AI Solutions for Healthcare

Stakeholders agree on the immense potential of AI to revolutionize healthcare cost containment while embracing collaborative opportunities across the industry to move the needle. 

The recent AI Summit in Atlanta served as a vibrant platform for open dialogue, exchange of best practices, and insights from healthcare leaders. Participants delved into critical topics such as the importance of data, governance and security; the significance of embracing experimentation; and strategies for identifying impactful use cases to boost AI adoption. 

Hosted by the AI for PI Community, the conference – themed “Generative AI in Payment Integrity: Separating Fantasy from Reality” – brought together policy makers, academics, healthcare payer and PBM executives, and top AI experts and solution providers from across payment integrity and healthcare cost containment spectrum to tackle some of the industry’s most pressing issues. Esteemed presenters included Congressman David Schweikert as keynote along with industry leaders from Highmark Health, Centene, Elevance Health, Capital Rx, BlueCross BlueShield South Carolina, BlueCross Blue Shield of North Carolina, BlueCross BlueShield of Louisiana, Health First and more.

A variety of topics sparked lively discussions around the potential and challenges of healthcare AI and generative AI adoption: 

  • Regulatory and legislative considerations for healthcare providers and consumers
  • The latest breakthroughs in generative AI and its implications on healthcare
  • Necessary governance to ensure ethical use and application of AI
  • Regulatory and technical risks associated with implementing AI solutions
  • Necessary people, process, and technology changes for the successful adoption of AI
  • Best practices for building a compelling business case, evaluating solutions, and implementing them effectively

The AI Summit was fertile ground for exchanging innovative ideas on better managing healthcare costs using AI in an era of healthcare transformation. Here are five key takeaways:

#1: Data Still Dominates: Challenges and Opportunities

Healthcare data remains one of the most complex and challenging aspects of AI adoption to manage. The industry continues to strive for clean, aggregated data to enhance transparency, decision-making, and the adoption of new innovations. Sunil Budhrani, MD, MPH, MBA, Chief Innovation and Medical Officer for Capital RX, emphasized that “he or she that holds the data is king” in healthcare. One major underlying issue is siloed data that exists in various payer and provider systems that cannot be aggregated and used in a transparent, clean way. 

Examples include hospitals that hold patient data in their EMR systems through vendors, but don’t want to release it because the data creates stickiness for patients to stay within that health system. Or insurance companies that have built complex claims systems over decades, making it difficult for members to retrieve personal data when they move to another insurer. Despite technological advancements, the goal of achieving high quality, integrated healthcare data remains an ongoing challenge.

#2: The Essential Role of Governance in AI

As AI becomes more embedded in healthcare, the importance of governance cannot be overstated. Sheila Caufield, Director Corporate Recoveries at Independent Health, spoke about the establishment of a governance committee as part of Independent Health’s commitment to continuous oversight to protect members and data. Because generative AI presents a whole different level of access and capabilities, ethical questions arise: how are we using this data? Who is using it? What should be allowed – and what shouldn’t? Nana Okyere, Director of Operations Analytics at Health First, raised the need to properly train teams to identify possible biases within data. 

Panelists stressed the need for data transparency and robust guardrails to ensure the ethical use of AI and generative AI technologies. Setting these standards is crucial for maintaining trust and ensuring that AI applications do not compromise patient care or privacy.

#3: Ensuring Secure Data Sharing: Protecting PHI in the Digital Age

The topic of data sharing sparked numerous discussions on how organizations and vendors can collaborate to ensure secure data exchanges. Chris Hammond, Compliance and Investigations Director at BlueCross BlueShield of South Carolina, stressed the importance of technical safeguards and training to protect data privacy and security. Participants agreed that protecting personal health information (PHI) is paramount, emphasizing the need for stringent security measures to prevent data breaches and maintain patient trust.  

At the same time, it’s important to not let security and compliance bog down productivity and snuff out innovation. Sean Kelly, Highmark Health’s Director of Cyber Governance, Risk, and Controls, candidly shared that in the past, new ideas were thwarted by too many internal controls that he says “went overboard.”  Today, Highmark Health achieves success with myriad projects – including a member listening system and in-house business rules engine that analyzes incoming claims to identify overpayments – by building in foundational and fundamental security controls. “Every business operates with risk,” Kelly stated. “The secret is understanding your risks, where you’re at how to manage those and take a reasonable and defensible approach to your processes to your use of sensitive data.” 

#4: Healthcare AI Success Strategies

The discussion wasn’t only about challenges. Healthcare payers are successfully adopting AI by securing buy-in, providing comprehensive training, transitioning to new solutions, and showcasing the value of AI. These steps are vital for overcoming resistance and ensuring smooth integration of AI technologies into existing workflows. 

In his keynote address, Congressman David Schweikert underscored the urgent need for effective AI solutions to curb healthcare payment inefficiencies. “Improper payments in Medicare are over $31 billion,” Schweikert stated. “Over the next 30 years, the federal government is expected to borrow close to $230 trillion, with three-quarters of this borrowing related to healthcare costs.”  Such statistics emphasize the critical role AI can play in reducing waste and improving financial sustainability in healthcare.

Sean Kelly of Highmark Health pointed out the importance of industry-wide collaboration and meaningful applications for advancing payment integrity programs at the conclusion of the AI Summit. “The discussions on business use cases and considerations for implementing AI, especially within payment integrity, were incredibly beneficial and educational,” he commented. “Healthcare AI is evolving so rapidly that it’s important for everyone involved with healthcare payment integrity to get out of their silos and better understand the business impacts of AI.”

#5: AI Adoption: A Work in Progress

One of the most resounding themes was the acknowledgment that no organization has fully mastered healthcare AI. Every organization is at a different phase of adoption, with many still validating use cases and trying to prove the return on investment (ROI). The diversity in AI implementation stages reflects the complexity and novelty of AI technologies in healthcare. 

Chris Hammond of Blue Cross Blue Shield of South Carolina emphasized the importance of developing a strong business case for AI adoption in healthcare, citing the need for concrete data and savings to prove value and gain trust from executives. “We need to show executives the money — where it will go, what will be saved,” Hammond urged attendees. “Without the dollars, you’ll get a lot of head shakes and idle ‘no’s’ when instead you need a business case to say, “here’s why we need to do this.’”  Shashank Suresh, Director of Analytic Enablement at Highmark, elaborated in a separate panel discussion that a well-rounded business case at Highmark must also address business alignment, data governance risk, and the organization’s technology stack. 

Embracing AI’s Potential in Healthcare Creates Optimism for the Future

The 2024 AI summit for payment integrity proved to be an invaluable platform for sharing knowledge and fostering collaboration. Inspired by fresh insights and peer connectivity, industry stakeholders are poised to support increased AI adoption and implementation across the healthcare sector, guiding the industry toward more efficient, ethical, and effective use of technology to tackle cost containment.

“It was enormously beneficial for attendees to have open and candid discussions, realizing that many in the payment integrity space are still early in their adoption of AI,” stated Dr. Musheer Ahmed, Founder of the AI for PI Community and CEO of Codoxo. “It was very exciting to see attendees, academics, and innovators come together to share AI successes, concerns, and challenges for payment integrity and healthcare organizations at large. We are proud to be a part of this necessary collaborative effort to build a growing community.”

Join us in our mission to transform healthcare with AI. Together, we can overcome the challenges and unlock the full potential of AI to contain healthcare costs and operational efficiency. To join the AI for PI Community, join the AI for PI Group on LinkedIn and follow the public AI for PI LinkedIn Page.