Many health plans offer wellness programs to encourage healthy behaviors, but getting members to engage and use the services can be a challenge.
Pager Health, a virtual care navigation platform, sees opportunities to use generative AI to help guide health plan members and provide a more personalized experience, like a companion to provide one-on-one support.
The company, which provides nurse triage, wellness and care management platforms for payers and providers, rolled out a new AI wellness agent as part of its ReallyWell health and wellness program. The AI agent is designed to remove friction that holds members back from fully gaining benefit from well-being programs, according to the company.
The AI wellness agent serves as a conversational AI companion, eliminating clicks through multiple pages or tedious searches for information. It proactively routes members to personalized actions including health challenges, coaching enrollment or health assessment completion, often in a single step.
The company works with payers, providers and employers, representing more than 26 million individuals across the U.S. and Latin America.
When it comes to health plan benefits, there can be a "discoverability" problem, noted Rita Sharma, chief product officer at Pager Health, in an exclusive interview.
Many members aren't aware of all the wellness programs and benefits available to them through their plan.
"With this AI wellness agent, we can take them right to those solutions. If they have resources like coaching available to them, we can also make that available to them proactively," Sharma said. "We're able to create this 'one-size-fits-one' experience for that member. We know this is very important because utilization is driven by that, people will use the tools that are personalized to them."
Pager Health's AI wellness agent can encourage users to complete actions like connecting fitness devices, finishing health assessments or redeeming wellness rewards. The agent also can answer complex FAQs around rewards, benefits and offline programs, reducing friction and call center traffic.
The agent also will personalize engagement based on the user's known activity, such as unfinished tasks or previous chats.
The AI wellness agent is currently deployed across web and mobile portals with a road map to expand to SMS and WhatsApp.
"It really allows us to deliver a guided experience with the power of AI to go through your wellness journey. As we learn about the person, as we learn about their health assessment, as we get their biometric data, as we get their fitness data, the agent is able to provide a journey, and the journey can be to other clinical support and other programs that they might have access to," Sharma said.
Based on Pager Health's data, about 15% of its patient and member population reports feeling symptoms of depression. "We can guide them to the programs that they have available," Sharma said.
The AI wellness agent includes emergency intent detection across 19 clinically validated scenarios, directing members to 911 or 988 when needed. These protocols are built using thousands of real member interactions and reviewed by clinical teams to ensure safe, responsible AI deployment, the company said.
A year ago, the company unveiled new enterprise tools using Google Cloud generative AI technology for its payer partners—chat summation, a frequently asked questions bot and sentiment analysis.
The company also built its AI wellness agent on Google Cloud AI and advanced natural language processing.
"We're built on the Google Vertex AI platform, which allows us to actually innovate much more quickly because we're not trying to maintain our own models and our own platforms. I think that that's been a huge accelerator for us as a company, to be able to bring these kind of agents to the market," Sharma said.
Unlike legacy chatbots or static menus, Pager Health agent understands natural, open-ended member requests, the company claims. It can detect when someone needs help, whether that’s a health program or an emergency intervention, and routes them accordingly.
The agent also can interpret intent across a wide range of phrasing styles and continuously improves its accuracy through machine learning. The result is faster time-to-task, better program utilization and a lower volume of members requiring service calls.
Founded 10 years ago, Pager Health combines high tech and high touch with AI capabilities and virtual nurse triage services. The company has nurses licensed in all 50 states and Puerto Rico, Sharma said.
The company can connect a member to a triage nurse in less than 30 seconds, she noted.
"About 66% of the time, we're able to keep that person from going to the emergency room or going to urgent care because we're able to provide the care right there, provide self-care or provide some kind of a referral to them so that they can get the care that they need," she said.
Organizations are exploring the use of AI to create more personalized experiences for patients and health plan members.
"We're in a very new territory. The organizations that are more innovative are saying, 'Yes, I want to participate in this AI economy.' We're very early in this adoption of AI, I would say, as an industry," Sharma noted.
She added, "I would say, it's moving very, very rapidly. Every payer I'm working with right now is doing something in AI. I think it's just going to take everyone getting very comfortable with it. And when I say everyone, I think legal teams and procurement teams."
Organizations need to be transparent about how they are using AI and data.
Pager Health says it has implemented robust data rights protections, including client-specific data silos and full compliance with HIPAA and privacy standards.
"We created a data rights memo to help our customers understand what we do with the data, what we don't do with the data, that it's anonymized, that it's not used to feed our foundational models, to help everyone feel much more comfortable with moving forward with AI tools," Sharma said.
Many health plans are moving forward with AI as they see opportunities to improve efficiencies in their operations. But they also recognize the potential to improve members' experience and engagement, Sharma said.
Only about 1 in 4 insured adults trust health plans to assist in their care journey, according to a Pager Health survey. And 76% of surveyed adults say poor customer experiences reduce trust in their health plan.
But two-thirds of surveyed individuals said they would trust a health insurer’s artificial intelligence copilot to accurately inform them about a health plan’s benefits. Of the respondents, 66% believe AI can correctly personalize digital healthcare with the goals and needs of the member.
"I think there's a great opportunity to actually win the consumer back," Sharma noted.
"What consumers have said in that survey is, if [health plans] create personalized experiences for me, I will be more inclined to have an affinity for my payer," she added.