Technology is transforming health care with enhanced data insights, personalized solutions, and simpler tools that help members achieve their health ambitions.
With three out of five Americans saying the health care system is stressful to navigate, technology – AI specifically – is transforming plan member experiences.1 This is important as positive experiences improve outcomes and reduce utilization of high-cost services, such as avoidable emergency room visits. Encouragingly, the shift is already underway and Americans are embracing the change, with one in five ready to use generative AI as a doctor’s assistant, and most willing to use AI to help support routine health care activities, like scheduling appointments, refilling medications and updating contact details.2
AI is revolutionizing member experiences. However, as with any technology, it must be used responsibly, ensuring that human decision making remains central. CVS Health® recognizes that advancements in AI, when applied thoughtfully, can enhance and simplify the plan member journey.
Three ways AI helps improve plan member experiences
- Care Navigation – Connecting members to high-quality providers
A member’s health journey begins with finding the right care. Knowing where to start can be challenging, and ongoing health care professional shortages in the U.S. have only made it more difficult – but AI helps. For example, a plan could use AI to match members needing care to providers who accept their insurance, have availability, and are likely to be a good fit based on hundreds of other attributes. Using quality and clinical data to define high-performing providers and intelligent matching to identify providers with the best likelihood to meet a member’s preferences and health needs can lower medical costs for plan members.
- Care Management - Keeping people healthy
AI can be used in health care to identify past behaviors and events to improve care management support. A plan could use unstructured data (e.g., calls, benefit eligibility, and provider notes from electronic records) to identify members who are a good fit for clinical programs, determine the best time to reach individuals, and prioritize gaps in care based on actions more likely to improve outcomes and reduce utilization, such as hospital visits.
This technology is beneficial for members who are at risk of adverse health events by increasing medication and treatment adherence, which is associated with improved clinical outcomes and reduced mortality. AI can help care management nurses prepare for a productive conversation with members by empowering them with a simple, context-rich summary of helpful information. This includes diagnoses, medications, recent provider notes and historical service interactions. An AI solution could also identify members eligible for programs and provide recommendations for high-value, clinical actions. If case notes are summarized using AI, case nurses can add feedback directly in the tool for safety monitoring and continuous improvement.
- Customer Service – Higher-quality human interactions
Every interaction shapes an employee plan member’s experience. AI can create seamless interactions by giving call agents more time to focus on the member and routing calls to the most useful agent based on the member’s needs.
Once on a call, AI-generated summaries can brief agents on a member’s call history, saving members from having to recount their health history. AI-powered knowledge can assist and help agents address a member’s needs in real time without having to transfer or put the member on hold. Additionally, benefit prediction technology can be used to help agents answer challenging benefit questions, resulting in a 20%-30% reduction in average call handling time. To close the loop and ensure continued positive experiences, AI can automate quality management practices by auditing calls to identify coaching and development opportunities.
As AI continues to enhance plan member experiences by elevating care navigation, care management and customer service, it will play a key role in delivering higher-quality support throughout the health journey.
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