AI in Healthcare

Nov 30, 2023

While everyone seems to be talking about AI, in many ways, AI is still in its infancy. And as we start to see it adopted in certain aspects of healthcare, it is already clear that AI will play an important role in the industry’s future. 

How can AI be used in healthcare?

Most of the headlines about AI in healthcare have focused on its potential clinical applications. For example, AI algorithms have been shown to accurately spot breast cancer in screening mammograms. These use cases would certainly be groundbreaking but, as of now, they are also hotly debated specifically in the context of patient privacy, how secure the data remains, and the concern of implementing proper oversight.

However, and perhaps more importantly at this juncture, AI can significantly streamline healthcare administration and operations–reducing costs and, ultimately, contributing to a better member experience.

What benefits can AI bring for PBMs and payers?

Among its many benefits, AI will allow healthcare organizations to be more proactive and predictive.

Take adherence, for example. Using patient and population data, AI will be able to determine which members are the most likely to deviate from their treatment plans. With this information, payers and PBMs can be more agile and targeted in making interventions, allowing for better utilization of limited resources, helping mitigate negative outcomes, and avoid additional costs.

What does the industry say?

There is not a consensus about how AI should be used in healthcare. And, across all industries, there are still questions and concerns about the technology and the proper levels of oversight. 

However, some healthcare groups, like the American Medical Association (AMA), are already developing guidelines that encourage a greater understanding of how to harness AI without compromising care.

Is Abarca using AI?

At Abarca, we’re already leveraging AI and machine learning to predict and detect fraud, waste, and abuse. Using this technology, and 15 years of data, we’re able to predict which claims have the highest probability of being fraudulent–allowing us to better optimize our internal resources in auditing pharmacies and investigating these claims. We’re also piloting other use cases, such as predictive prior authorization and determining proper adherence interventions.

At Abarca, innovation and technology are fundamental to who we are as a company, so it’s only natural that we will be using AI to advance our mission to find a better way in healthcare.