AI Opportunity in Healthcare Payers
Executive Summary:
Healthcare payers face significant economic pressures due to rising medical service utilization, provider cost-passing, and diminishing Medicare Advantage reimbursement rates. Artificial Intelligence (AI) and automation offer substantial untapped opportunities to enhance affordability, quality, and patient experience by reducing administrative and medical costs while increasing revenue.
Key Findings:
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Opportunity Size: By adopting the latest technology, including AI and generative AI, payers can achieve net savings of 13%-25% in administrative costs, 5%-11% in medical costs, and 3%-12% higher revenue. This analysis is based on an average-performing payer, with the potential for higher improvements in lower-performing entities.
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Domain-Specific Impact: AI impacts vary by domain. Notably, domains such as claims processing, network and contracting, utilization management, care management, and information technology show significant opportunities for improvement. For example, utilization management can achieve 20%-30% administrative efficiency savings on pharmacy benefit manager (PBM) administration costs.
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Strategic Approach: Capturing AI's potential requires a comprehensive strategy that encompasses:
- A business-led digital roadmap.
- Skilled talent with the right capabilities.
- An optimized operating model.
- Advanced technology infrastructure.
- Robust data management.
- Effective change management and scaling.
Detailed Analysis:
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Opportunity Assessment: Payers can realize substantial benefits by leveraging AI and automation. The impact on different domains is quantified through an analysis of current processes and the potential for enhancement through AI application. The impact is illustrated with estimated values for every $10 billion of revenue.
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Domains with High Potential:
- Claims Processing: Potential for 0.9%-3.4% improvement in claims processing efficiency.
- Network and Contracting: Possibility of 0.4%-0.7% improvement in network and contracting efficiency.
- Utilization Management: Up to 0.7%-2.7% improvement in utilization management processes.
- Care Management: Potential for 1.6%-1.8% improvement in care management efficiency.
- IT Operations: Up to 5.0%-5.5% improvement in IT development and maintenance.
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Strategy for Success:
- Business Roadmap: Aligns the company's strategy with AI integration.
- Talent Development: Ensures the workforce possesses the necessary skills and capabilities.
- Operational Efficiency: Integrates business and technology to streamline operations.
- Data Enrichment: Improves data quality and accessibility across the organization.
- Adoption and Scaling: Accelerates value capture through innovation and strategic management.
- Leadership Alignment: Senior leadership commits to the transformation vision and oversees progress.
Conclusion:
Healthcare payers have a significant opportunity to leverage AI and automation to reduce costs, improve efficiency, and enhance patient outcomes. Implementing a structured strategy that addresses key areas of focus is essential for realizing these benefits. This approach requires a collaborative effort across the organization, led by executive oversight, to ensure successful adoption and scalability of AI solutions.
医疗保健实践
AI机会：付款人现在如何抓住它
人工智能和自动化可以降低管理和医疗成本并增加收入。但是付款人还没有动员起来改变他们的组织以抓住这个机会。
作者：ShubhamSinghal和JessicaLamb
付款人目前面临经济压力可能会持续几年。医疗服务的利用率高于预期，提供商正在通过费率谈判转嫁更高的成本，而Medicare Advatage报销费率正面临着多年来付款人所面临的最大下行压力。面对这些问题，人工智能和自动化为付款人提供了未开发的机会。
机会是巨大的，现在可用
改善负担能力，质量和患者体验的机会是巨大的。为了更好地了解经济机会，我们分析了健康保险中的每个功能或流程，发现采用最新可用技术（包括AI和生成AI）的付款人可以节省大量潜在的管理和医疗成本，并增加了收入。我们估计，通过使用当前可用的技术，付款人可以节省13％至25％的行政费用和5％至11％的医疗费用以及3％至12％的收入。我们基于表现平均的付款人进行计算-表现较低的付款人可能会看到更大的改善，这表明有机会超越竞争对手。1
医疗服务的利用率高于预期，提供商正在通过费率谈判转嫁更高的成本，而MedicareAdvantage报销费率正面临着多年来付款人所面临的最巨大的下行压力。
麦肯锡公司
There are improvement opportunities in all payer domain. Some stood out, including claims, network and contracting,utilization management, care management, and information technology (Exhibit 2).
正如我们迄今为止在大多数行业中看到的那样，增量方法将继续仅产生少量节省。为了获得全部价值，付款人必须重新构想每个领域的端到端流程。其他行业的公司的经验表明，能够利用AI和自动化技术的公司具有竞争优势。2
2“重新布线并向前迈进：数字和AI领导者正在抛弃其余的人，”麦肯锡，2024年1月12日。
麦肯锡公司
抓住机会将需要从根本上重新布线
捕获影响不仅仅是技术。在重新连线：麦肯锡数字和人工智能时代的竞争指南（Wiley，2023）中，作者概述了对希望改变其运营方式和
采用技术-以业务为主导的数字路线图，人才，运营模型，技术，数据以及采用和扩展3(附件3)。
根据我们的经验，成功执行人工智能转型的公司追求所有六个领域4;做一个子集是不够的。这不仅仅是建立一个运营模型或投资于技术基础设施。完成这项工作需要关注在采用和扩展过程中出现的变革管理挑战。这是首席执行官和整个高管的工作，而不仅仅是首席信息官或CDO。
这对付款人意味着什么？
付款人首席执行官应该考虑他们是否想领导或跟随。机会的大小表明，如果竞争对手继续前进，那些选择等待的人将需要准备好应对计划
成功。例如，追随者可能会发现自己处于行业领导者医疗费用降低10％或行政费用降低20％的位置，这是一个令人生畏的前景。因此，成为快速追随者的能力至关重要。
In general, most payers are mid - equipped to purse this opportunity. To do so, they have to close the gap that existsbetween their current capabilities and those needed to fully address six areas outlined above (Exhibit 4).
麦肯锡公司
付款人首席执行官可以通过回答以下问题开始评估他们各自的情况：
—我们将如何应对管理成本降低20％或医疗成本降低10％的竞争对手？
—我们业务的最大价值在哪里？那是一个领域吗？一个业务部门？一个功能？
—即使我们今天还没有准备好冒险，我们是否可以“重新连接”一部分业务，以便我们知道在需要以及何时需要前进时该怎么办？我们是否可以接触到沉浸在新技术中的人才？这些技术人才了解我们的业务运作方式吗？
—我们的领导者和管理者是否了解这些技术是如何工作的，至少足以发现机会并与我们的技术人员合作？
—我们是否拥有底层技术基础设施，以允许建模和创新快速发生，没有摩擦？
—我们的数据是否干净、清晰、便于那些需要它来更好地完成工作的人使用？
抓住这个机会对首席执行官和他们的顶级团队来说是一个巨大的领导力挑战。他们将需要建立治理和风险框架，并动员整个组织致力于上述六个领域。他们不可能在一夜之间做到这一点，但机会规模和行业压力的结合意味着是时候开始问自己这些棘手的问题了。
Shubham Singhal是麦肯锡社会，医疗保健和公共实体（SHAPE）实践的全球领导者。杰西卡·兰姆是纽约办公室的合伙人.
作者希望感谢Rahul Agarwal，Senthu Arumugam Mazen Elfakhani，Bryce Hall，Aaron Lee，Hyun Lee和Prashanth Reddy对本文的贡献。
