Artificial and augmented intelligence
As more electronic health data becomes available, artificial intelligence (AI) can unlock the potential for that information to be used to improve healthcare. “No more will ‘doctor knows best’ be sufficient,” says Jodi Daniel, a partner in Crowell & Moring’s Healthcare Group and a member of the firm’s Digital Transformation Practice. “Clinicians will need to apply their training and experience along with data and sophisticated systems that can identify new information that may not have been available or transparent before. This could lead to significant improvements in diagnosis and treatment and create efficiencies for provider and patient interactions and administrative functions.”
AI applications include:
- Population health management, in which AI software can help clinicians and insurers better identify and prioritize patients to provide the right level of resources to minimize costs and improve patient outcomes, Daniel says.
- Diagnostics, in which AI is assisting with diagnoses. For example, this year, the FDA approved AI-based tools for detecting wrist fractures and diabetic retinopathy in patients, decreasing time from onset to treatment.
- Patient care, in which it can help providers determine the treatment approach. In February, for example, the FDA approved clinical decision support software that uses AI algorithms to analyze images for indicators associated with a stroke, Daniel says.
Growth in the AI health market is expected to reach $6.6 billion by 2021—a compound annual growth rate of 40%, according to Accenture. Several trends are driving that growth:
- The continued, unmanageable increase in healthcare costs. “Value-based payment requires that clinicians have actionable data to manage patients and that health plans have data and tools to evaluate performance and health outcomes,” says Daniel.
- Concerns continue to grow regarding physician burnout and medical labor shortages. “AI software can reduce the burden of providers when doing documentation and data management, and AI tools can help triage patients so that physician time is available to patients with the greatest need,” Daniel says.
- Technology advancements across all industries have resulted in patients changing their expectations of their healthcare interactions. “Individuals are used to quick responses, electronic access to information, and the ability to be more engaged in decision making,” Daniel says. “There will be a growing need for the healthcare sector to adopt AI technology to streamline services and to improve quality of those services.”
- A thirst for improving the understanding of complex diseases and treatments and conducting research. “AI will be an important tool for analyzing vast amounts of data to develop future treatments,” she says.
Ultimately, Daniel says the single-most significant potential for AI is its power to change the standards of practice. “Better analytical tools for improved diagnosis and treatment and more data from outside the clinical care setting such as patient-generated health data and social determinants data can provide a more accurate picture of the patient and improve care decisions and outcomes,” she says.
State government interventions
State governments have been operating the Medicaid program, which has become a fundamental driver of U.S. healthcare policy and service delivery, since 1965. Medicaid now covers 74 million people, including paying for more than half of the country’s births and more than 65% of nursing home residents.
Thirty three states and the District of Columbia have expanded Medicaid to cover childless adults under the ACA. Legislation introduced by U.S. Sen. Brian Schatz (D-Hawaii) and U.S. Rep. Ben Ray Luján (D-New Mexico 3rd District) in October 2017 titled the State Public Option Act, would create a Medicaid-based public healthcare option on the insurance marketplace. Since then several states, including Nevada, Iowa, Massachusetts, Minnesota, Missouri, New Jersey, and Washington, have introduced Medicaid buy-in proposals to cover more uninsured or underinsured individuals, says Pamela Coleman, senior consultant, Sellers Dorsey, a national healthcare consultancy.
Having worked with the Medicaid program since the mid-1980s, Coleman has seen it evolve from one where states passively paid claims to one where the emphasis is on paying for positive healthcare outcomes. “The majority of states have implemented managed care models where health plans are put at risk for poor patient outcomes,” she says. “Performance measurement and continuous quality improvement are central to these models. Many healthcare delivery innovations have come from state Medicaid programs.”
Because states must balance their budgets, unlike the federal government, they must innovate to ensure their programs are sustainable and produce results for their Medicaid population, Coleman says. “In order to innovate, state policymakers must disrupt the status quo and develop and implement new ways to finance their Medicaid programs, reimburse providers by paying for value, not volume, and work with health plans to ensure providers are available to deliver healthcare services throughout a state.”
Given the current political climate, Coleman views Medicaid for All as more attainable than the Medicare for All proposal. Medicaid for All proposes the option for individuals to buy into Medicaid coverage and be eligible for premium subsidies and reduced cost sharing. In contrast, Medicare for All, as proposed by U.S. Sen. Bernie Sanders (D-Vermont), would create a national insurance system for single-payer coverage for all U.S. citizens.
A recent analysis by The Mercatus Center estimated that this proposal would lead to a $32.6 trillion increase in federal spending over a 10-year period. A Medicaid for All buy-in program would likely cost the federal government much less, says Coleman.
Also, unlike Medicare, states administer Medicaid, which covers populations from newborns to frail seniors and includes many individuals with mental health conditions and substance abuse disorders.
“Medicaid is leading the fight on the opioid epidemic by requiring health plans to develop innovative interventions to address problems at the community level,” Coleman says. “Medicaid initiatives that focus on social determinants of health such as housing, nutrition, obesity, and education are also expanding.”
As the ultimate safety net provider, Medicaid faces continuous challenges to provide quality services to beneficiaries while keeping costs down. New flexibilities offered through managed care models and waivers allow for payment of such things as minor home modifications for persons with disabilities, air conditioners for persons with asthma, and supportive employment for persons with intellectual disabilities. “These interventions are far more cost effective than traditional healthcare services and promote personal independence,” Coleman says.
In order to receive federal funding, states must provide a core set of services and beneficiary coverage. To manage these expenditures, states have developed creative solutions to reform healthcare service delivery, such as accountable care systems and value-based payment models. “These transformations can be truly disruptive as Medicaid will no longer pay providers on the basis of volume, but rather on the basis of value,” Coleman says
Whether states adopt Medicaid for All strategies, they will continue to reform Medicaid practices to promote quality and cost-effective delivery, she says. “Large national Medicaid managed care organizations are agreeing to enhanced performance requirements and states are enacting more sophisticated and comprehensive oversight of managed care contracts.”
Karen Appold is a medical writer in Lehigh Valley, Pennsylvania.