Artificial intelligence (AI) is unfolding across employer health plans to drive health up and health plan costs down. AI can enhance disease management, enable preventive care, activate early intervention and has the potential to make a significant difference in chronic illness. People with chronic conditions account for a huge percentage of hospital admissions, prescriptions filled, and physician visits in the US. According to the CDC, 90% of the US’s $3.8 trillion annual healthcare expenditure is for people with chronic and mental health conditions. About one half of Americans suffer from at least one chronic disease. Chronically ill patients need thoughtful, consistent care to help them manage their health. Those with multiple chronic conditions have an even tougher road, requiring multiple providers to carefully coordinate care.

AI Enables Early Intervention

There’s an abundance of data on disease onset or progression for illnesses like diabetes, kidney disease, COPD, and cardiac disease. Patient data is just as available to health insurers in the form of electronic health records, claims, social determinants of health, provider notes, imaging, wearable-device information, and more.

The issue is not finding data; it’s the ability to process it. That’s where deep learning, the most advanced AI, comes in with the ability to analyze mountains of data in a variety of forms (free text, claims, images, etc.) and accurately predict when individuals are likely to experience a near-term health event (e.g. emergency room visit) related to a chronic disease, or if they are headed for a major health incident (e.g., a cardiac event) or procedure (i.e., surgery for kidney stones) or if they have a worsening disease state.

When AI identifies a concern about an individual, it should alert a clinician to intervene, and it’s critical for the clinician to reach out as quickly as possible. He or she can explain the situation, why it’s important to address it, and what the options are for mitigating the potential issue. The goal is to get the patient on the best health journey by alerting them, educating them, and helping them find a provider who can evaluate and treat the condition. Insurers that plan to use AI technology to identify potential health issues should plan to incorporate a comprehensive clinical program for reaching out to patients and following up as necessary.

AI Helps Close Care Gaps

In addition to enabling early intervention through prediction, AI can play a vital role in addressing care gaps. Simply keeping track of health appointments, health screenings, prescription refills, dietary needs, vaccinations, and more can be daunting. Chronic care patients must handle all those tasks in multiples, and the sheer volume can lead to care gaps that are frustrating for providers and potentially dangerous for patients.

Fortunately, AI is ideal for automatically tracking and reminding patients (and, for some items, providers) about all relevant health-related events, from exams and procedures to prescriptions needing refill and upcoming screenings.

Preventing major events is obviously the most important way AI can be combined with health data, with interventions helping patients avoid costly hospital stays. But addressing care gaps through wellness intervention has been shown to offer a high return on investment.

AI for Employer Plans Today

Until recently, AI programs aimed at early health predictions and care gaps have only been available to the largest national health insurers. Today, companies of any size can access AI technology. Marpai, a SMART health plan services company, brings AI to the self-insured sector.  The company combines TPA (Third Party Administrator) services, AI-powered services and a clinical component that works directly with members. Marpai’s deep learning algorithms predict potential near-term health events and activate early intervention with a clinician. These URAC accredited clinicians guide members on the best care journey which avoids unnecessary and excessive costs while ensuring quality care.

AI is taking health plans to the next level. AI has the potential to uncover the hidden value of data for employer health plans, enabling healthcare stakeholders to make more informed decisions, improve patient experiences, and deliver better quality care. AI can help payers leverage intelligence to detect fraud and optimize claims processing and management, improve member engagement, personalize experiences, and support value-based care models. Predictive AI and ML data models can improve patient care; streamline care coordination; and help empower physicians, clinicians, and staff to make more informed decisions.