 17:50
  - that patients with renal failure get identified earlier,
• 17:54
  - get connected to the right care, and don't
• 17:56
  - wind up crashing into dialysis.
• 17:59
  - This is a unique moment, and I hope
• 18:01
  - that all of us
• 18:03
  - have the the foresight,
• 18:05
  - and the commitment
• 18:07
  - to sort of get,
• 18:08
  - beyond the short questions of our day to
• 18:10
  - day jobs and actually look bigger and and
• 18:13
  - and and stretch out a hand
• 18:15
  - across the aisle to our colleagues across the
• 18:18
  - health care ecosystem,
• 18:19
  - because the only way we're gonna solve these
• 18:21
  - problems is by doing it and rowing in
• 18:23
  - the same direction together.
• 18:25
  - Well, doctor Kornitzer, I I hope that you
• 18:27
  - will join us again soon, to talk a
• 18:29
  - little bit more about how you're navigating this
• 18:31
  - unique moment and how Aetna is as well.
• 18:33
  - And I can't thank you enough for taking
• 18:35
  - the time out of a busy schedule to
• 18:37
  - join me today. Really appreciate it. It's a
• 18:39
  - pleasure, Jacob. Hope to join again soon. Take
• 18:41
  - care.
• 18:42
  - Absolutely. And and to our listeners, if you'd
• 18:44
  - like to listen to more podcasts from Becker's
• 18:46
  - Healthcare, you can visit beckershospitalreview.com.