Agentic AI and the Architecture of Healthcare Transformation
The Affordable Care Act (ACA) of 2010 had a clear goal: to revolutionize healthcare and make it more accessible. Today, over 92% of Americans are covered, rising from 84% back then. However, we face a new problem today – the system is too complex, too slow, and too expensive.
Over $5.1 trillion a year is spent on healthcare, nearly 1 in every 5 dollars in the U.S. economy. Yet, patients feel stuck in red tape, doctors are burnt out, and public trust is falling, which needs to be fixed—more than just digital forms and portals, technology that helps people (not replaces them). The answer lies with Agentic AI.
The Hidden Burden
The real problem behind all the delays, denied claims, and classic burnout stems from manual, outdated operations. Here’s why:
- Prior Authorization: This takes about 35+ minutes for each request, where some payers handle over 100,000 daily.
- Medical Record/Claim Review: These require humans to interpret handwritten notes, PDFs, and faxes.
- Hospitals & Health Systems: Still reliant on email and spreadsheets for multidisciplinary care coordination.
With the current inefficiencies, over 25% of U.S. healthcare spending is now administrative waste.
Why The System Hasn’t Kept Up
While the ACA had its focus set on helping more people get insurance, it was unable to foresee how complicated healthcare would become over time. It overlooked the rise of large, powerful healthcare companies and the massive growth of data and new technologies. Furthermore, the failure to notice that it would take a while for hospitals to change their operational modes plays its role. Therefore, while healthcare looks modern on the outside with applications and online portals, it still is running outdated processes behind the scenes, which are affecting the efficiency of the system.
Leadership at the Centers for Medicare & Medicaid Services (CMS) is calling for real reform. Dr. Memat Oz, the incoming administrator, said the system is “controlled by 150 people who don’t want anything to change.” He wants to see:
- Real-time data use
- Smarter, faster systems
- Technology that supports both patients and providers
Furthermore, he warned that AI must be used responsibly, making it clear: we need tools that are both powerful and trustworthy. Now that’s where Agentic AI comes in.
What is Agentic AI?
A new, smart kind of technology that understands healthcare. This isn’t your traditional automation, which follows a bunch of set rules; instead, agentic AI can:
- Understand complex information
- Learn from data over time
- Work alongside humans to make decisions
- Adjust quickly as rules and needs change
It won’t just save your time, it’ll help your people do their jobs better. Consider Agentic AI as a helpful teammate!
To top it all, healthcare can leverage Agentic AI in various ways, such as:
For Health Plans:
- Faster Prior Authorizations: From reviewing treatments to giving quick and explainable decisions.
- Spotting Care Gaps: Timely alerts are sent whenever a patient needs a check-up or tests.
- Claims and Appeals: It skims through clinic notes and helps expedite decisions.
- Risk Assessments: It matches codes and pricing models quickly and accurately.
For Hospitals and Health Systems:
- Clinical Research: It helps researchers find the right patients for case studies.
- Care Management: It brings together a patient’s risks, needs, and treatment plans.
- Billing and Compliance: It writes summaries for approvals and insurance claims.
- Team Coordination: It helps doctors and nurses share updates clearly and quickly.
If your team wants to focus on care and not paperwork, Agentic AI is your answer. Not only does it reduce your burden and paperwork, it also improves communication.
Healthcare is under immense pressure, specifically with costs rising, frustrated patients, and exhausted staff members. Regulators are looking forward to better results and less waste. Building the team is not going to change a thing, especially if we need systems and not more people. If your team wants to focus on care and not paperwork, Agentic AI is your answer. Not only does it reduce your burden and paperwork, it also improves communication, empowers the team with effective assistance, and can transform messy, complex tasks into smart, efficient actions – the future is Agentic.
