CHAI CEO Explains Its "Hardest" Task: Prior Auth Reform

Newsweek

16 hours ago

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Newsweek hosted its first Women's Global Impactforum on Tuesday, and health care was a hot topic.
In preparation for the forum, I got to know some incredible health care executives and dive deeper into a question I've been mulling over for ages.
According to the World Health Organization, women make up nearly 70 percent of the global health care workforce. However, McKinsey & Company found that women only hold about a quarter of the industry's leadership roles and less than 20 percent of C-suite positions. How might hospitals benefit from closing the gap?
Health care's stubborn "glass ceiling" has been researched for decades, yet women still haven't made substantial gains in its C-suites. And recently, workforce woes have shed new light on the issue. Frontline workers are reporting record-high levels of burnout and waning faith in management. Meanwhile, leadership teams are struggling to retain them.
There's a clear disconnect between those who provide health care and those who steer health care organizations. Notably, one group is overwhelmingly female while the other is overwhelmingly male.
Rhonda Jordan, executive vice president and chief human resources officer at Virtua Health, believes that balancing the scales can improve satisfaction across all levels of the organization. The New Jersey health system is a quality case study; it recently landed on Newsweek's ranking of America's Greatest Workplaces 2025 with a perfect five-star score, and it has been recognized by Press Ganey for an exceptional "culture of belonging."
At the Women's Global Impact forum, Jordan shared that 60 percent of Virtua's executive leaders and 41 percent of its board members are women. That's significantly higher than the industry average and took intentional effort.
"We started with a foundation, and we asked ourselves the question, 'Who did we want to be and why, and what was the culture we wanted to set?'" Jordan said. "We wanted that culture to be focused on belonging and inclusion."
Virtua established a nominating committee on the board that had targets and goals around diversifying the board. Then, they inked that promise, instituting bylaws to ensure that half of the board of trustees reflects the demographics of its patient population, and more than half of its senior leaders are women. That wasn't to hit a "DEI" quota, but to get serious about succession planning and what the future of the health system should look like. Jordan and her team wanted it to represent the people they serve.
Jordan and the other women on the panel—including Dr. Heather Farley (chief well-being officer at the Medical University of South Carolina, and future vice president of professional satisfaction at the American Hospital Association), Dr. Stacey Rosen (executive vice president of the Katz Institute for Women's Health at Northwell Health, and president of the American Heart Association) and Jannine Versi (co-founder and CEO of Elektra Health)—also spoke about the importance of sponsorship in raising the next generation of leaders.
A mentor shares knowledge, speaking with you. But a sponsor takes the relationship to the next level by speaking about you, Jordan told the audience.
"A sponsor is someone who talks about you when you're not in the room," she said. "It's that individual who is the influencer. They have to have some credibility, and they could speak to the work that you do.
"Everyone should have a sponsor."
Check out our live blog for more takeaways from the cross-industry event. And don't miss our Digital Health Care Forum on September 16.
In Other News
Major health care headlines from the week
AI has solved health care's note-taking problem, but moving beyond ambient scribes—and fixing the core business—is proving to be more difficult . In my latest article for Newsweek, I spoke with leaders from Hospital for Special Surgery, MIT and more to learn how they're navigating the next phase of AI implementation. Get the scoop here.
. In my latest article for Newsweek, I spoke with leaders from Hospital for Special Surgery, MIT and more to learn how they're navigating the next phase of AI implementation. Get the scoop here. In 2017, only three urban hospitals dually qualified as rural hospitals. By 2023, there were 425 hospitals with that designation , per a new study published in Health Affairs.
, per a new study published in Health Affairs. That's thanks to a 2016 CMS rule which allows hospitals to use urban wage indexes to calculate Medicare reimbursements—while simultaneously benefiting from programs reserved for rural hospitals, like easier eligibility for 340B.
"Congress should ensure that federal programs supporting rural health are directed solely to geographically rural hospitals," argued the report's authors from Brown University and Johns Hopkins University. However, such changes would likely prompt pushback from hospitals that are based in urban epicenters yet treat a significant rural population.
argued the report's authors from Brown University and Johns Hopkins University. However, such changes would likely prompt pushback from hospitals that are based in urban epicenters yet treat a significant rural population. Outcomes are improving for hospital surgical patients , according to a new report from the American Hospital Association (AHA) and Vizient. The new analysis builds on findings from last fall that hospitalized patients were nearly 20 percent more likely to survive than expected in the first quarter of 2024 than in the fourth quarter of 2019, based on their acuity.
