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Thursday, December 8, 2022
Home MedInsights Symbiosis between AI, ML and digital platforms for PBMs; driving value-based programs

Symbiosis between AI, ML and digital platforms for PBMs; driving value-based programs

By Vinesh Kolpe, Head of Engineering, HealthPlan CIO, Lumeris

PBMs continue to invest in data & analytics to develop value-based programs given that payers are increasingly looking for ways to utilize real-time data to reduce cost and drive outcomes for their members. Other PBMs may also join the larger PBMs to explore insights derived through analytics. PBMs play a very important in managing healthcare costs and driving value-based programs due to their growing influence on population health.

Value-based programs demand high-end technology

As the care delivery model shifts more Fee For Service to Preventive Value Based care, payers are looking to AI , predictive analytics and genomics to draw actionable analysis from their big data sources to customize care delivery mechanisms. These programs will then support providers to prescribe the most appropriate and effective treatment options to some of the costliest therapy classes for payers, including cancer, diabetes, inflammatory diseases, and high blood cholesterol. When applied with value-based payment strategies, these programs should deliver better medication adherence and improved compliance, reducing unnecessary costs.

For instance, using an advanced analytics platform, the CVS Transform Diabetes program identifies at-risk members, usually prediabetics, and reaches out to enroll them. Members receive digital scales and app-based yearly diabetes prevention coaching for continuous monitoring. Studies have shown that through better lifestyle management, medication adherence, and control of A1C, health can improve while costs can be significantly reduced.

To really understand the vision of the future of pharmacy, it is important to begin with the consumer and think about how their health care journey changes. As technology becomes ubiquitous and integrated into the smart home, the role of the pharmacy and pharmacist evolves into one that may not even be recognized by today’s standards. I see a convergence of health and wellness, along with an expanded role of telehealth and virtual health care. And while the traditional retail pharmacy experience may no longer exist, there still is likely to be a role for coordinated and high-touch care delivered locally— we see competition between health care professionals for these roles (RPhs, RNs, NPs, PAs, and MDs).

As the pharmacy industry increases its use of enabling technologies, pharmacists may find themselves at a professional crossroads: either grow their role’s scope and value or face potential disintermediation. After all, in a not-so-distant future, robots will likely dispense medication to patients, 3D printers may print combination therapies, and algorithms may address most clinical edits. When combined with technology like smart contact lenses that use augmented reality (AR), it’s possible that lower-skilled staff such as pharmacy technicians may be able to conduct basic tasks like visual verification.

At Lumeris, we are bringing common sense back to the business of healthcare by empowering value-based care. We create the partnerships and perspectives that are making healthcare safer, more affordable and more personalized for providers, patients and payers alike.

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