AUSTIN, Texas—The second annual Fierce Health Payer Summit kicked off Wednesday to tackle the most pressing issues facing health plan leaders.
Executives from the healthcare payer industry joined Fierce Healthcare reporters onstage to discuss the role of technology in plan improvement and member engagement and trends in the payer market.
The first day panels included discussions of individual exchange plans and broker fraud, the changing landscape of Medicare Advantage given this year's high profile exits, and the staggering changes to Medicare Part D in 2025. Payer experts also discussed the shared burden of prior authorization and how to make healthcare insurance more equitable.
Keynote given by Transcarent CEO Glen Tullman
Glen Tullman, CEO of Transcarent, took the stage with Fierce Healthcare Executive Editor Heather Landi for a keynote discussion. Tullman and Landi talked about Transcarent’s use of artificial intelligence and the need for payers to incorporate technology into the consumer experience to survive in the marketplace.
“The incentive is survival … consumers, ultimately, are going to win the battle. They won in every other space,” Tullman said.
Tullman talked about Transcarent’s journey developing its generative-AI-powered care benefits solution, Wayfinding.
He also revealed that the company will be launching partnerships with several Fortune 100 companies to provide their employees access to the Wayfinding tool.
He said the company spent north of $100 million developing its AI capabilities. Most companies won’t be able to afford to spend this much on AI development, he noted, and making hefty investments in AI can be risky. One strategy for payers is to band together with other players in the healthcare industry to learn more about the technology.
“Find a partner. Learn from them, then decide if you want to make that investment,” he advised.
Tullman explained how Wayfinding is replacing the broken care navigator industry that, in the end, doesn't get patients the information they need as quickly as they want, given that consumer expectations have changed with digital technology. In many cases, consumers can get access to their financial information or book travel within minutes using their smartphones. Rather than making care experiences more seamless, care navigators typically just "navigate" around an already broken system, Tullman said.
"I use the analogy: If you broke the glass in a room at your house, you would clean it up," Tullman said. "But if you're in healthcare, you make a little path through it, and you hire somebody to stand outside and charge you every time and say, 'I'll show you the path through so you won't get cut up by the glass.'"
With Wayfinding, members can get the exact answer they want, like how much they’re going to pay for a procedure on their plan.
“Wayfinding interacts with the accumulator and policy. And it would say your company's policy is 80/20, but for you, you would owe, with this surgery, $783 because you've already spent this much and your limit, your cap is this much,” Tullman explained. “[It] give[s] you the exact answer, instantly, faster than you can make a phone call.”
He also touched on the shift from point solutions and apps toward platforms that are simpler for customers to use. Platforms like Transcarent’s help retain more customers throughout care transitions, he noted.
AI proves mental health care impact for Brightside
Online mental health care provider Brightside gave a message to payers about using technology to increase the efficacy of mental healthcare.
“I think mental health care has lagged in some ways, in terms of measurement-based care, evidence-based care,” Chief Medical Officer and Co-Founder Mimi Winsberg said. “I think payers want to see the kind of outcomes that go with treatment. So you don't just want therapy to be open-ended with no sense of what outcome one can expect from that therapy. And in taking the approach of overlaying data with measurement-based care, treatment path prediction, these are good [measures]."
Brightside has implemented AI copilots that help their providers understand a patient’s history, symptoms and future risks faster than the provider alone could do.
“We designed a lot of machine learning algorithms where we could collect information from patients through a digital questionnaire, and then, through that, assign a digital phenotype to patients," Winsberg said. “This is the kind of thing that a skilled provider might be able to do in a session, but a machine can do it very rapidly and with a lot of accuracy, so just right away, recognize the digital fingerprint of that patient.”
Because of the AI layer in its platform, Brightside is better able to offer the right level of treatment for the patient, especially if they know that the condition requires a more advanced treatment.
Brightside has also been engaging patients between sessions with remote patient monitoring technologies that can keep patients more engaged in their care and alert providers when their patients may demonstrate a concerning symptom that requires intervention.
“If you have a really good, curated, structured data set, that's when you can do wonders with technology like AI,” she said.
Prior authorization: Reducing burdens for the patient, the doctor and the payer
Another topic of Day 1 was prior authorization and the extraordinary burden it places on all parties in the healthcare system.