, according to a new report from the American Hospital Association (AHA) and Vizient. The new analysis builds on findings from last fall that hospitalized patients were nearly in the first quarter of 2024 than in the fourth quarter of 2019, based on their acuity. This week's report attributed that win to declining rates of falls and hospital-acquired infections, plus fewer instances of post-operative conditions like hemorrhage, sepsis and respiratory failure .
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Still, as care shifts to the outpatient and ambulatory setting, hospitals are likely to see higher-acuity patients over the next decade. The AHA and Vizient found that the average length of stay for hospitalized surgical patients has increased by about one full day over the past five years.
over the past five years. Secretary Robert F. Kennedy Jr. and the Department of Health and Human Services (HHS) have rolled back more federal policies that incentivized hospitals to report staff vaccination rates .
. The move will decouple hospitals' reimbursement rates from staff vaccination rates, which is sure to eliminate some of the reporting burden on health systems. But it also raises questions about hospitals' responsibilities to public health as vaccination rates decline across the nation, while diseases like measles, whooping cough and hand, foot and mouth disease are back on the rise.
Pulse Check
Executive perspectives on key industry issues
Dr. Brian Anderson is the president and CEO of the Coalition for Health AI, known as CHAI.
Dr. Brian Anderson is the president and CEO of the Coalition for Health AI, known as CHAI.
CHAI
When I want a well-rounded perspective on the health care industry, Dr. Brian Anderson is my first call.
He's the president and CEO of the Coalition for Health AI (CHAI), which brings together more than 3,000 organizations from across the industry to develop best practices for health care AI. He works closely with technology developers, government officials, patient advocates, payers and providers to find solutions that all parties can get behind.
On Monday, I spoke with Anderson about CHAI's working group that focuses on prior authorization reform. The goal is to get payers and provider groups "on the same page," he told me. That's easier said than done.
But it's necessary work, and a priority of the federal government, too. CMS is also working to automate prior authorization through its WISeR model, which aims to leverage technology and expedite the claims process for certain conditions.
Below, find a portion of my interview with Anderson about prior authorization automation—and aligning stakeholders on a common goal.
Editor's Note: Responses have been lightly edited for length and clarity.
Brian, you've said that payers and providers need to align on the technical aspects of a best-practice framework for digitally driven prior auth reform. What do providers want to include in that framework?
One of the more common areas of agreement with the provider groups is the minimum amount of data that's needed to make the decision. I think many patients would agree with that, right? Like, I don't necessarily want my data to be shared openly with everyone if that data is not going to be used for a specific purpose.
And I think that's part of the challenge. If the payers need a certain amount of data to make a decision, and the providers are willing to give that data, what is the minimum amount of data that's needed that we can share as quickly as possible—ideally electronically—in such a way that that decision can be made accurately and quickly for the patient?
It's obvious, but worth stating, [that] sharing that data electronically versus on a paper form that's filled out and then faxed over [would be faster]. So creating the kinds of preauthorization pathways that allow data to flow in a more automated fashion, leveraging things like the technical framework or some of these CMS Aligned Networks , that, of course, requires a level of interoperability between providers and payers that would be beneficial to both sides.
In July, you spoke on a panel at CMS' Quality Conference. During that discussion, the moderator, CMS Administrator Dr. Mehmet Oz, mentioned that 49 percent of doctors are still responding to prior auth requests on paper. How can technology be used to reduce that number?
Yeah, [there are] a number of things. In a pre-AI world, if you wanted to digitally map each field of a preauthorization form to specific elements within the EHR, that's a hand-crank manual process of mapping to extract those data elements and be able to fill out a form electronically.
In an AI-driven world, if you're training a model to be able to understand the kinds of data and the intent of what that specific field in that form is trying to get, you can then train a model to look for those specific data elements in the EHR. The heart of all this is going to be, can we have AI models that are trained in an appropriate way to look at an EHR record and extract the minimum amount of data needed for that pre-authorization form?
AI can be trained in in a way that doesn't require the kind of hard coding of "field X here, field 1 here, field Y here." These models can be trained to look for that kind of data or to summarize a particular field in the preauthorization form that might come from several different parts of an EHR. That kind of summarization, or that kind of intent, is something that you can train these models on, particularly in the generative AI space.
