When I was in business school in 2016, I wrote a composition on Blockchain and its implications in healthcare. At the time, all the experts proclaimed confidently that this new technology would “revolutionize” healthcare. I remember thinking at the time that I really didn’t get it. The systemic issues that exist in healthcare, with misaligned economic incentives driving system behavior that rewards sickness instead of wellness, wouldn’t be even remotely addressed by Blockchain technology. Absolutely, Blockchain helps ensure data privacy, but that’s a point solution, not a comprehensive solution that we need to truly revolutionize healthcare.
The current dialog around generative AI (GenAI) strikes me in a similar vein. Yes, I believe GenAI can enable solutions that will remarkably impact healthcare workflows. One example is through the automation of low risk, repetitive tasks, such as those associated with administrative responsibilities. Imagine mundane administrative tasks handled by AI, with exception-based outliers pushed to human users. Automating these workflows free up clinicians to focus on their patients and provide improved care.
For this technology to further take off in 2025, GenAI in healthcare needs to shift from potential to practical value, focusing on delivering concrete benefits for clinicians AND patients. Healthcare systems will develop robust governance systems for the evaluation, purchase, implementation, and ongoing monitoring of GenAI solutions, and will demand tangible ROI for any solution. This transition from the hype cycle to the value cycle will focus on quantifying GenAI benefits. One example would be measuring reduced administrative burdens such as time savings and reduced burnout of clinicians using tools such as ambient scribes.
However, to truly “revolutionize” healthcare, we need to address the underlying need for those vast administrative tasks that are fundamental requirements yet add no value and represent dollars spent that have no impact on high quality patient care. According to a recent study in JAMA Network, for a primary care provider to receive $100 in payment for patient services, they must spend $20.49 in administrative costs. Those administrative costs represent a 20% tax on patient care that provides zero value towards better healthcare outcomes.
Could GenAI help standardize administrative costs? Prior authorization tasks are already being addressed by GenAI, but the variability in payer requirements for prior authorization clinical data and medical necessity requirements limit its effectiveness. What if the prior authorization data and medical necessity requirements were standardized across all state, federal, and commercial payers? GenAI could also analyze the multitude of payer contracts held by healthcare systems, all of which vary drastically between different state, commercial, and federal payer lines of businesses, to find commonality and standardize payer contracts. Finally, envision GenAI as a tool to enable a single transactional model that allows healthcare systems to transact payments in a uniform way for state, federal, and commercial payers.
Despite what some may claim, AI will never replace doctors, but we could use AI to help improve the overall scaffolding that healthcare reimbursement runs on, decreasing costs and freeing up spending to focus on expenses directly tied to patient care activities.
Leveraging GenAI to address administrative tasks, which incurs its own expenses, can improve workflows but won’t address the fundamental, systemic issues facing healthcare. Yes, we need a revolution in healthcare. However, it needs to come through standardization of data exchange, simplified and streamlined payment methodologies, and comprehensive healthcare policy to regulate all of the above. That requires human effort and will, however, can be enabled by GenAI.
Photo: Damon_Moss, Getty Images
Holly Urban, MD, MBA has extensive experience in healthcare technology and believes in the power of evidence-based content to transform EHRs beyond transactional systems into tools that allow clinicians to provide improved patient outcomes. After practicing as a primary care pediatrician, Dr. Urban worked for several EHR technology and evidence-based content companies, and has served in healthcare IT leadership roles for over fifteen years. Before joining Wolters Kluwer Health, she served as CMIO at Oracle Cerner, Director of Product Management at MCG Health, and VP of Product Management at McKesson Horizon Clinicals.
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