Latest / Becker’s Payer Issues Podcast / Using Data and AI to Drive Proactive Member Care

Transcript

Using Data and AI to Drive Proactive Member Care · Becker’s Payer Issues Podcast

• 0:02
  - Generative AI is driving the era of infinite
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  - healthcare abundance
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  - At Hippocratic AI, we partner with more than
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  - 60 innovative healthcare organizations
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  - across payers, providers, and life sciences
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  - to drive patient and member outcomes.
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  - 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.
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  - Safety, clinical accuracy,
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  - empathy, consistency.
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  - 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.
• 0:39
  - I'm currently joined by Patrick Stevenson, who is
• 0:41
  - the vice president of data and technology at
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  - McLaren Health Plan. Patrick, thanks for being here
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  - today. I would love to have you start
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  - off by introducing yourself and sharing a little
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  - bit more about your role and organization.
• 0:51
  - Yeah. Sure. Thanks for having me. Excited to
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  - be here. My name is Patrick Stevenson. I've
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  - been in health care for twenty years,
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  - in data and technology leadership for about fifteen.
• 1:02
  - Really, I started in health care a long
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  - time ago because I I knew we could
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  - do better. We could we could make this
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  - better.
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  - I remember my first first time a doctor
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  - asked me, he's like, hey. We need to
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  - count how many diabetic patients we have. And
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  - I said, how do we do that? He
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  - said, well, go into the file room and
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  - grab everything that has a red tab on
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  - it. And I was like, oh my gosh.
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  - And so after about eight hours of a
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  - full day and a full shift of pulling
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  - those tabs,
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  - I asked, well, what happens if we forgot
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  - to tap one? What what happens if we've
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  - missed one? It's like, well, we'll we'll figure
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  - it out next time they visit us next
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  - year. I was like, oh my gosh. It
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  - may never happen. And so I I knew
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  - right there and then we could do better.
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  - So it's part of the reason I was
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  - drawn to health care. In my current role,
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  - I'm the vice president of data and technology
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  - at McLaren Health Plan. We're a a Medicaid
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  - health plan primarily owned by,
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  - McLaren Healthcare,
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  - our provider group.
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  - We service 240,000
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  - members in the Flint, Michigan area. And, again,
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  - those are primarily Medicaid members. So exciting role
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  - there in really helping to scale and and
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  - bring bring more size to that organization.
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  - And let's start our conversation with from your
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  - perspective, what is the most pressing operational challenge
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  - facing payers right now, and how are you
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  - addressing it?
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  - That's a good question. Really, I think a
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  - big a big issue that's facing payers right
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  - now is watching particularly of small and large
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  - small and midsize payers like our own organization.
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  - A big risk is larger payers just choosing
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  - to enter and exit markets as they please.
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  - And that's hard. That's something that's happening across
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  - the country. So I've spoken with a lot
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  - of payers out here today,
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  - around the challenges in their environments. And what's
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  - happening is larger payers are able to somehow,
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  - manipulate, maneuver which which,
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  - which markets they're participating in. And particularly, they're
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  - avoiding markets that have a lot of risk,
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  - like a disproportionate amount of risk. And so
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  - the bad news for payers like ourselves who
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  - serve the communities in which we participate, you
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  - know, we we can't exit those markets. We
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  - don't want to exit those markets. Those are
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  - our that's our community that we serve.
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  - But with allowing those large payers to really
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  - move in and out of those markets puts
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  - this huge burden on us to identify this
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  - unknown risk.
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  - And so for us, how we're trying to
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  - address that is
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  - is quickly and proactively as possible identify,
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  - the current condition of our new membership and
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  - making sure to
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  - understand that risk and underwrite that risk appropriately.
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  - That way we can continue to function and
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  - maintain maintain operations. Otherwise, if you handle this
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  - poorly, you have these new members who come
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  - in who have
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  - unknown, usually more risk, disproportionate risk to the
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  - rest of your community, brush through your panel,
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  - and you just have to sort of bear
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  - that cost for the first year or however
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  - long it takes you to appropriately risk adjust
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  - those members. So that's a huge a huge
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  - concern facing health care right now, payers particularly
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  - of small and midsize across the country.
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  - And there is a constant tension between keeping
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  - costs down and actually delivering a good member
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  - experience, especially as it comes to care coordination.
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  - So how is your organization balancing cost containment
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  - with improving member experience and quality outcomes? And
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  - where are you seeing the greatest opportunity for
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  - impact?
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  - Wow. That that's a heavy question. I think
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  - there's a lot of ways we can talk
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  - about that. I think maybe first I'd say
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  - is we don't really view cost containment and
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  - member experience as trade offs.
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  - They're really improved together. We can reduce unnecessary
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  - variation
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  - and intervene earlier with our membership.
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  - So really the the summary there is how
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  - do we pull our intervention sooner and make
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  - them more proactive instead of reactive?
