Pharmacy Experts: Data-Readiness Key in Reaching Medicaid Population

June 28, 2024
In data-heavy healthcare, having the information in one place is a challenge, industry experts remarked during an online event.

In an online event on June 20, hosted by CaryHealth in collaboration with Medicaid Health Plans of America (MHPA), industry experts discussed innovative pharmacy strategies and the latest in technology to close care gaps in Medicaid populations. According to MPHPA, “In 2025, healthcare will generate 36 percent of the world’s data volume.” “Barriers to utilizing this wealth of data often include insufficient human or clinical resources and the inability to turn raw data around into actionable insights in a timely manner,” MHPA stated in an announcement. In the online discussion, panelists discussed how Medicaid individuals can efficiently be targeted based on their health profile.

“We have a lot of data,” said Jose Diaz-Luna, PharmD, director of pharmacy policy and government affairs with CareFirst BlueCross BlueShield. “You have to go through all these different steps to get anything in some kind of semi-useful data, and you still have to manipulate the data once you get it in,” he added.

“Certainly,” remarked Ryan Steadman, PharmD and SVP with Pharmacy CareSource, “I’ve lived through all the pain points.” Then added, “I would say some of the biggest pain points that we face as a pharmacy industry is being reactive versus proactive.” “[G]etting the data into one place,” Steadman emphasized, is key.

“[I]f you have external partners in the community or even within your own organization, you want to know the success of their outreach,” Steadman noted. You want to be able to get a hold of these vulnerable Medicaid patients, Steadman pointed out.

Miranda Law, PharmD and director of clinical services with CaryHealth agreed that it felt like they would be chasing their tails when obtaining data, especially when reports were delayed and did not include medical information. “[T]he person giving you that report doesn't have all of the components that need to be considered within that population,” Law shared, “you’re getting only half of the picture.” Law believes that telehealth has a solution.

Diaz-Luna stated that data readiness means consolidating all the data in one platform and making it usable. “In my past experience with Medicare,” Diaz-Luna noted, “we created the physician care program to be able to handle high utilizers, and we found out that those patients were disconnected from any care for many reasons.” If having all the data in one platform, he explained, we can intervene and get them into a pharmaceutical care program and follow them as well as clinical and financial outcomes.

“We partner with our care management team day in and day out as an interdisciplinary team,” Steadman added. This shows the patient that we’re looking at them holistically, he said. He noted that the whole patient profile depends on efficient and timely data.

From a technology perspective, Mathew Hawkins, CTO of CaryHealth, remarked, we’re talking about reliable, up-to-date data providing a holistic view of the patient and the wider population. This, he said, will provide the opportunity to dig deeper.

Regarding technological advances, such as Generative Artificial Intelligence (GenAI), Hawkins said, “I think there's been a lot of skepticism generally around GenAI; it's often viewed as a barrier between a patient and a healthcare provider.” Instead, Hawkins added, I look at it as an opportunity to reach more people. “AI is going to give us the ability to look at much more information and find those outliers that we need to interact with to find those very specific patients who have a particular condition or a particular metric that we want to capture and identify.” AI will also help streamline communication, Hawkins said.

“What we do here at Carey is we take the algorithms provided by these companies, which are spending billions and billions of dollars and huge amounts of infrastructure to train those models,” Hawkins explained when asked about AI being trained by humans and whether different healthcare providers and patients are included in focus groups. “We insert our own expertise or our own datasets completely separate from those larger models,” he answered.

“I think that it brings a great solution to healthcare, especially when you're creating your programs,” Diaz-Luna agreed when asked about AI.  “As an industry, we need not to be afraid of it,” Steadman added. “It gives us more time to spend with the members and the patients.” “We’ve been using automation and machine learning (ML) for years,” Steadman reminded the audience. “There’s going to be industry standards…best practices.”

“[A]t the end of the day, it’s being able to know who needs help and being able to do that right away,” Law stated. Being data-ready allows you to streamline patient care, she added. “There's a lot of things that we can do, having all the data in one place, and start interfacing with a provider to make those administrative costs lower,” Diaz-Luna remarked. “Pharmacy is the fastest growing spend in healthcare.

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