On a panel about prior authorization, providers-turned-entrepreneurs discussed the necessary oversight and payer overreach on prior authorization, including the use of AI, with Fierce Healthcare Senior Writer Anastassia Gliadkovskaya.
Jeremy Friese, founder and CEO of Humata Health, argued that AI should only be used in prior authorization to say 'yes' to patients, and that denying care should be left to humans.
“We as a health care system need to balance the need between managing costs and making sure patients get the right care … I would actually argue that the part that is overreaching is when you're requiring all this human intervention, rather than the fact that [prior authorization] exists,” he said.
Michael Anne Kyle, assistant professor at the Perelman School of Medicine at the University of Pennsylvania, explained the burden that patients are under when prior authorization is required.
“I found that about one in four people are delaying or foregoing care because of the administrative burden of prior auth,” Kyle said. “This is higher for people with … higher health needs, like cancer, and so particularly people who are already on the sicker side, who already don't feel well.”
Kyle highlighted the patient burden of prior authorization, but the burden also extends to doctors and payers.
“The docs are spending their next week dealing with this,” Kyle said. “People are probably working around the clock in payer offices too, and meanwhile the patient is also sitting at home doing it. So there's multiple parties here who are really exhausted.”
The panel discussed the potential for prior authorization to be less burdensome with technology, particularly large language models, that can extract the necessary information from a provider’s notes or patient record to reduce the administrative burden.
“There's still all this human intervention on both sides that, frankly. I personally believe that 90% of all of it should be done by a computer to submit it and a computer to make a decision, period," Friese said. "And that's already possible today, but there's always going to be this gray zone. And that gray zone, you need a computer to help take that 30 minute review down to two minutes."
“If you look at spine surgeries, at least 50% don't need to be done,” Raiszadeh, a spine surgeon by training, said. “And the solution is not going to come from saying no [to a prior authorization request], this is going to be from providing, you know, the wraparound services that those patients need. So I feel like [prior authorization] is a very incomplete solution.”
Tackling health equity through data and technology
Payers rely heavily on member data to make beneficial coverage changes for their members and to meet the government's regulatory requirements. This health equity panel, led by Abner Mason, chief strategy and transformation officer at GroundGame.Health, discussed why payers need to move beyond static data points to create equitable health outcomes for their members.
Vindell Washington, chief clinical officer and head of the health equity center of excellence at Verily, said that payers need to collect more data than they are currently gathering on their members.
“One of the things that strikes me … is the importance of data and the importance of knowing more about an individual rather than less about the individual,” he said. "It is not good enough to know what a blood pressure number is. It is important to know lots of other factors in order to drive equity that we seek. It's a fundamental change that has to be executed.”
Washington also shared some principles for how Verily is tackling health equity. "Design for health equity from the beginning. It's hard to retrofit," he said.
"If we don't innovate, we won't close the health disparities that exist in the country. The change is going to have to come from innovation. As an industry, we need to make sure we design with the communities we serve," he said.
But, he also cautioned about the use of AI and ensuring that it healthcare organizations don't incorporate bias into AI.
"Be thoughtful about what data you're training the model on. This is essential for us as we're advancing our AI coach to support chronic disease management," he said.
Alexander Ding, board member of the American Medical Association and associate vice president of physician strategy and medical affairs at Humana, said that plans can be too focused on hitting metrics to understand what’s going on with their members.
“So many conversations that we're having with plans, so frequently people are realizing that if you're just trying to go and get this very narrowly defined thing, you're not actually addressing the core underlying issues,” Ding said.
Ding discussed the many health equity targets set by CMS in recent years where health plans are being required to report data on social determinants of health.
“There are new incentives built into the contracts to achieve the highest possible quality for members with social risk factors. So I think there's some complexities in how we actually identify what those social risk factors are. I think they're using some readily available proximate measures, which I don't necessarily think are the best measures,” he said.
Washington pushed payers in the room to not stop at the collection of race and ethnicity data but to figure out how to ensure marginalized patient populations are being served over time.
Jeremy Gurewitz, founder and CEO of patient advocacy company Solace Health, discussed why the ethos of his company is to never leave a patient with “homework.”
Gurewitz explained that leaving a patient with no homework means identifying the root cause of their barriers to accessing quality healthcare.
“We have to get to the root cause of what's really going on, right and make it so that patients actually feel comfortable … that's why you see lack of engagement. That's why you see lack of compliance in so many care plans."