NEW REPORT: Q&A with Mike Gualtieri, VP Principal Analyst at Forrester

Care Optimization Interventions

The Member/Patient journey through the healthcare system and care management programs can benefit greatly from personalized AI-powered insights. Understanding the cost of care and its impact on quality of care is challenging for patients, providers and payers. Proactive insights based on higher quality cost estimates (for all parties involved) delivered at the right time via the right channel (mobile, web, call center, conversational AI, etc.) can alter the trajectory of care management journeys to more valuable, higher quality outcomes.

Care Optimization Applications

High Cost Claim Prediction leverages a Member or Patient risk score model to enable cognitive interventions designed to change the trajectory of a Member or Patient journey to more effective treatment, lower costs, and better outcomes.

  • High Cost ClaimsCare
  • Interventions
  • Star Ratings ImprovementCOVID-19
  • Interventions

Care Optimization AI Use Cases

AI is giving payers and providers the ability to calculate more personalized cost of care estimates for high-cost events (e.g. expensive surgeries like hip and knee replacements) to chronic, long-term conditions. AI-powered risk scores for numerous possible healthcare events, conditions, or costs can enable proactive management before, during, and after these encounters. And the COVID-19 pandemic has highlighted the need for cost and quality management via AI-powered interventions across a broad spectrum of external and internal data sources and AI models.

Care Optimization Interventions are based on personalized profiles

CognitiveScale’s Profile of One is a 360-degree, temporal, longitudinal view of key entities (Consumers, Members, Patients, Providers, Agents, Claims). Profiles form a key foundation for personalized insights and proactive interventions as well as a means to deliver cost estimates personalized to the specifics of an individual Member/Patient.

Care Optimization components that scale

The anatomy of an AI-powered Cost of Care Intervention consists of numerous moving parts: data connectivity and preparation, internal and external models, rules engines and algorithms, integration with enterprise IT systems, measurement and learning ‘feedback loops,’ and assurance that models and solutions can be trusted. Scaling trusted intervention solutions across an enterprise requires CognitiveScale’s Cortex AI platform, and reusable assets and accelerators.

Care Discrimination

CognitiveScale’s Certifai gives organizations the ability to manage trust, bias, fairness and accuracy in the use of AI solutions and their models. Cost of Care AI use cases and models need to be continually evaluated to be sure there is no discrimination based on bias or fairness (e.g. discrimination based on race, sex, or age).

A low-code, assembly line of Care Optimization solutions, campaigns and missions

CognitiveScale’s Cortex software enables clients to manage an assembly line for the development, deployment, management and optimization of numerous Cost of Care solutions as well as manage intervention campaigns and deploy Cognitive Intervention mission templates.

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