Consumer Engagement

Insurers Invest in Generative AI, but Long-Term Impact Remains Uncertain

Health insurers, like most companies, are experimenting with how to incorporate artificial intelligence into their work processes to help them make more timely decisions, cut costs, improve profitability and help members. While it is still early to assess how AI will be most effective, plans should make sure they apply AI in an ethical manner and involve multiple stakeholders in any efforts, according to three executives who spoke during a July 26 webinar sponsored by consulting firm ZS.

Onyinyechi Daniel, Ph.D., who until recently was Highmark Health’s vice president of data and analytics strategy, noted that using AI was “nothing new” for employees in companies’ data and analytics departments. But she added that “the onset of generative AI brought a lot more visibility and really amplified efforts,” especially among executives who are leading the charge in pushing for the adoption of AI throughout their organizations.

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With Brokers’ Blessing, CMS Targets Unauthorized Plan Switching

CMS on July 19 took new steps to protect Affordable Care Act marketplace enrollees from unauthorized plan switching — moves that were applauded by the independent broker industry. One policy expert says the new policies are welcome and should help with unauthorized plan switching, but she suggests that more must be done to prevent unauthorized plan signups. Meanwhile, a new Senate bill and industry efforts could make a difference in unauthorized signups.

In a July 19 press release, CMS said it would make notable changes in the way it processes plan switches on HealthCare.gov, including:

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UnitedHealthcare to Offer Risk-Sharing in Type 2 Diabetes Program

More and more plan sponsors are interested in introducing risk-based reimbursement in their contracts with health insurers. That interest has grown into a range of plan designs: On the extreme end, plan sponsors like CalPERS are introducing upside and downside risk to entire third-party administrator contracts. A more incremental approach sees health insurers offering upside risk to plan sponsors based on the health insurer’s ability to control costs for a specific condition.

UnitedHealthcare on June 26 launched such an offering, called the Level2 Assured Value Program. It’s a new payment model for an existing Type 2 diabetes management benefit design called Level2.

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MA VBID Model Participants Face New Era of Increased Accountability

CMS’s Medicare Advantage Value-Based Insurance Design (MA VBID) model — which offers MA organizations enhanced flexibility to tailor a variety of interventions to address health-related social needs — has gone through multiple iterations since its inception. In what CMS officials consider the third phase of its evolution, MA VBID participants will soon face new accountability for driving savings, addressing health equity and delivering meaningful supplemental benefits.

The MA VBID model, which was launched by the CMS Center for Medicare and Medicaid Innovation (CMMI) in 2017, has seen participation grow from nine MA organizations in three states to 69 MAOs serving an estimated 8.7 million VBID beneficiaries across the U.S. Having been extended through 2030, it is currently CMMI’s longest-running model and the only model specifically testing innovations in MA. Those innovations initially included offering supplemental benefits or reduced cost sharing to enrollees with certain chronic conditions or who participated in care management and/or disease management activities.

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News Briefs: Doctors Use AI to Counter Insurers’ Prior Auth Paperwork Blitz

Doctors are increasingly turning to artificial intelligence (AI) chatbots to fight back against health insurers’ claim denials and prior authorization requests, The New York Times reported. Tools like ChatGPT and the HIPAA-compliant Doximity GPT are helping justify treatments they say patients need by drafting letters in seconds that cite scientific studies to back up their arguments. One doctor told the publication that Doximity GPT cut the time he spent on prior authorization requests in half. Major insurers, meanwhile, are facing increasing scrutiny — and a spate of lawsuits — over their use of AI for tasks like denying large batches of claims or determining the length of patients’ post-acute rehabilitation stays. An AHIP spokesperson told the Times that the insurer trade group welcomes efforts to streamline the prior authorization process, including those that involve the “appropriate use” of AI.

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Elevance: AI Can Cure Provider Directory Headaches

While use cases for artificial intelligence are still largely being tested in health care, AI may be helpful right now for health plans seeking to manage their provider directories — a troublesome task that even the largest payers struggle to handle.

“There’s a lot of hype here, and really, so far, not much has really materialized,” said Neel Butala, M.D., cofounder of HiLabs, during a June 25 AHIP webinar.

“However, there’s a big appetite [for AI]…everything ranging from automating administrative tasks, apps, data analytics, to risk prediction, and even you know, personalized medicine. AI has applications in each of these buckets with varying ranges of maturity. And we feel, right now at least, that the easiest thing for people to engage AI in right now is automating administrative tasks. And this is because it improves efficiency; has direct, easily measurable ROI; and it’s pretty low risk for health plans in particular, as it's not really directly involved in member care. And finally, an easy win here can help any AI across an organization that can then be used…for other types of applications that are more advanced, that have a big impact.”

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UnitedHealthcare to Offer Risk-Sharing in Type 2 Diabetes Program

More and more plan sponsors are interested in introducing risk-based reimbursement in their contracts with health insurers. That interest has grown into a range of plan designs: On the extreme end, plan sponsors like CalPERS are introducing upside and downside risk to entire third-party administrator contracts. A more incremental approach sees health insurers offering upside risk to plan sponsors based on the health insurer’s ability to control costs for a specific condition.

UnitedHealthcare on June 26 launched such an offering, called the Level2 Assured Value Program. It’s a new payment model for an existing Type 2 diabetes management benefit design called Level2.

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With Falling Drug Prices, Hepatitis C Could Be Eliminated if Plans Play Ball

The U.S. health care system could save billions if it increases access to treatment for hepatitis C, now that a series of curative therapies approved in the 2010s have decreased in price, according to the Congressional Budget Office (CBO). However, one expert says that federal and state governments will have to force health plans — particularly Medicaid managed care organizations — to increase access to those therapies.

Doubling hepatitis C treatment access in Medicaid could save the federal government $7 billion over 10 years, the CBO found in a report published June 14. In addition, a 2023 white paper from researchers affiliated with the National Bureau of Economic Research found that a Biden administration budget request for a federal program to eliminate hepatitis C would diagnose and cure about 90% of all U.S. hepatitis C patients, saving the health care system $18.1 billion, of which $13.3 billion would accrue to the federal government.

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Amazon Opens Up ‘RxPass’ to Medicare Enrollees, but Will They Bite?

Amazon Pharmacy revealed earlier this month that its RxPass subscription savings program is now available to “more than 50 million Medicare beneficiaries,” allowing those who are Prime members to get 60 common generic medications delivered for a $5 monthly fee. Industry experts tell AIS Health that they can see the appeal in such an offering — including both convenience and potential cost savings — but they aren’t expecting the newly expanded service to significantly impact the Medicare Part D space.

“To be very honest, when I read the news, I didn’t really give it too much of a second glance,” says Marc Guieb, Pharm.D., a consultant at Milliman. “In terms of big-picture market stuff, I don’t think this really is going to change much or have any sort of tangible effects.”

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With IRA Impacts Looming, Manufacturers Should Focus on Providing Patient Support

Most industry experts likely would agree that certain provisions in the Inflation Reduction Act (IRA), such as a $2,000 out-of-pocket spending cap for Medicare Part D beneficiaries and copay smoothing — known as the Medicare Prescription Payment Plan (M3P) — are no-doubt wins for patients. But other aspects of the law, particularly Medicare drug price negotiations and inflation-based rebates, have prompted disagreements over their ultimate outcomes, with some experts claiming that they will hurt drug development and will prompt more restrictive utilization management among payers. Ultimately, said pharma industry experts during a recent webinar, stakeholders should keep patient support top of mind as they navigate these changes.

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