08: Improving What We Know
How we add to our understanding of how healthcare works, and make the system better for all stakeholders.
2 AI use casesUnderstand Our Members
Know the personalized, optimal care and engagement plan for each individual member.
Ingest More Member Data
Understand our members more deeply by ingesting richer data sources on their health.
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Status: Idea / Exploration
Healthcare customer service is an order of magnitude more complex than other types of customer service (e.g. e-commerce). We spend considerable effort sifting through customer service signals to identify emerging themes and issues that warrant follow up. LLMs can automate aspects of this by generating summaries for batches of inquiries in addition to our more manual tactics.
Build Personalized Member Engagement Understanding
Understand how to engage our members personally and help them care for their health.
Compile Member Interactions
Know all member interactions with healthcare, not just their claims.
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Status: Idea / Exploration
Episode groups are a common type of algorithm in healthcare, used to determine which services were part of the same visit or series of healthcare events. LLMs open up new ways of grouping episodes of care across claims and non-claims datasets and can go a step further by describing the journey of a patient in elegant prose.
Capture Value
The government has formal programs for the scoring of an insurer’s performance in quality and risk management. Manage those well.
Manage Risk Identification
Predict and verify the detailed healthcare needs of each member.
Manage Quality
Predict and verify the quality of care delivery experienced by each member.
Quantify Utilization And Costs
Generate the most real-time picture possible of utilization and costs.
Set Reserves
Calculate the dollar reserves we set aside to pay for healthcare.
Track The Medical Loss Ratio
Calculate the medical costs we will be responsible for.
Track Utilization
Generate the most predictive, real-time picture of utilization.
Quantify Deepest Understanding of Cost Drivers
Continuously craft the picture of what, fundamentally, drives healthcare costs, and how we can reduce them.
Capture Insights
Build up our understanding of how healthcare works.