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Leader Spotlight: Siva Namasivayam, CEO & Co-Founder, Cohere Health


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Welcome to your briefing:

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  • INSIGHTS CORNER: Spotlight: Siva Namasivayam, CEO & Co-Founder, Cohere Health

  • TRIVIA: What is the term for healthcare that designs treatments based on the individual characteristics of each patient?


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With your expertise in business, healthcare, and entrepreneurship, what motivated you to enter health tech and start Cohere Health? What does the company offer health plans?

I'm deeply invested in enhancing healthcare through entrepreneurship. My journey began in a family of physicians, sparking my interest in solving healthcare challenges. With an engineering background and a knack for product creation, I leveraged those skills to address critical issues in healthcare.

The idea for my current venture, Cohere Health, emerged from a knee injury and the subsequent struggles associated with the prior authorization process, highlighting the system's inefficiencies.

Launched in late 2019, Cohere is a clinical intelligence company that utilizes AI technology and deep clinical expertise within the prior authorization process to improve patient outcomes and foster greater collaboration between providers and health plans. Currently processing 5.5 million intelligent prior authorizations annually, we positively impact more than 15 million health plan members and 420,000 healthcare providers nationwide.

Prior to Cohere, I led SCIO Health Analytics, a healthcare analytics company, which, after more than a decade of growth, was acquired by EXL for $250M in 2018. This is my third successful venture focused on transforming the healthcare landscape through innovative solutions.

Why do you believe AI can enhance care quality in the prior authorization process?

AI in the prior authorization process is a launch pad for a more longitudinal approach to helping achieve the best and fastest patient outcomes.

Applying AI and machine learning (ML) models to healthcare data will improve care quality with upstream moments of influence. For example, data-driven provider recommendations get patients to the right specialists sooner.

Whether getting patients to the right providers or authorizing multiple service requests on a care path in an episodic authorization, AI can improve care access and drive better health outcomes.

Physicians will always be needed to care for their patients, and we are committed to getting medical professionals back at the bedside. Our intelligent prior authorization platform takes a care-path approach to utilization management (UM), orienting prior authorization transactions within the broader context of the entire patient journey. Prior authorizations can be moments of influence to drive better care, using AI and ML to leverage data and collaborate with physicians to move toward higher-quality care.

We see a future where AI technology drives preventative measures to reduce risk, decrease the need for more invasive interventions, help physicians practice at the top of their licenses, and simplify the path to better care quality.

With ongoing advancements in healthcare technology, what key trends do you predict will notably shape the industry in the near future?

Rapid advancements in AI technology have made healthcare administrative workflows far more efficient and enabled stakeholders to increase and automate previously manual outputs. AI is already changing prior authorization and UM, and I believe we are well-positioned to lead the movement toward improved patient outcomes and reduced administrative burden. 

When you think about UM, a huge part of the practice is moving data from one site to another, and then having individuals review that data to determine medical necessity. We believe that there’s a great opportunity for AI and ML to accelerate this process and increase its efficiency. However, AI should never be used to deny care to patients; responsible AI practices should ensure that AI does not replace the work done by licensed physicians, but instead should change how individuals work to make the prior authorization process more efficient.

We’ve found that AI technology guides clinical choices to help providers and patients get to a quicker “yes” for their prior authorization request, without that unnecessary and abrasive back-and-forth with legacy systems. AI plays a very powerful role in extracting and transforming previously unstructured clinical data into a format that enables automated clinical decision-making and lightens the workload of clinical reviewers for more complex cases.

AI’s greatest potential to transform prior authorization and UM will be seen when there’s a collective focus on improving patients’ access to care by:

  • Leveraging all patient data to make prior authorization decisions

  • Protecting patient information from these models’ long memories

  • Balancing the benefits of reduced administrative burden with accuracy

  • Keeping a human in the loop: AI shouldn’t be used to deny care

The healthcare sector is grappling with serious workforce issues like burnout and staffing deficits. What strategies can effectively mitigate these problems?

At Cohere Health, we envision a future wherein physicians and nurses can refocus their time and attention on patients instead of paperwork. The bloated administrative tasks weighing down the healthcare system prevent medical professionals from doing their best work, at the top of their medical license.

We see the potential of AI to restore the focus to the art of medicine. Technology is a catalyst to make healthcare more human.

It is common for prior authorization requests to be submitted with incorrect or missing attachments. Instead of burdening providers with time-consuming and often redundant clinical assessment questions, technology can identify which documentation is necessary for an authorization to be decisioned automatically and prevent incorrect attachments or incomplete submissions. By retrieving critical information at the point of care, Cohere’s solutions can ameliorate provider burden and burnout, and improve transparency of information and decision-making.

One of the best ways to reduce provider abrasion is to make prior authorization touchless, and interoperability is critical to achieving this end. A frictionless end-to-end authorization process means providers and health plans never have to deal with prior authorizations for appropriate care.

