Cohere Health recently hosted a webinar to discuss how health plans can improve member care by exploring new opportunities for AI and machine learning (ML) in utilization management.
Despite the many advancements being made to digitize prior authorization and apply AI and ML to reduce the frustration and administrative burden created for physicians by traditional UM systems and processes, existing solutions continue to fall short on leveraging these technologies to drive truly transformative change.
While AI certainly has the capacity to dramatically improve the provider experience, and can present clinical alternatives to help drive better patient outcomes, there remains significant untapped potential for health plans and their members. Maximizing the use of AI and ML in utilization management drives value for all key stakeholders and creates a natural bridge from utilization management to true care management.
Outlined below is a five-step approach to maximizing the value of AI and ML in utilization management as highlighted in our recent webinar. For further details, including the quantitative impact of this approach, click here to view our recorded presentation.
1. Reimagine prior authorization
Foundational to maximizing the potential of AI and ML in utilization management is rethinking the current approach to prior authorization. Legacy solutions lack important patient-level clinical context, applying a one-size fits all approach based on the individual service requested without regard for the patient’s goals and care journey.
AI, combined with real-time analytics, paves the way for health plans to build in that critical patient context, creating a longitudinal view of the patient, and enabling health plans, providers, and patients to align on evidence-based, patient-specific care pathways across the entire care journey. This sets the stage for greater collaboration between these stakeholders earlier in the process, and with the individual patient’s goals at the forefront.
2. Unlock information from the EMR
Interoperability alone does not unlock the value of EMR integration. Doing so requires being able to intelligently extract critical clinical information which currently exists as largely unstructured data. Applying AI in the form of natural language processing (NLP), in addition to interoperability, allows health plans to quickly and efficiently extract the clinical information essential to ensuring the best care journey and outcomes for the individual patient.
3. Leverage the technology to drive both administrative and clinical impact
To realize the true potential of AI and ML in utilization management, health plans should think beyond administrative impact. Cohere’s platform has proven that rethinking how advanced technology is applied in prior authorization opens the door to previously unrealized clinical impact and medical expense savings as well. As an example, ML may be applied during the prior authorization process to guide providers towards optimal care choices aligned to the patient’s specific clinical history and care journey, such as site-of-care. These in-workflow “nudges” are designed to enhance clinical judgement, not replace it, creating greater collaboration between health plans and providers and diminishing the reliance on the traditional denial approach, a source of considerable frustration for providers.
4. Activate patients and providers
In-workflow, ML-enabled prompts like nudges also create opportunities to drive engagement in care management programs tailored and appropriate for the individual patient. Cohere’s platform looks across the patient’s clinical information and individual care path, then steers patients towards pre-vetted, high value programs designed to improve health outcomes. These include smoking cessation, virtual physical therapy, weight-loss, behavioral health, and other programs that might be indicated for an MSK or cardiac patient.
5. Monitor performance
Finally, one of the most important elements of a successful digital-first approach to utilization management leveraging AI and ML is measurement. Analytics applied to ML driven programs provides the insights required for evaluating and adjusting programs in real-time. This includes forward-thinking initiatives like provider “greenlighting” programs, a more nuanced and effective approach vs. goldcarding for rewarding high-value physicians.
Interested in learning more about how Cohere’s unique technology platform can help your health plan realize the potential of a digital-first approach? Contact us.
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About the Author: Niall O'Connor, Brian Covino, MD
