With pharmacy benefits comes a lot of paperwork and process. Pharmacy Benefit Managers (PBMs), partners, and employers need automation to simplify benefits management. And to some degree, this is where Artificial Intelligence (AI) and health care technology can shine.
In fact, much has been written about AI and its impact on the lives of patients receiving health care. While there is clear value in the use of high-technology applications for PBMs to build efficiencies, handle administrative tasks, and simplify processes for employers and partners, the true game changer in health care lies in integrating these technological advancements with a patient-centered approach that emphasizes personalized care and well-being.
AI, when used effectively, can enhance the patient experience, but it may not be appropriate for every circumstance. Is your PBM relying on clinicians or AI to make prior authorization (PA) and treatment decisions? Are live people answering phone calls or does an AI-driven phone tree force patients to navigate through a lengthy series of pre-recorded messages and prompts before reaching someone that might be able to help?
The answers to these questions are impacting employee satisfaction, productivity, health, and your bottom line. It’s time for employers to take notice of how their PBMs are interacting with their employees.
Balancing high-tech with high-touch: Three things to look for when evaluating your PBM
Human clinical support and guidance is essential to provide the best patient care. Here are three things to look for when evaluating a PBM.
"Thank you so much for your help. I know you guys deal with people all the time, but I was to the point of wanting to cry and pull my hair out or stop taking my medication. I was at a loss, but you have relieved so much pressure. I appreciate you following up."
- Patient, True Rx Health Strategists
#1 – Human guidance in prior authorization decisions is critical
The ProPublica article highlighting the AI-backed algorithms that support systematic denials of PAs by health care giants has rightfully caused a stir in the industry. When PBMs are following PA practices that seem unjustified, it can lead to member distrust and confusion.
Notably, a new survey from the American Medical Association (AMA), found that out of 1,000 physicians, 61% of physicians are concerned about AI’s impact on health care PA denials, which can both create safety risks and add to increased, unnecessary costs.
At the same time, when effectively executed, PAs have an important place in pharmacy benefits and health care overall. They provide an extra layer of safety and cost-management to help ensure that treatments get to the people who really need them.
AI and technology can certainly play a role in streamlining the PA process, but human clinical review of each prior authorization is critical – particularly because mistakes can affect both health outcomes and costs. Relying solely on AI to determine the outcome of a PA process poses a significant risk to patient health and safety, potentially compromising care quality.
Ensuring that your PBM uses an effective mix of high-tech and high-touch in its PA process is beneficial for the employer and employee alike.
"I know you are always getting a lot of negativity, but the group of people I have talked to in the last few days have been the most helpful. They have gone out of their way to help me, and I even got a call back. I’m not used to any of this. The first lady I spoke to told me what I needed to do and was so nice even though I was not very nice to them. They even marked my PA as ‘urgent’ so they could help me even more quickly."
- Patient, True Rx Health Strategists
#2 – Proactive Consulting: AI Can't Replace Human Clinical Consultation
While PBM claims management relies heavily on advanced technology, it’s important to remember there is a person behind every claim.
A human connection is one of the most valuable tools in health care. It’s a standard that all employers should expect when making decisions about PBMs for their team members. Managing pharmacy benefits effectively takes a balance of efficiency for patients and organizations through technology and providing empathetic care to patients through personal connection.
PBMs that take a proactive approach to monitoring claims, reaching out to members with concerns about medications and potential drug interactions or to support complex disease states can help keep patients safe and healthy while reducing medication waste.
Health conditions can be complex, and medication needs are often very individualized. Questions about care are best answered using expertise and experience from health care professionals, informed by listening to the patient, instead of an algorithm or app.
For example, helping a patient manage complex diseases like diabetes requires a human touch and clinical intervention to provide a more holistic approach to identify patient-specific lifestyle and medication challenges and offer support.
Advanced medication monitoring programs, like True Genomics is another example of proactive clinical support. With True Genomics, after a patient takes a pharmacogenomics test, if a claim comes through with a medication or dosage that the test has identified as a potential safety or health concern, a clinical pharmacist reviews the data and decides if provider or patient outreach is necessary.
So, when evaluating a PBM for your company, ensure that your employees have access to personalized consultation with a clinical pharmacist and that a clinician is behind every claim. Ultimately, human-centered care is something AI just can’t provide.
#3 – Personalized Customer Service: How quickly can your employee get help when they need it most?
From the prior authorization process and formulary information to specific medication questions, pharmacy benefits can be complex. Members are seeking quick, personalized assistance to navigate these details.
While AI-powered phone trees and chatbots can offer efficiency, many users still seek human connection for more meaningful support.
The real question is: if your employee needs help, can your employees easily reach a human representative for support? If not, and your PBM is prioritizing automation over human touch leading to long hold times and unanswered questions – are they truly prioritizing people and their care? It’s time for employers to ask more of their PBM.
Benefits administration, along with medical and pharmaceutical care, must strike a balance between high-tech and high-touch to be truly effective in serving patients. While technology is an essential tool, it should not be solely relied upon to make life-altering medical decisions. Pharmacy benefits management should focus on patients first, with personalized attention to individual health stories – a process that empowers employers and patients to thrive.
Ultimately, as AI matures, its potential comes with risk due to compliance, patient safety, and security. Integrating AI into health care must be carefully planned out to ensure the value of the human touch is not lost and patients have easy access to care coordinators. At True Rx we are committed to emphasizing the need for human touch while investing in technology transformation.”
- Praveen Kotha, True Rx Health Strategists, Chief Technology Officer
Founded and owned by a family of pharmacists, True Rx Health Strategists was built from the ground up with a clinical, patient-first approach. Read more about True Rx programs that are hands-on, personal…and are producing results.