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  - Our strategy is really centered on using data
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  - and identify the risk sooner as as I
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  - mentioned earlier. Identify that risk as soon as
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  - possible, guide members to the right level of
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  - care, and support providers in delivering consistent evidence
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  - based medicine.
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  - From a cost perspective,
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  - the biggest drivers are obviously avoidable utilizations of
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  - ER visits, inpatient admissions,
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  - and unmanaged chronic conditions.
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  - We're investing in predictive analytics and segmentation
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  - to identify high risk and rising risk numbers.
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  - I think that rising risk is, like, a
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  - really key spot
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  - because those are folks that you can help
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  - to avoid, you you know, the most long
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  - lasting,
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  - risk pools and chronic conditions if you can
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  - just get intervene sooner. So that rising risk
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  - is really where we're trying to focus.
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  - Any either intervening with those folks through care
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  - management, primary care alignment, and targeted outreach,
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  - that really helps us shift that care upstream,
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  - as I mentioned earlier, which lowers the cost
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  - while improving the outcomes.
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  - When I really think about it, the the
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  - biggest lever that we're trying to do is,
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  - again, mentioning moving from
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  - from that reactive model to a proactive model,
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  - data driven approach. One in which we anticipate
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  - the needs of our of our membership support
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  - providers and actions through insights, and make it
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  - easier for members to stay engaged in their
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  - own care. You know, we have to make
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  - it an easy on ramp for them and
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  - show them show them how we help them
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  - succeed together.
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  - And digital engagement and transformation
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  - continue to accelerate across health care.
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  - So what technologies and AI are you prioritizing
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  - right now, and where are you seeing seeing
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  - meaningful ROI as well as better engagement with
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  - members?
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  - That's a good one. Because there's a lot
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  - of ways we're we're scoping to use AI.
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  - I think one of the biggest opportunities right
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  - now with CMS double o five seven f,
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  - prior authorization data sharing, is really not just
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  - stopping at what you're required to do. So
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  - the requirement is just to be able to
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  - receive those electronically. Right? Like, be able to
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  - communicate back and forth electronically.
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  - What we're trying to do at McLaren Health
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  - Plan is really take those and automate using
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  - AI and other other tools and services.
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  - Automate our decision making on that prior auth.
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  - So I think the the most the best
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  - thing we can do is remove prior auth
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  - where it doesn't make any sense. Right? So,
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  - as an example, if we have something that
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  - requires prioritization
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  - and 95%
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  - of the time we're approving it, we should
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  - probably reconsider if we should require prior auth
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  - for that. There are other cases that are
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  - obviously more meaningful that meaningful than that. But
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  - for those, what we wanna do is make
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  - that process as quick as possible. So if
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  - we if CMS is saying, hey, we'll we
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  - have to send that data to you now,
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  - then what we wanna do is very quickly
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  - in an automated fashion, intake that data, measure
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  - it against our policies, then spit back the
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  - answer as quickly as possible so the provider
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  - can take action of it. So that's how
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  - we're really trying to do that. We're really
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  - trying to use technologies like AI to prioritize
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  - prioritizing those right now.
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  - Prior auth is a place place a big
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  - focus for us.
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  - And final question as we conclude our conversation.
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  - I'd love to know how you see AI
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  - supporting member facing interactions while also maintaining trust
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  - and quality.
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  - I mean, we have to find the right
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  - place for that to happen.
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  - What I consider at first is just, like,
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  - low risk interactions,
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  - finding ways of getting not only our membership
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  - used to that AI interaction, but also our
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  - team members use that interaction.
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  - It's something that there's interesting resistance on depending
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  - on which way you go. But I think
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  - it's both from internal and external. And so
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  - what we have to do, I think, is
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  - is health plan organizations,
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  - is help everyone get better. But the fact
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  - that AI is here to stay, it's a
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  - way it's a tool and a mechanism that
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  - can help us achieve our goals of lower
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  - cost, higher quality.
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  - We just need to increase our comfort with
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  - those tools
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  - and,
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  - really make sure we we keep it safe
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  - and track those outcomes. So by starting with
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  - lower lower risk interventions with AI, I think
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  - that's the way we do it. We sort
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  - of increase that slowly over time as we
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  - get as we get more comfortable, our customers
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  - get more comfortable, and also the AI itself
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  - improves a little bit. So that's that's how
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  - we approach that.
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  - Well, Patrick, thank thank you so much for
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  - joining me today on the Becker's healthcare podcast
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  - and sharing these thoughts and insights. Again, we
• 8:10
  - are recording live at the fourth annual spring
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  - payer issues roundtable.
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  - Awesome. Thanks for having me. I appreciate it.