James Grana and Andrew Fogner: The Payer Perspective on Explainable AI and Population Health
Sunday, October 18, 2026
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The speaker reports that healthcare payers have used predictive models for risk stratification and population health for years, and are now applying generative AI to improve decision support, automate administrative work, extract insights from unstructured data, enhance documentation, and accelerate analytic workflows.
“healthcare payers been using predictive models for years for risk stratification and population health what's changing now is how generative ai is transforming the way people interact with you know large data sets information analytics so organizations are using ai to improve decision support how do we automate administrative work can we extract insights from unstructured data you know enhance documentation accelerate analytic workflows and pipelines”
The speaker reports that AI care management solutions require humans in the loop to check, review, and verify quality due to risks like hallucinations that could have concrete consequences on health status or care management.
“i saw a pitch recently and i was just overwhelmed by how sophisticated the ai was now there there are risks associated with this going back to andrew's comment about trust there are risks associated with turning over your care management to ai i mean if there's a hallucination it could have really concrete consequences and that could that's obviously problematic so there have to be humans in the loop checking reviewing recording checking the quality of any ai solution that we would bring to bear on somebody's health status or health coaching or care management”
The speaker reports that AI can automate administrative tasks such as generating letters, responding to inquiries, and conducting proper outreach to specific groups, which are currently done manually.
In this episode of the University of Pittsburgh’s Health and Explainable AI (HexAI) Podcast, host Jordan Gass-Pooré speaks with James Grana, Vice President of Value-Based Care Programs, Innovations, and Contracting with BlueCross BlueShield of South Carolina, and his colleague Andrew Fogner, Epidemiologist and Manager of Data Science and Strategic Analytics. Exploring a new vantage point for the podcast, the conversation examines the integration of artificial intelligence and advanced analytics into healthcare from the perspective of health insurance providers. James and Andrew reflect on the unique position that payers occupy within the healthcare ecosystem, highlighting how health insurance providers leverage longitudinal, population-level data across multiple health systems and care settings to evaluate total cost of care, patient outcomes, and health equity. Bridging operational data science with clinical decision support, the discussion outlines the distinct roles of predictive models in risk stratification and generative AI in accelerating administrative workflows, documentation and care management outreach. The guests address the growing "arms race" between payers and providers regarding AI adoption for coding, approvals and contract review, while emphasizing the imperative of maintaining "humans in the loop" to mitigate hallucination risks and ensure trust. Crucially, the dialogue connects explainable AI directly to value-based care, illustrating how transparent and interpretable models build clinician confidence, support proactive population health interventions and ensure AI tools drive meaningful health improvements rather than fee-for-service volume. Aligning with the mission of Pitt’s HexAI Research Laboratory, James and Andrew offer insights for students and computational researchers on addressing sparse data, establishing AI governance frameworks and evaluating real-world model impact. Reflecting core priorities of Pitt's Computational Pathology and AI Center of Excellence (CPACE), the discussion illustrates how explainable machine learning and sensor-driven molecular profiling advance the frontiers of computational pathology and precision diagnostics. They close the episode by inviting academic research labs to partner with payers in establishing independent model evaluations, acting as a trusted "Consumer Reports for AI” and developing an ethical moral compass to prevent fraud, waste, and abuse in AI-powered healthcare. Host: Jordan Gass-Pooré | Producer: Brent Phillips | Guests: James Grana (VP of Value-Based Care Programs, Innovations & Contracting, Blue Cross Blue Shield) & Andrew Fogner (Epidemiologist & Manager of Data Science & Strategic Analytics, Blue Cross Blue Shield) Topics: Health Insurance Analytics | Value-Based Care | Explainable AI (XAI) | Population Health Management | AI Governance & Ethics | Predictive vs. Generative AI Institutions: University of Pittsburgh | Blue Cross Blue Shield of South Carolina Links: [Pitt HexAI Lab] https://hexai.pitt.edu/
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