Artificial intelligence could be the downfall of the community and mission-focused health plans.

Let me rephrase.

When community health plans start losing state contracts to the commercial plans in the next few years, it won’t be because of the usual reasons. It’ll be from their failure to take AI seriously.

Author: Trey Sutten

We’re Missing Something Here

This spring, I attended various events led by leaders in both the public and private health sector. 

On the for-profit side of things, all anyone could talk about was AI’s cost- and life-saving potential. While the specifics varied, the consensus was that AI is undeniably tied to the future of healthcare. 

By contrast, AI was barely mentioned throughout several conferences and meetings that were hosted and attended by mission-focused community health plans. 

The difference in priorities was clear, but I understand why. When I ran a Managed Care Organization (MCO), it was all we could do to keep up with member councils, provider councils, regulatory reporting requirements, local politics… oh, then actually improving member outcomes on Medicaid rates.  We did it and did it well, but shiny new technology often, if not always, took a back seat. 

AI is different and revolutionary in nature. Dealing with it later or taking a “head-in-the-sand” approach will have consequences here. AI is surging forward and will change the face of healthcare globally, and plans that don’t embrace it will be left behind—especially the health plans supporting our most underserved communities.

The goal isn’t to scare anyone here. It’s a wakeup call that AI is coming whether you embrace it or not and I believe it could be fundamental to community health plans’ paths forward. 

Learning From the Big Guys

For large national commercial plans, incorporating AI is an easy call and it’s already been happening. Their multiple lines of business, national footprint, and overall financial situation allows them to dream—and spend—big. Research and development is prioritized. Salaries and high-dollar technology can draw in data scientists. But even with these advantages, they are having a tough time recruiting superstars. 

“Health Plan of Somewhereville” – doesn’t have the cash or cache. 

Having more money and infrastructure enables large plans to invest in performance improving projects (like AI). And if a $10M initiative fails? They have the luxury of saying: “Well, at least we tried something! On to the next.”

With experimentation comes improvement. This is one of the ways they compete and win Medicaid contracts.

So what’s a public sector plan to do?

Streamline and Simplify: Take a hard look at everything that isn’t mission aligned and essential. Are people generating reports that aren’t being used or aren’t required? Are people dedicated to the right things and at the right level of effort? Do you have the right people in the right roles executing at the right levels of performance?

Collaborate and Leverage: One of the best parts of working at a community plan is being able to work with leaders at other plans collaboratively. Learning from one another. Learn how your peers are using AI or considering the use of AI. Talk to your health systems to understand how they are using the technology to care for your members. Leverage your relationships and collaborate with your partners to understand and learn.

Get started: Lastly, get cracking. Different forms of AI have been used for years by commercial plans. You need to get started now. It’s easy to start small. Use it to help your frontline teams make the best use of their time, in functions like HR, communications/marketing, financial management, etc. Get your teams comfortable talking about it and using it. Start transitioning away from the old school, centralized and support ticket-based analytics and MedEcon, and start to bring in the really powerful tools. Tools that identify the who, the why, and the what to do about it. Lean on trusted partners to make this transition easy – you don’t have to learn it all in one day.  The ability to pinpoint the right members, the right care, and at the right level and time will drastically optimize your use of people and care dollars.

You Have a Leverage

The national plans spread their attention between thousands of groups (with varying cultures, geographies, and relevant health risks) and shareholder obligations, so they lack the local focus, local presence, and local knowledge in many cases. In this regard, their weakness is your strength.

It’s likely that your members live within the same region and face similar socioeconomic barriers and a similar range of health challenges. It’s also likely that your physical location places you closer to not only your members but also local organizations embodying their system of care. 

With this closeness, you have the opportunity to better understand the members you serve and pivot quickly to drive improvements in outcomes and financial performance.

“I Get by With a Little Help From AI”

Granted, AI can’t solve all your problems (POLITICS). However, paired with your advantages, it can help you amplify your existing resources, reduce costs, and improve health outcomes.

“Hold on, Trey,” you may be thinking. “We’re still just a community health plan. I’m busy with state-mandated reporting. There’s not enough time (or funding, staff, etc.) to take on AI.” 

That’s where Siftwell comes in. 

With our award-winning team, you can begin exploring AI-powered strategies without adding to your workload.

Ours isn’t a one-size-fits-all approach. Every Siftwell model is unique to your organization, datasets, populations, and prioritized questions. And with our experience in the commercial and public sectors, we can offer Goliath-level solutions and roadmaps while respecting the limitations of your resources. 

Plus, humans come with the package. We know your time is limited, so our team orients itself to your organizational priorities and work style. We’ll lend as much support as desired when it comes to:

  • Providing analyses
  • Strategy development
  • Initiative execution

Getting started with us doesn’t have to be a big lift, either. Simply send us the data you have (in whatever format), and we’ll tell you what we see and how we might be able to help lighten the load—without holding you back.