This interview explores the regulatory and technological challenges in achieving more personalized and patient-centric care.
Healthcare industry expert Alexander Earlywine discusses the evolving landscape of healthcare in a recent interview. He emphasizes the growing importance of interoperability and the role of artificial intelligence in streamlining processes and improving decision-making. Earlywine also highlights the shift from fee-for-service models to managed care, focusing on patient-centric approaches. The interview concludes with recommendations for health plans to create a more digital healthcare ecosystem, stressing the need to stay informed about new regulations and adopt proactive data analysis strategies.
Stephanie Butler:
Welcome. I am delighted to be here with Alex Earlywine, who is a senior industry expert and healthcare CoE, and he's been working with Newgen. And I'm delighted to be able to speak with you today about some of the issues that I think are really important for the healthcare industry.
Alexander Earlywine:
Thanks for having me.
Stephanie Butler:
I want to start with something a little more general, just could set the stage. So I'd love to hear from you, from your perspective, what do you think is the biggest challenge facing the healthcare industry today?
Alexander Earlywine:
Yes. Actually, I spoke on it yesterday, so I'll bring that back and it's interoperability. And it's just value-based care, interoperability, AI. There is no singular word that describes it. It's a combination of many things. So when we talk about interoperability, it's reaching into the payers, it's reaching into the providers, and it's even impacting members because of the regulations that have come around for real-time access to information, not just... It's interesting. When these rules started, it was more or less the providers need to have real-time access to things at a payer.
The payer needs to have real-time access to the records that the provider. Now, the focus is really on the member needs to be in control of their care. And it's shifted things from the insurance companies somewhat being in control of managing the journey of a member and allowing the member to take control of their own journey in an educated manner.
Stephanie Butler:
No, that's definitely been a challenge. So I would love to hear also from you, how are healthcare payers adapting their strategies to align with these evolving expectations of providers, also members and regulators, as you mentioned, in this shift toward personalized and patient-centric care.
Alexander Earlywine:
Sure. So I think that definitely CMS started this whole ball of rolling, if you will, with a series of regulations, really dating back to 2009 with high trust. And then since then, there's been a series of, I would say, every year or every other year, some type of regulations. But what you're seeing in the last few years is three and four regulations coming down, or at least an RFI from CMS. So in another way, they're not just looking at Medicare. CMS has started to use their overarching umbrella as the Department of Health and Human Services to say, who do we have even the smallest amount of oversight. So obviously they've moved right into Medicaid, rightfully so, but they're even starting to dip into the federally administered exchanges to see where can they drive some changes there. As far as the members, their perception has changed.
Stephanie Butler:
That's right, absolutely.
Alexander Earlywine:
When I cut my teeth way back in managed care in my 20s leading an appeal and grievance unit, and here I was coaching members when I would take an escalation call of, we have 30 days to resolve your grievance and complaint. That is still the regulation, but is that even reasonable? So as we have become more member-centric in saying, what's the maximum amount of time that we have to work something, the expectation now is really what is the minimum amount of time that we could possibly take? And that has to be supported through things like what I've mentioned, interoperability, getting the data in the right place, and then layering tools such as AI to take away that, let's call it, the mundane work of sorting, extracting, and allowing people to use their brain for the, let's call it, the most critical of tasks.
Stephanie Butler:
I want to follow up on that because you mentioned AI. So what are those key technological breakthroughs that are driving this transformation toward more personalized and patient-centric care and experiences for everyone?
Alexander Earlywine:
And I'll answer it in two parts. Part of it is technology-based, and part of it is interoperability, meaning how we have pieced together these technologies as a puzzle. So we started with things like OCR and ICR, extracting information out, but it required a great deal of programming. We still loved it because it saved us, as payers, lots of money in those extractions. But you'd have to administer standardized documents. We need you to fill out this exact form so we know we can go look in this place.
Now, with the introduction of AI-based extraction, we're able to really just allow these machines to learn from themselves. So now we're able to pull away the structure, which is expected, as I mentioned in my time in appeals and grievance. I've gotten appeals and grievances written on everything from notebook paper to the back of an envelope and sent in.
Stephanie Butler:
On the back of a napkin.
Alexander Earlywine:
Literally.
Stephanie Butler:
In the restaurant.
Alexander Earlywine:
Exactly. So AI is well-prepared to extract that. If it's sideways, if it's upside down, OCR couldn't have done that. So now as we're starting to realize, okay, AI is not just one thing. It's how can we take these engines like ChatGPT, Generated AI, or whatever the thing is, and actually embed them in a workflow or process saying, I want you to come in here, here, and here, not just at the extraction. We started with extraction because we felt comfortable. But now, for example, Newgen, we have implemented a decision assistant that's allowing us to analyze clinical decisions, administrative decisions, and predict that decision. We've also been able to say, we don't want to be denying anything just because of the regulations. But if we have the ability to dismiss it as an incomplete case and requested additional information, we can do that up front without human intervention, ask for what we need, and actually get a resolution instead of it sitting in a queue for, as I mentioned, 30 or 60 days, then someone realizes, we don't have the form we need. Now it's got to...
Stephanie Butler:
And then it's back to the queue again for 30 or 60 more days.