And in doing that, you're reducing the burden significantly on a provider or a nurse. Oftentimes other people have to fill out these forms, and it takes time, and it's on paper. So, the hope is that, one, it's digitized. Two, it's automated. Three, it's automated in such a way that you can get these kinds of communications as close to real time as possible.
You've been a part of a number of these conversations at a national level and work with thousands of organizations across the ecosystem. What is the sentiment about this sort of reform right now? Is there excitement, skepticism? How are people feeling?
I'd say there's probably more skepticism than excitement. This is a really hard space. It's probably one of the hardest, if not the hardest working group that we have, because of the lack of trust and the stakes. But that's why it's so important.
And I mean, this is something that our community has asked us to try to focus on, so we're going to try our best. I think it's important to remember that these documents are living documents, and so developing a best practice doesn't mean that we've developed it and we can move on to something else entirely. This is the beginning of a journey, and hopefully building the kind of common language and frameworks that both parties can agree to will ultimately get us to a level of trust.
Will we get there in six months? If I'm being honest, I don't know. Chances are we might not. I'd be pleasantly surprised if we did. I think the stakes are pretty high. And we're hearing from patients pretty clearly that they want this solved. The administration has made that clear too, and so this is absolutely a priority for us.
C-Suite Shuffles
Where health care leaders are coming and going
Intermountain Health is switching up its pediatric leadership ahead of Katy Welkie's planned retirement in late August. Welkie is currently the CEO of Intermountain Primary Children's Hospital in Salt Lake City and vice president of children's health for the system.
Dustin Lipson , president of Intermountain Primary Children's Hospital, will assume an expanded role overseeing pediatric care throughout southwest Idaho and central Utah.
Mandy Richards —Intermountain's chief nurse executive—will take the reins from Lipson to become president of Intermountain Primary Children's Hospital.
Highmark Health, based in Pittsburgh, has tapped Dr. Alistair Erskine as its chief information digital officer.
He joins the payer-provider enterprise from Emory Healthcare and University in Atlanta, where he managed a $350 million annual budget as senior vice president, chief information officer and chief digital officer. He also established a chief financial informatics officer role at Emory and was instrumental in creating the world's first hospital that is fully powered by Apple products.
Susan Monarez as director of the Centers for Disease Control and Prevention (CDC) last Thursday. In case you missed it, Robert F. Kennedy Jr. swore in last Thursday.
Monarez previously served as acting director of CDC and deputy director for the Advanced Research Projects Agency for Health, working on disease detection, treatment technologies and data collection.
According to NPR, she is the first CDC director to be confirmed by the Senate and the first to hold the title without a medical degree in more than seven decades. She received her PhD in microbiology and immunology from the University of Wisconsin-Madison.
Executive Edge
How health care execs are managing their own health
Dr. Jessica Shepherd is the chief medical officer at Hers.
Dr. Jessica Shepherd is the chief medical officer at Hers.
Hers
Hers blessed us twice at Tuesday's Women's Global Impact forum, with (1.) a sponsored cocktail hour and (2.) their Chief Medical Officer Dr. Jessica Shepherd.
Shepherd joined Newsweek's Kylie McCoy for a fireside chat, sharing personal stories and professional insights on improving access to women's health care.
The conversation covered innovations in telehealth, drug compounding and personalized care. But for today's Executive Edge, I pulled a few of her insights on self-awareness and advocacy. I think they'll prove useful for anyone who is working to care for themselves while pouring out for others.
Editor's Note: Responses have been lightly edited for length and clarity.
"Midlife...just wink, if you know what I'm talking about. Even as a physician, going through it myself right now, it's [about] my favorite word, self-awareness."
"I would [suggest] for everyone who's in midlife to say, "Let me do a pause and take a stop right here and reflect on myself. What do I need in this moment, and how am I going to get that?" Being the chief medical officer, that's one of the biggest emphases that I can have. How do I care for women in a way that is going to make them more self-aware and advocate for themselves?
Being the chief medical officer, that's one of the biggest emphases that I can have. How do I care for women in a way that is going to make them more self-aware and advocate for themselves? "I think the best advice that I've been given is always believe in yourself. You are going to be that best vehicle that's going to get you to the place that you want to go within yourself. If I were to talk to my 30-year-old self, I would say, believe in yourself, but also never fear the outcome.
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