Highmark Analytics Exec Details Prior Authorization Partnership with Abridge

At the same time that it is deploying Abridge’s ambient clinical documentation platform at its Allegheny Health Network, Pittsburgh-based Highmark Health is also co-developing with Abridge a prior authorization solution at the point of conversation. Richard Clarke, Ph.D., Highmark’s senior vice president and chief analytics officer, explained the significance of the deal in a conversation with Healthcare Innovation. 

Highmark Health includes a multi-state insurance division (Highmark Inc.) and a 14-hospital care provider (Allegheny Health Network).

Abridge, also based in Pittsburgh, is developing AI solutions to improve patient outcomes and reduce clinician burdens. An Aug. 14 Business Insider story describes the startup as being on a hot streak. It notes that in 18 months, Abridge has raised $700 million in total and boosted its valuation from $850 million to $5.3 billion, and the company is now working with over 150 large health systems.

As chief analytics officer, Clarke leads Highmark’s AI Center of Excellence, which helps with the organization-wide responsible adoption and use of AI. “We advise a lot of our business units on how to incorporate AI into their strategies,” he said. He also oversees the advanced analytic development team, building software tools involving value-based reimbursement and health outcome optimization.

“Ambient clinical intelligence is being used to reduce documentation burden for clinicians at the point of care, and that is super important,” Clarke said. “But we're also talking about how it can reduce friction between payer and provider. The first step will be in the prior authorization work that we're doing together, but we see many more opportunities in the future to bring payer-related insights into workflow to improve health outcomes and create more affordable care.”

The first phase of the collaboration involves implementing Abridge’s ambient clinical intelligence platform at Allegheny Health Network’s office locations and hospitals. 

Highmark explained that until now, most attempts at solving the challenges of prior authorization have focused on streamlining the approval process post-encounter, but in this solution the authorization process will now happen at the point of conversation. Abridge’s AI solution automates tasks such as completing forms, submitting and reviewing requests, tracking their status, and identifying when prior authorization is needed in the first place. Clinicians remain at the helm of the process, reviewing all AI-generated recommendations before anything is submitted, and will be able to understand in real-time whether they have inadequate evidence for a prior authorization, Highmark said. 

This partnership will build on Highmark’s earlier efforts around prior authorization, Clarke stressed. “We’ve been focused very intently on continuing to improve that experience. We've been doing that with both Allegheny Health Network as well as other provider partners through our active Gold Carding program,” he said. “We’re not just gold carding providers based on their historic performance, but also actively working with providers help them understand what requirements they might be missing, to help them get to some of those thresholds to become gold card. Because we've been doing all that work, we were really well positioned to partner with Abridge. We said let's take the natural next step to bring that into the actual conversation between clinician and patient at the point of care.”

Clarke said the partners are not disclosing any financial terms of the partnership, but he said their intent is to have these things scaled via the Abridge product suite to make sure that they're available to a broad swath of the industry. “We’re looking at how we can develop tests and prove that it works within our environment and then scale it broadly,” he said. “This is an industry-wide challenge and we want to make sure there are amazing solutions out there to help solve it.”

In situations where a health system is using Abridge and they are seeing a health plan member that is covered by Highmark, this could scale very easily, Clarke said, “but our intent is also make sure a lot of this is built on technology that is aligned wit regulations, aligned with industry standards, so that it can expand beyond that, so other health systems and health plans will be able to follow these patterns. We’re really trying to drive towards industry-level solutions.”

The two organizations are already piloting some components in a limited way. “We don’t have timelines in the sense of hard dates, but we're working really fast,” Clarke said, “and our plan is certainly for weeks and months, not months and years.”