Alexander Earlywine:
The provider's four months in or the member, and that's just no longer acceptable.
Stephanie Butler:
No. And this allows us to be able to fix those issues.
Alexander Earlywine:
It does.
Stephanie Butler:
What are actionable recommendations that are suggested for health plans to lead the charge in creating a smarter and simpler and more digital-focused healthcare ecosystem?
Alexander Earlywine:
Anybody that's listening, I would recommend if you go out to the two new regulations on interoperability, one is just interoperability. The second is around prior authorizations. It gives you a lens into the expectations that are starting to come into force, and truly, you have to read into what's coming next. I spoke about yesterday, just to take it back to the Medicare stars program. There's these stars measures that everyone seems to know what they are.
There's this thing called a display measure. And those things people ignore because it's not tied to a bonus payment. But interestingly enough, things often start at the display measure and move up to a stars measure. So you lose the opportunity and the runway to make changes while it's not mandatory. So in the same way with these two new regulations coming out, they have rolled out, and I have to give kudos to CMS in this case because traditionally they would release a federal register that is 50,000 words. It looks like a Bible because it's got two columns on one page, as you mentioned.
Stephanie Butler:
I've seen it. Who can read that?
Alexander Earlywine:
Who put two paragraphs side by side on one page, 8x10. But now what they've started to move into is full training. So our payers can actually go out, get business level information, technical information, let's call it scripts on how to test and make sure that it's not just developed, but you know how to test it. So CMS has moved a little bit away from the true stick approach, which is we're going to wait one to two years, come in and audit you every so often, then spend a year going back and forth the entire process of issuing you some corrective actions.
The flip side of that is this expectation for real-time brings near real-time visibility to issues. So what we've got to move away from as payers in the industry is this annual task approach. Aggregating data at the end, doing your reports at the end of the year. For example, in many of the operational that I did in my years that Centene, WellCare, Highmark, Coventry, Aetna is, in my business reports, I would want them ran at least monthly or at least quarterly if IT wouldn't support me monthly. I would say I need it quarterly. I can't wait all year to look at my data. With these new, let's call it, interoperability and real-time data tools, business users that are not report users can actually get in there, design their own reports, get that data out, and take a look at it before it's requested by a regulator. And that's really the key to success.
Stephanie Butler:
Is to make sure you're doing that and doing it regularly. Yeah, that's great advice. So in the few minutes we have left, I want to close and ask you, what do you think, if we look toward the future, what do you think are going to be the big disruptors or innovations that are going to take place within the healthcare industry in five to 10 years?
Alexander Earlywine:
And the first one, I'll just hit one more time, which is AI, but it's not one thing. We continue to have this proliferation of AI in all these different points that we're realizing, we can use it from a generative perspective to summarize and do things. As I mentioned earlier, we can use an AI-enabled extraction. There's all these different tools that are out there, and folks are just starting to realize. When they say I've got AI, they mean maybe they have one component.
Stephanie Butler:
They think about different things when they say AI. You're having a conversation with someone about AI. One person is talking about generative AI, another person, and then somewhere they realize.
Alexander Earlywine:
So I'd put on my business hat to say, celebrate that win. And then I'll put on my strategic initiatives hat and say, it's not good enough. You've got to keep moving. The second piece I would mention is, and I hate to put it this way, but it's the dying of an insurance company, meaning the fee for service. What are we here discussing in this conference? It's managed care, this concept of managed care. When someone says, "Alex, you worked for an insurance company." I said, "No, I worked for a managed care." I managed nurses, I managed a pharmacist, clinical caseworkers, all of those things, making sure that folks are healthy.
And it's such a pivot from, I think back to my very first days in my 20s, working in a supplemental Medicare and TRICARE insurance. We didn't even know. We wanted their EDI file. What was the co-insurance that we had to pay? And then we sent out a check. There was no concept of how is this person doing or really what is their name besides does it match the member ID? Now, we don't want just their name, we want everything, not from a matter of being invasive, but rather knowing that... And we just heard Alex, our czar from Trump's administration over the Department of Health and Human Services, really talking about how there's these changes that are being made to even the PDP plan, for example, in Medicare that is setting it up to be unsustainable. Why is that? Because a PDP plan is meant to be married with traditional Medicare and supplement. It's not managed care.
Stephanie Butler:
It's not how we're doing it now.
Alexander Earlywine:
So there is this unintentional, let's say publicly, but behind the scenes, I would say very intentional push to move the industry into managed care. So what I would predict is we're going to see this continued collapse of these insurance models. And not just as we said earlier, where CMS is, we're seeing changes and plans that have oversight where CMS has their thumb on them.
But we're going to see the employer group plans and commercial plans realize. Why are they doing this? It's the only way to be profitable in these days with the cost of rising care.
Stephanie Butler:
Yeah, it should be really interesting to see where things go. So thank you so much. Thank you to Newgen, and thank you to Alex. Really enjoyed speaking with you.
Alexander Earlywine:
Thank you.
Stephanie Butler:
It should be very interesting to see where things are in a few years.
Alexander Earlywine:
Thank you so much.
Stephanie Butler:
So thank you for your time today.
Alexander Earlywine:
I appreciate it.