business
Insurers talk big AI game
Insurers are stepping up their use of artificial intelligence to uncover fraud and tamp down unnecessary care, Casey Ross reports. A survey of earnings calls in recent weeks saw executives from UnitedHealth Group, Centene, Elevance, Cigna, Humana, and CVS Health all boasting about their AI investments and strategies.
There's some hope that AI may help promote a more harmonious prior-authorization process, where most care is approved automatically with fewer improper denials. But insurers face mistrust over their opaque use of AI, and there's concern among providers that the technology will be used to deny care more aggressively.
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policy
Medicare ACCESS pricing underscores AI focus
The Medicare innovation center's ACCESS (Advancing Chronic Care with Effective, Scalable Solutions) model was met with praise when it was announced last year. The program will test paying providers to help patients manage chronic cardiometabolic, musculoskeletal, and behavioral health conditions. Health care providers will get paid the full price only if they do a good job. It's an experiment to see if incentivizing providers to use tech to achieve positive health outcomes can outperform paying providers to offer a bunch of tech services intended to make people healthier. Sounds great. But tech companies also had a lot of questions, most importantly: How much are we gonna get paid?
The answer came late last week, and the rates were lower than industry expected (or hoped). "It is not clear the juice is worth the squeeze," said Julie Barnes, CEO of Maverick Health Policy. Two big takeaways after asking around about this:
It might not be worth the headache and risk
The ACCESS model prohibits participants from billing Medicare fee-for-service for people they are treating in ACCESS, essentially barring traditional providers from signing up. That limits participation to health tech companies. Barnes points out that enrolling in Medicare alone can be "daunting for the uninitiated." Meanwhile, she said the payment rates "pale in comparison" to what telehealth providers get from commercial payers. She also pointed out that the need to deliver outcomes presents a "huge risk" to participants.
"Software and mobile app tech may find the payment rates worth it, but it doesn't seem like remote monitoring with traditional FDA-cleared medical tech has a real incentive here," she said.
Health tech attorney Carrie Nixon crunched the fees usually paid to providers offering remote physiologic monitoring and chronic care management services and wondered: "Why would medical practices give up $216.83 per chronic patient per month for what amounts to a $35/month payment?" She added: "This seems like a 'set it and forget it' method of care management that doesn't take into account the need for ANY clinician interaction."
All about AI
Indeed, multiple observers pointed out that the rates more less ensure that the only providers that show up to play will be ones with very low cost solutions — or ones that can use AI to create efficiencies. "Time will tell, but my sense is these rates will be viable for very tech-heavy/agentic offerings but will be challenging at scale for digital health companies with meaningful clinician involvement," said Jared Augenstein, senior managing director with Manatt Health.
OK, so there are some hurdles. But is this a reasonable alternative to fee-for-service for digital health companies?
"Arguably no. At least not for digital health companies in the traditional sense," said Ross Harper, the CEO of Limbic, a mental health AI company that has been considering an application. "CMMI is offering a route to market for AI-led care delivery."
He added: "The payment rates make that distinction explicit. They expose whether ACCESS participants are planning to do more of the same: driving access or volume rather than outcomes. If that's the case, then CMMI isn't offering the free ride some may have expected. But for participants who are confident they can reliably drive patient outcomes using validated, clinically tested AI, then yes, CMMI is offering a credible alternative."
So what do you think? Will ACCESS help high-quality AI-enabled care flourish? Or will it promote wellness slop that can eke out a margin at low rates? Let me know!
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