| A losing battle
The war between healthcare providers and payers has increasingly become a battle of algorithms, with AI tools for prior authorizations on one side and AI-powered appeals on the other. Hospital for Special Surgery (HSS) chief digital and information officer Ashis Barad thinks providers and payers racing to out-automate each other is a losing strategy. “We're playing a finite game when there's an infinite game to be played,” he declared. “If we play the finite game of today, we're going to continue on the inflationary route. So we have to figure out how to work together to figure out what the deflationary path for AI is, because that's what we owe the people, honestly.” Instead of pouring resources into AI for faster authorizations and appeals, Barad wants to see providers and payers pool their data to build more personalized care pathways. Connecting data
Barad pointed to HSS' own data as an example of what's possible. The hospital performs more than 40,000 orthopedic surgeries a year and has developed a structured repository connecting imaging data to surgical outcomes. During a recent meeting with a large insurance company, Barad asked how valuable HSS' linked imaging-and-outcomes data would be to their actuarial teams. "They were like, we would salivate over it," he said. That's because payers typically only have access to basic claims data — infection or readmission rates after a first surgery, for instance — not the outcomes data for patients on their third, fourth or fifth procedure. But those are the kind of complex cases that make up much of HSS’ patient population, Barad pointed out. A better future is possible
Barad thinks the real opportunity lies in using richer data to reshape how authorization works in the first place. He pointed to gold carding, the practice of exempting high-performing providers from prior authorization, as a concept ripe for reinvention. Today's version is a blunt instrument based on flowcharts and cost thresholds rather than actual outcomes, he explained. Built the right way, Barad thinks it could instead be personalized down to each patient. Authorization would be baked into a care pathway, not requested after the fact. — By Katie Adams |
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