Harnessing AI to Navigate the Shifting Landscape of Member Engagement

The healthcare landscape continues to evolve rapidly, driven by advancements in technology and the ongoing shift towards alternative payment models. As payers navigate this increasingly complex environment, member engagement has emerged as a critical factor in ensuring the success of healthcare initiatives. Now, with the emergence of artificial intelligence (AI) in healthcare and value-based care, understanding and prioritizing member engagement has become more important than ever.

Patient engagement has been a top-of-mind concept in healthcare for years now. So, what exactly is member engagement?

At its core, member engagement refers to the active involvement of individuals in their own healthcare. In the context of value-based care, this means empowering members to take an active role in determining the services they need and advocating for their own well-being. And now, AI is playing an increasingly crucial role in supporting this engagement by providing predictive analytics, decision support, and proactive health management tools.

Challenges for health plans and the role of AI-powered tools

Health plans face numerous challenges as they navigate the shift towards value-based care and population health management. One of the primary concerns is maintaining financial viability in a model that prioritizes quality over quantity. Payers must also contend with an ever-changing member population, ensuring high levels of satisfaction while managing evolving preferences and needs. The interoperability of internal systems, financial incentives, social determinants of health, and complex regulatory requirements further complicate the landscape.

AI-powered tools offer significant potential in addressing these and other challenges faced by health plans. Clinically validated navigation tools, for example, can provide members with personalized symptom assessments and guidance on appropriate care options. These tools not only empower members to make informed decisions about their health and treatment options, but also can alleviate the growing administrative burden faced by payers. Additionally, AI can provide valuable insights into member activities and trends, enabling early detection and intervention to avoid potential health issues.

Opportunities for payers in utilizing AI and care navigation tools

By leveraging AI and care navigation tools, payers can access a wealth of pre-claim information on member behavior and care-seeking patterns. This proactive and holistic understanding of the member population allows health plans to anticipate needs, tailor interventions, and optimize resource allocation. Rather than relying solely on retrospective claims data, a health plan can gain real-time insights into the health and engagement of its members.

Despite the potential benefits, health plans face several barriers when implementing AI-powered tools for member engagement. Privacy concerns and regulatory compliance are ongoing challenges, requiring careful navigation and strict adherence to multiple standards. Interoperability and integration with existing tools can also present technical hurdles, as payers strive to create a seamless and efficient ecosystem. Variability in member populations, including differences in digital literacy and access, must also be considered. Finally, ensuring cost-effectiveness and profitability remains a primary concern for payers.

To overcome these barriers, health plans must focus on addressing core business concerns while recognizing the shift towards patient-driven change. Implementing easy-to-integrate, low-tech solutions can provide a starting point for engagement without requiring significant upheaval of existing systems and workflows. Emphasizing the many benefits of healthier, happier, and lower-cost members can help build buy-in and support for AI-powered initiatives. Payers should also prioritize open communication and education to help members understand and embrace these tools.

Trends in member engagement, AI adoption, and value-based care

As the healthcare industry continues to evolve, several trends are shaping the future of member engagement, AI adoption, and value-based care. The rise of self-funded plans and unique payment models reflects a growing desire for more personalized, flexible healthcare options. Preventative health and provider collaboration are also gaining prominence, as payers recognize the importance of proactive care and integrated services. Virtual care, remote care, and AI-powered virtual assistants are all becoming increasingly common, offering members convenient and accessible support regardless of location. Personalization has emerged as a key factor in maintaining member engagement, as individuals seek tailored experiences and recommendations.

Member engagement plays a vital role in the future of healthcare, particularly in the context of AI and value-based care. As payers navigate this transformative landscape, embracing tools and strategies that prioritize member involvement and empowerment will be essential. 

By leveraging the potential of AI and adapting to the demands of value-based care, payers can position themselves for success in an increasingly competitive and dynamic industry. The path forward requires a commitment to innovation, collaboration, and a steadfast focus on the needs and preferences of healthcare consumers.

About Amanda L. Bury

Amanda L. Bury, MS is the Chief Commercial Officer of Infermedica, an AI-powered healthcare platform that helps providers deliver efficient, safe, and reliable care to their patients. Bury brings more than 15 years of experience connecting health systems and insurers with cutting-edge technology. Most recently, Bury served as the Vice President of Global Strategic Alliances at TeraRecon, the leading provider of medical imaging visualization, AI development, and interoperability technologies. Prior to that, she spent nearly three years as Senior Director of Channel Development & Strategy Kyruus. Bury has also become a leading voice in the healthcare technology community, presenting at various industry conferences and events, including SHSMD, HCIC, and HIMSS.