By Shannon Smith, Assistant VP of Clinical Success, Zyter|TruCare
LinkedIn: Shannon Smith, RN, BSN
LinkedIn: Zyter|TruCare
With volatility in Medicaid reimbursement as well as both administrative and medical costs continuing to rise rapidly, health plans need to be as strategic as possible when it comes to allocating resources if they are to serve members well while remaining financially solvent.
Unsurprisingly, insurers have been turning to artificial intelligence, predictive analytics and other sophisticated technologies to help them gauge risk and manage their members’ health issues before they spiral into more complex, costly problems.
Using these technologies is no longer a matter of gaining competitive advantage — it’s a matter of remaining competitive as a health plan. The question is no longer whether to use AI, but how best to deploy it.
One area of untapped potential for insurers lies in using AI to better identify and support rising risk patient populations—or those who seem healthy enough today but whose conditions are trending toward more illness and more costly interventions.
Understanding and managing this population is critical. As healthcare costs continue to rise, getting ahead of rising-risk patients might be what separates profitable health plans from those that continue to struggle.
Tech-Enabled Triage
Triage, or risk stratification, is probably as old as healthcare itself. Categorizing patients into high, moderate, and low-risk groups allows care providers to prioritize care for those with the most urgent needs. Health plans also stratify risk, but many are missing an opportunity by not devoting enough attention to the rising risk group.
Members dealing with chronic conditions like Type 2 diabetes, which is cited by JAMA as one of the most expensive of the chronic conditions in the United States, with a total annual cost of $412.9 billion, are rising risk patients. People managing hypertension, or early-stage heart disease also qualify as rising-risk patients, as do those who are overweight, anxious, or depressed. Without timely intervention, their conditions are likely to worsen, leading to hospitalizations and significantly higher costs. Identifying these patients earlier allows health plans to intervene before complications develop. With proactive care strategies enabled by new technology, insurers can in some cases slow disease progression, reduce visits to the ER and the hospital, and ultimately tame costs.
Risk stratification has traditionally relied heavily on claims data, meaning information solely based on past healthcare usage. And while it can be valuable, this rearview mirror approach risks missing important changes as they happen.
Today’s AI-powered tools, on the other hand, offer payers a forward-looking strategy when it comes to rising risk. With access to real-time clinical data, electronic health records (EHRs), prior authorization trends, and other data points, health plans can see in advance which members are likely to see a major uptick in treatment and cost – then intervene before it happens.
Predictive modeling helps insurers take meaningful action at the right time. The insights gleaned from AI and analytics can trigger coordinated care efforts, lifestyle coaching, remote monitoring, and regular check-ins—all of which can stop disease progression in its tracks.
AI-Driven Intervention
Identifying rising risk patients is just the beginning. The next step—intervening at the right time—is where AI and automation provide the real return on investment.
Health plans can build a robust infrastructure for proactive care by combining predictive analytics with tools like automated prior authorization, AI-generated alerts, remote patient monitoring, and clinician-led care management.
A key benefit of such systems is the automation of complex administrative processes. Integrating AI with prior authorization systems, for example, can speed the approval of critical treatments and referrals. This is critical for members with chronic conditions, for whom time is of the essence.
For many health plans, clinical business process outsourcing (BPO) is the glue that binds these capabilities into a cohesive program that shows results. By partnering with a clinical BPO provider, risk-bearing organizations get access to a scalable model that combines experienced clinicians, sophisticated population health management tools and predictive analytics. The result is a powerful, future-ready approach to managing rising risk.
Healthcare organizations can no longer afford to be passive when it comes to managing risk. The financial pressures on the system are too great, and they show no signs of easing. Proactive strategies—which combine data, automation and expert clinical partnerships—are a matter of economic survival for many insurers.
Understanding and addressing rising risk is not just a priority. It has become a strategic imperative. The same is true of using insights on rising risk patients to craft the right proactive intervention at the right time.
Health plans that recognize this shift and act decisively will be the ones to successfully navigate the future of healthcare, controlling costs while delivering better outcomes for their members.