Panelists at an Emerge Innovation Experience at HIMSS25 are, from left: Edward Marx of Marx Advisory; Aric Sharp of Clover Health, Khin-Kyemon Aung of SCAN and Heather Lavoie of Horizon BCBS of New Jersey.
Photo: Susan Morse/Healthcare Finance News, HIMSS
LAS VEGAS – As AI is transforming all aspects of healthcare, it’s affecting the care model for payers.
Health insurers have end-to-end visibility into individual care needs and utilization patterns across providers and settings.
Virtual care, technology and AI have helped payers define a more active role in care delivery.
Barriers include resistance to change and lack of better payer and provider alignment, panelists said during the first Emerge Innovation Experience at HIMSS25.
Edward Marx, CEO of Marx Advisory and a former global chief information officer at Cleveland Clinic, moderated the panel of experts from Clover Health, SCAN Health Plan and Horizon Blue Cross Blue Shield of New Jersey and Humana.
The session “Voices of Innovation: Transforming Healthcare in a Payer-Driven World,” mirrors the title of the book “Voices of Innovation – Payers,” co-edited by Marx and Sakshika Dhingra, medical strategy director for Humana.
Clover Health has developed AI powered technology which enables it to harness big data and run algorithms to help with early diagnoses and better outcomes, said Aric Sharp, CEO of Value-Based Care at Clover Health.
“Culturally we encourage everyone to use AI,” Sharp said. “The core of our focus is at the point of care.”
Point-of-care solutions for most payers now include AI assistants and Chatbox, which can streamline member interactions.
Members want information quickly, said Heather Lavoie, chief information officer and executive vice president of Enterprise Operations for Blue Cross Blue Shield New Jersey. One of the pain points for patients is calling their insurer, she said.
“People don’t want to call us,” Lavoie said. What they want is answers, she said.
A more automated approach is helping with staff turnover, said Khin-Kyemon Aung, senior director of Healthcare Services, medical director and primary care physician for SCAN.
It’s difficult to find people to work in a call center, Lavoie said. AI can be used to do a summary of information for what’s covered. This makes it easier for people to work at a higher level.
“We’re asking people to do the same job, but do it more effectively,” Lavoie said.
AI is also helping with the bigger aims such as allowing outbound calls to be labeled correctly so case managers can implement stratification and nurses can rout cases appropriately by disease state, according to Lavoie.
It’s being used for voice interpretation for patients with Parkinson’s disease, she said.
SCAN has started working with Cresta, Aung said. The AI-powered contact center platform provides real-time automation and guidance to chat agents as they navigate complex care conversations.
“It’s listening in the background,” she said.
Direct to consumer AI is making it easier for members, though there’s real root causes that AI can’t Band-aid over, Aung said.
“AI is an accelerator to all of these other technologies,” Lavoie said. “We’re excited about technology.” .
Plans focused on claims, but there’s so much more, including member preference information, she said.
“We’re bringing in sensor data, health risk assessments to create better profiles of members,” Lavoie said.
Right now, AI is being used to make the way healthcare runs more efficiently, according to Sharp.
“We have to think about breaking the way the system works in its entirety,” Sharp said, even suggesting that “revenue cycle could go by the wayside if we look at entirely different models.”
Sharp said one of the biggest barriers to innovation is culture and people wanting to stay entrenched.
Aung mentioned the challenge of payer and provider alignment.
Sharp said payers and providers are solving problems in different ways. What’s needed, he said, is to get on the same page and have one path.
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