Making Healthcare More Human...Using AI | with Amanda Volner

This video provides an in-depth exploration of the intersection of artificial intelligence, employee benefits, and care navigation, featuring Amanda Volner of Healthee. The central theme is that advanced AI is no longer optional but a fundamental requirement for optimizing complex health plans and driving positive member behavior change. Volner argues that while AI excels at synthesizing information and providing personalized guidance, uniquely human skills—such as critical thinking, relationship building, and understanding the context behind a request—remain essential, particularly in high-stakes commercial environments.

The conversation details how Healthee’s AI platform, Zoe, is engineered to create a "hyper-personalized" experience. This personalization is achieved by ingesting and integrating three distinct layers of data: broad foundational data (like machine-readable files and aggregated claims), the employer’s specific plan design (including complex elements like Reference-Based Pricing or direct contracts), and individual user data (such as deductible status and copay structure). This sophisticated data integration ensures that the AI provides accurate, cost-specific recommendations at the critical moment of decision-making, effectively addressing the clunkiness and fragmentation often associated with unbundled, self-funded plans.

A major focus is placed on leveraging AI to tackle rising prescription drug costs. The platform proactively identifies opportunities for savings, such as recommending generic or biosimilar alternatives (e.g., Pregabalin instead of Lyrica) and integrating a discount card feature to find the lowest cash price, which can sometimes be cheaper than using the plan's copay. Furthermore, the video introduces "Healthy Connect," a new integrated platform designed to enhance employee engagement. This tool allows employers and brokers to build and deploy targeted, omni-channel communication campaigns (via text, push notifications, and email) to reach decentralized workforces effectively, ensuring that cost-saving solutions are adopted and utilized consistently throughout the year, not just at open enrollment.

Key Takeaways: • AI as a Necessary Augmentation Tool: In the benefits space, AI's primary value is augmenting human decision-making by synthesizing complex data rapidly. It does not replace the need for human critical thinking, contextual application, or relationship influence, especially in sales and underwriting negotiations where nuance is paramount. • Care Navigation is Foundational for Complex Plans: For unbundled, self-funded plans utilizing cost-containment strategies like RBP or direct contracting, care navigation is essential "connective tissue." Without a seamless navigation tool, the plan becomes disjointed, leading to member confusion, low engagement, and costly mistakes like out-of-network utilization. • Three-Tier Data Integration for Precision: To achieve accurate, personalized cost guidance, AI platforms must integrate data across three tiers: broad market data (MRFs), specific plan design documents (SBCs, RBP rules), and individual member status (deductible remaining, copay tier). • Pharmacy is the Most Fixable Cost Driver: Pharmacy spend is identified as the area most ripe for immediate optimization, with potential savings of 25-30% or more. AI can drive this by intervening at the point of decision to recommend lower-cost generics or biosimilars and integrating cash discount options. • Overcoming Behavioral Inertia: Employees often revert to familiar, costly healthcare patterns (e.g., going to the doctor’s referral without checking cost). Navigation must meet the member at the point of urgency and make the correct, cost-effective decision the path of least resistance. • The "Question Behind the Question" Strategy: Effective AI navigation must be intuitive, much like ChatGPT, to understand the member’s underlying intent rather than just the literal prompt, as most employees lack the expertise to ask the right benefits questions. • Omni-Channel Engagement is Crucial for Adoption: Relying solely on open enrollment communication is ineffective. Employers must use targeted, omni-channel tools (like the Healthy Connect platform) to send timely push notifications and texts, which have an "insanely high read rate," to drive continuous engagement with benefits throughout the year. • Plan Design Support Must Be Holistic: Decision support tools should cover the entire benefits package—medical, dental, vision, and voluntary/supplemental—to help employees choose the optimal combination based on their anticipated needs (e.g., family expansion). • Incremental Improvement is the Strategy: Optimizing a health plan is a multi-year process of "chipping away" at inefficiencies. Success is achieved through continuous, incremental improvements in areas like pharmacy and network utilization, rather than seeking a single, immediate fix. • Future Demand for Precision and Proactivity: Future generations will demand highly precise, proactive healthcare solutions that integrate well-being, preventive care, and predictive analytics, potentially including pharmacogenomics to tailor drug selection based on genetic makeup.

Tools/Resources Mentioned:

• Healthee (and Zoe): AI-driven care navigation and benefits decision support platform.
• Healthy Connect: Integrated platform for employers/brokers to run omni-channel engagement campaigns.
• RX Mapper: Mentioned as an example of an organization focused on pharmacogenomics.

Key Concepts:

• Care Navigation: The process of assisting an employee in becoming a smarter healthcare consumer by guiding them to the right benefits, providers, and cost-effective decisions.
• Hyper-Personalized Healthcare: A benefits experience tailored to the individual's specific plan design, financial status (deductible), and health needs, delivered through a modern, mobile-first interface.
• Comparative Effectiveness Analysis: A method of comparing the efficacy and cost of multiple drugs within the same therapeutic category to determine the maximum value option, moving beyond simple comparisons against a placebo.