The relationship between health systems and health plans has historically been fraught with tension, as each side tries to outmaneuver the other. The latest secret weapon each side has been deploying? Artificial intelligence.
As HLTH take-aways suggest, payers may even have the upper hand in what some are calling an “AI arms race.”
However, a recent panel discussion at Xsolis’ annual user conference highlighted how health systems and health plans are using data-driven analytics to foster greater collaboration and alignment.
"Speaking the Same Language: How Objective Analytics Unifies Providers and Health Plans," featured leaders from OSF HealthCare, Humana, and AnMed Health. They shared how their organizations overcame initial skepticism to embrace a shared analytics platform that provides an objective, transparent view of medical necessity decisions.
For OSF HealthCare, a 16-hospital system in Illinois, the motivation to try a new approach was clear. Vice President of Case Management Hoa Cooper said OSF was struggling with high observation rates, clinical denials, and capacity challenges. The organization wanted to streamline utilization management and reduce the cost of care, but it lacked the staff to handle the workload.
"The reason I went with Xsolis is that its AI platform and the relationship with payers, plus the analytics, was really what we needed," Cooper said. "It took out a lot of the tension" between OSF and Humana.
Suzanne Wilson, assistant vice president of population health at AnMed Health in South Carolina, echoed those sentiments. AnMed is the only health system in its county, with more than 600 beds and 3,600 employees. While the organization was performing well in its value-based contracts, Wilson was hearing very different stories from the acute care side about pain points with observation and abrasion.
"It was like night and day, those two opportunities," Wilson said. "How are we able to work on that collaboration and make it a win-win situation?"
Removing Guesswork to Instill Confidence, Trust
By aligning on a shared view of medical necessity, AnMed and Humana were able to rebuild trust and improve their working relationship. The Care Level Scoring system took the guesswork out of inpatient versus observation status decisions, empowering providers to make more confident calls.
"We've pretty much eliminated the observation versus inpatient pondering in the chart," Wilson said. "They can lean into that (Care Level) Score."
For Humana, the analytics also helped address a common pain point – lack of clinical information to make timely utilization management decisions. Dr. Kathryn Lueken, vice president of clinical utilization management at Humana, estimated that most delays and denials are due to missing data.
"This scoring has just been instrumental in getting us to exactly what we need to be having the conversations about," Lueken said. "It's letting the doctors do what the doctors should do – take care of the people."
The panel agreed that the technology was just one piece of the puzzle. Driving adoption and trust required significant stakeholder engagement, both internally and among provider-payer partners.
OSF HealthCare, for example, invested heavily in educating physicians on how to use the Care Level Score to support their decision-making.
"Accountability and clinical decision-making still have to take place," Cooper said. "This is the tool. You're the expert."
Looking ahead, the panelists see tremendous opportunity to expand the collaborative model beyond the inpatient setting.
Next Frontier for AI-Powered Collaboration
Xsolis' predictive analytics for post-acute care placement have already yielded benefits for AnMed, helping the organization avoid overutilizing one setting over the other as patients are discharged to skilled nursing versus rehab and other facilities. It’s about getting the right patients in the right settings at the right time, according to Wilson.
"The opportunity is tremendous and exciting right now," she said. "How do we take this technology and be able to solve some of the other challenges that we have and really collaborate?"
As health systems and plans continue to navigate the shift to value-based care, the panelists agreed that data-driven collaboration is essential. By aligning on shared data points, they are not only improving efficiency and reducing friction, but also rebuilding trust and finding new ways to work together.
"It's about right-sizing that, not over-documenting or under-documenting, but accurately reflecting the acuity of those patients," Wilson said. "That's what payers want as well. We all want to make sure we're taking good care of our community.”