The transport of information is one part of the end-to-end automation puzzle, but exchanging information doesn’t result in automatic decisions; it’s like having a rocket ship without any fuel. Cohere’s decisioning platform draws on thoughtful, evidence-based care and specialized society guidelines to empower doctors to make the right choices for their patients.

For example, Cohere can pre-authorize the next best step earlier in a patient’s care journey, and assist non-specialty physicians in identifying complex conditions, giving them the keys to get patients to and through the best treatment more efficiently.

It’s not technology but rather excessive administrative tasks that are stripping away humanity from healthcare.

How does Cohere Health ensure patient privacy and data security while collaborating with various healthcare stakeholders, such as payers, providers, and patients?

At Cohere Health, we are leveraging AI to transform prior authorization and create elevated patient care journeys, rather than focusing on the process as a simple transaction.

In creating guidelines for AI use within the prior authorization process, I believe that ethics are crucial and that guidelines should be built with the collaboration of governmental agencies, clinical experts, and software engineers.

For Cohere, there are four main pillars of thought around ensuring the ethical use of AI:

  1. Accountability: Cohere’s team of nearly 190 clinical experts ensures accountability is grounded in evidence-based clinical knowledge and expertise.

  2. Transparency: Cohere shares with the requesting provider the clinical basis for our decision to approve or pend the prior authorization for further review. Again, our AI technology never denies care to patients.

  3. Privacy (& security): Cohere’s AI models do not use explicit identifiers for patients–such as names, locations, and providers–for additional care option suggestions.

  4. Inclusiveness (& equity): Cohere’s AI models leverage a variety of policies, and clinical experts always review pended requests, to apply standards of care with inclusivity and equity across a health plan’s entire membership.

We ensure our AI technology systems are clear and transparent in how they work, keeping patient data secure, and ensuring everyone gets fair treatment, regardless of background. 

What key considerations should payers prioritize when evaluating AI solutions for automated prior authorization, to ensure a strategic and effective choice?

The right health plan partner connects the dots to leverage AI responsibly and restore humanity in healthcare. Physicians weren’t meant to be a computer or complete medical school just so they could do paperwork all day. The right AI solution gives them the freedom to focus on their patients.

Some prior authorization solutions are all “carrot” (approving every authorization request) and others are all “stick” (denying every authorization request). At Cohere Health, we never deny care through AI and always put physicians in front of clinical decisions. We empower physicians by giving them the keys to get patients to and through their best treatment more efficiently. 

Any reputable AI and ML-powered prior authorization solution can process enormous stores of data, but pairing it with clinical intelligence is how the right AI solution partner enables more patients to receive the right care, at the right time. 

By championing responsible AI alongside advanced clinical innovation and oversight, the healthcare industry can chart a course toward a more patient-centric, precise, and equitable healthcare system.

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More about Siva Namasivayam

In his third entrepreneurial healthcare venture, Siva Namasivayam is passionate about building companies focused on improving the healthcare system. Before co-founding Cohere Health and serving as its CEO since 2019, Siva was a founder and CEO of SCIO Health Analytics - a healthcare predictive analytics company for health plans, providers, life sciences, and pharmacy benefit managers. The company was acquired by EXL for $250M in 2018. Siva has more than 20 years of experience in utilizing technology and data to improve healthcare processes. He holds a master’s in computer science from the University of Pittsburgh, as well as an M.B.A. from the University of Michigan.

GE HealthCare “A breakthrough moment in healthcare”

GE HealthCare's blog, "A Breakthrough Moment in Healthcare," underscores a pivotal shift: healthcare is being fundamentally transformed by technology.

Here’s a breakdown of how this transformation is unfolding:

1. Precision in Practice: Mastering the Molecular: The growing prevalence of chronic diseases like dementia and cancer is necessitating a shift towards precision healthcare. This approach tailors treatments based on individual genetics and lifestyles, promising not only to enhance patient outcomes but also to alleviate the pressures on health systems. With an expected 28 million cancer cases by 2040, precision healthcare offers hope for improving patient care.

2. Leveraging Data: Synthesizing Big Data: Hospitals annually accumulate 50 petabytes of data, of which 97% remains unused. The application of AI and cloud technologies is pivotal in harnessing this dormant data, transforming it into actionable insights. This has the potential to unlock $1 trillion in productivity improvements, revolutionizing the efficiency of healthcare operations.

3. Access for All: Democratizing Healthcare: Access to advanced healthcare remains a significant challenge, particularly in remote areas. Innovations in AI-guided diagnostics and cloud technology are crucial for extending the reach of advanced care, promising to democratize healthcare. By making quality healthcare more accessible, these technologies aim to ensure equitable health outcomes across diverse populations.

Key breakthroughs to watch:

  • Alzheimer’s Therapy: FDA-approved treatments targeting amyloid proteins, with precision imaging crucial for monitoring.

  • Theranostics: A blend of diagnostics and therapy, personalizing cancer care.

  • Immunotherapy: Set to revolutionize disease treatment, supported by AI and advanced imaging.

Looking Ahead: The integration of genomics, AI, and bioinformatics will shape the next decade of healthcare innovation.


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