AI Solutions for Healthcare

With more than 35 years of experience in healthcare, former health plan and health system executive, Dan Rosenthal is a wealth of knowledge who tells it like it is. Healthcare, strategic planning and leadership development are his major strengths (though he has many). He’s passionate about creating meaningful healthcare experiences that are anchored by  high quality and affordable care and believes that focusing on these fundamental elements of healthcare will lead to much needed industry-wide improvements. 

Codoxo recently sat down with Rosenthal to get an overview of the current healthcare landscape, areas in which health plans and providers can improve, and how artificial intelligence (AI) can help. Rosenthal also shed light on provider education, and how health plans and providers must put in the work to increase trust on both sides. 

Codoxo:  How do you see technology, including AI and machine learning, playing an impact in healthcare overall? 

Dan Rosenthal: When you think about healthcare, there are three primary objectives. The first one – and it’s always the first one — is improved quality. Fifty percent of people don’t get the care they need in accordance with the current body of clinical evidence. We can improve the quality of care that people receive — that is our number one objective.  

The second objective is affordability. Healthcare costs too much, especially in the United States. What can we do to help make healthcare more affordable for people? Right now, there are a lot of reasons why it’s expensive such as misaligned incentives and too much fragmentation and complexity.  We have a tremendous opportunity to improve the affordability of healthcare.  

The third objective is about the experience — the patient experience, the member experience, the provider experience. It’s so complicated and exhausting — just think about how you navigate healthcare on your own for you and your family. It must be better. 

The three objectives are intertwined: better quality, lower cost, and a stronger experience. 

Now, how does technology – especially machine learning and AI — impact this realm? It should make it easier for people to make better decisions about what’s the right course of treatment.  

Think about how fragmented the healthcare system is, how many moving pieces there are, and the complex conditions people have. We should use technology to connect the dots when you can’t see the big picture or there are too many variables. It can also help streamline how the system operates and simplify the experience. Technology can help us understand the environment better and play a role as we act on that understanding to deliver on our three key objectives. This will  empower us to act, in a way that is better and smarter than what you could do without it. Technology can give us a view that we cannot see without it. That view can fuel better decision making. 

Then, the question becomes, can you point to one aspect of the Quadruple AIM (care, health, cost and meaning in work) and make a meaningful difference? 

Codoxo: How can AI-based provider education, like Codoxo’s, make a difference in healthcare? 

Dan Rosenthal: While there’s a very small percentage of providers who behave in a fraudulent way, they are a drag on the entire system and as a result, get a lot of attention. What Codoxo does is to identify abusive behavior and then at least mitigate some of the risk associated with it. However, the vast majority of providers (90+%) are doing what they think is the right thing and just trying to figure out how to get through the system.  

That’s where AI can provide value to those providers who are trying to figure out how to better navigate the system (like getting paid faster and more accurately). These are small businesses, for the most part, and cash flow is important. Helping them understand how to bill for service, how to transmit that information, how to understand what the accurate payment level should be — it sounds straightforward, but it’s not because there are a lot of different plan designs and complex payment arrangements. 

Provider education should have the goal of helping the provider collect payment faster and more accurately. 

Codoxo: Why is it important to educate and empower providers? Why do providers need to be strategic about moving earlier in the payment cycle? 

Dan Rosenthal: Don’t you want your physician focused on providing great care to you? That’s the ‘why’. How do we apply technology and other innovations that make it easier for physicians to pay more attention to the healthcare they provide? To keep up with their craft? To do all the things that remind them of why they went into medicine?  

If we can educate them on ways to streamline the complications, it’s just going to lead to a better healthcare system. It’s going to lead to one that embraces the Quadruple AIM in a much stronger way. 

Codoxo: What are some best practices in the provider education space? 

Dan Rosenthal: If a payer wants to offer provider education, they need to ask themselves, “Why do we want to do it? What are our goals? How do the actions support the goals?” 

Codoxo: When it comes to payment integrity, is there a level of readiness in which payers and providers can open up and collaborate? What are some of the barriers and where are we at right now? 

Dan Rosenthal: There’s certainly a lack of trust, which becomes a monumental problem because both “sides” have a lack of trust about the other side. If you could study a model about how to build trust and bake that into what we try to do, and if the environment that you are part of generates a higher level of trust than the rest of the market, that alone will give you a competitive advantage. The answer to your question is, no, we’re not ready…but everyone wants to be ready.  

So how do we get started? The currency is NPS [Net Promoter Score, a consumer experience measurement that shares how patients view your organization and its services] – how do you drive a stronger and more favorable NPS? It’s trust, transparency, honesty, integrity, standing behind commitments, not being overly complicated when you don’t need to be.  

Also, access to data in a digestible form is critical. Provide access to information that can be acted upon. Listening, leaning in, being a better partner — ask providers what they would find valuable so we can then build transparency and tools that support [providers and payers]. 

Codoxo: How can provider education lead to more trust? 

Dan Rosenthal: As it relates to the administrative complexity, any time a payer can help a provider understand simple things, like which networks they participate in. Also, being responsive and proactive to questions of how to navigate the product maze that payers offer, proper ways to bill, the connection between billing and documentation, and completing the payment cycle in a more effective way – that’s all very helpful.  

On the experience side, the plan can offer provider information that will allow the provider to have a more distinguished experience with their patients. 

All of this is about listening first and efficiently delivering meaningful and timely information from the plan to the provider. Health plans that consistently treat providers with more trust will  stronger relationships that weathers the ups and the downs of the marketplace and create competitive advantage. This will result in better healthcare – better quality, lower costs and a stronger experience. 

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