The Transformation of Payers in Healthcare: Innovations Unveiled at HIMSS25
Exploring AI’s Role in Shaping Future Healthcare Delivery
Las Vegas Sets the Stage for Innovation
At the recent HIMSS25 conference in Las Vegas, the Emerge Innovation Experience highlighted the pivotal role of artificial intelligence (AI) in revolutionizing healthcare—particularly its influence on payers. Industry leaders gathered to discuss how AI is reshaping care models, providing payers with unprecedented visibility into patient care needs and utilization patterns across diverse healthcare settings.
AI: The Game-Changer for Health Insurers
Health insurers are now leveraging advanced technologies to take on a more proactive role in patient care delivery. This shift is largely driven by the integration of virtual care, technology, and AI, as discussed by panelists during the conference. However, they also acknowledged significant hurdles that still impede progress, including organizational resistance to change and insufficient alignment between payers and providers.
Voices of Innovation Panel Discussion
The panel featured notable experts, including Edward Marx, the CEO of Marx Advisory and former global CIO at Cleveland Clinic. He moderated discussions with leaders from Clover Health, SCAN Health Plan, and Horizon Blue Cross Blue Shield of New Jersey. Together, they explored themes from the book "Voices of Innovation – Payers," co-edited by Marx and Sakshika Dhingra of Humana.
Big Data Meets AI at Clover Health
Aric Sharp, the CEO of Value-Based Care at Clover Health, presented the company’s use of AI-powered technology to harness big data effectively. These tools not only enhance early diagnosis but also improve patient outcomes. “Culturally, we encourage everyone to use AI,” Sharp emphasized, highlighting the focus on point-of-care solutions.
Enhancing Member Interactions Through AI Assistance
Point-of-care solutions increasingly include AI assistants and chatbots, optimizing member interactions and making healthcare more accessible. Heather Lavoie, Chief Information Officer at Horizon Blue Cross Blue Shield of New Jersey, noted that patients prefer immediate information, stating, “People don’t want to call us. They want answers.” This sentiment underscores the necessity for efficient digital platforms in today’s fast-paced environment.
Automating Processes to Combat Turnover
Khin-Kyemon Aung, senior director and medical director for SCAN, acknowledged that automation through AI can also mitigate the challenges posed by staff turnover. With recruiting difficulties in call centers, AI systems can summarize coverage details, enabling staff to provide higher-level support more efficiently. Lavoie reiterated this point, stating, “We’re asking people to do the same job but do it more effectively.”
Streamlining Healthcare Conversations
AI is now also being deployed to enhance care coordination. Lavoie mentioned that it aids in labeling outbound calls to improve stratification and case management. The technology extends even to voice interpretation services for patients with conditions like Parkinson’s disease, showcasing its versatility.
Cresta’s Role in Enhancing Customer Interaction
SCAN Health has begun implementing Cresta, an AI-powered contact center platform designed to support agents during complex conversations. “It’s listening in the background,” Aung explained, highlighting the tool’s real-time automation capabilities that help navigate intricate care discussions.
AI: A Double-Edged Sword
Despite the capabilities AI brings to the healthcare landscape, Aung pointed out that it can only address surface-level issues. She remarked, “There are root causes that AI can’t Band-aid over.” This statement invites reflection on the need for deeper systemic changes within the industry.
Technology as an Acceleration Force
Lavoie emphasized that AI acts as an accelerator for a broader array of technologies. “We’re excited about technology,” she said, noting that beyond claims management, there is a need to incorporate member preference data and sensor information to develop comprehensive member profiles.
Rethinking Healthcare Efficiency
Sharp asserted that current applications of AI are focused on enhancing operational efficiency within healthcare systems. He proposed a radical shift in thinking—suggesting that the traditional revenue cycle could become obsolete if new models are embraced. “We have to think about breaking the way the system works in its entirety,” he stated.
Cultural Resistance: A Significant Barrier
One of the panel’s key takeaways was the cultural resistance to innovation within healthcare. Sharp noted that entrenched mindsets pose one of the most significant barriers to progress, requiring a collective willingness to adapt and evolve.
Aligning Payers and Providers for Better Outcomes
Aung brought attention to the ongoing challenge of aligning payer and provider approaches. According to Sharp, an essential step is for both sides to converge on solutions and share a common path forward.
Preparing for a Technologically-Driven Future
The discussions at HIMSS25 illustrate a critical juncture for healthcare payers as they navigate the evolving landscape dominated by AI and advanced technologies. The integration of these innovative tools holds promise for improving patient outcomes while enhancing the overall healthcare experience.
The Road Ahead: Embracing Change
In summary, while AI is heralding a new era of possibilities in healthcare, the path to effective transformation is fraught with challenges. As payers and providers work towards greater alignment, the incorporation of AI could revolutionize the industry by creating a more efficient and responsive healthcare system. Embracing this change may well determine the future trajectory of healthcare delivery in the coming years.
