PBM contracting could be getting a major overhaul in the near future. Implementing AI tools into the PBM contracting process could turn the old-school grind of sifting through dense contract language (pricing clauses, rebate structures, discounts, etc.) into an instantaneous and streamlined process. AI can extract and analyze the data with ridiculous speed and accuracy; this, of course, could expedite review times for teams spending weeks, or sometimes even months, pulling out key terms and trying to spot leverage points to address. The edge AI provides may let PBM negotiators have more productive conversations with drug manufacturers, arming them with real-time market trends to push for terms that drive down costs for plans and patients.
Beyond speeding up the grunt work associated with contractual reviews and negotiations, generative AI may be able to optimize formularies by crunching clinical data alongside pricing forecasts. Ultimately, this may lead to crafting smarter contracts that balance access and affordability. On the patient side, PBMs may begin developing and/or expanding tools that can power personalized patient adherence programs, which could lead to less hospital visits and a healthier society. All told, AI is pushing PBMs towards efficiency and transparency, potentially freeing up PBMs to focus on more patient-focused value programs.
AI is still in its infancy. Many PBMs are still running on systems that do not have the processing power that AI would command, and data privacy issues are still a major concern in the industry. Integrating AI is easier said than done. You can expect big up-front costs, serious training requirements, and a lot of trial and error in an industry that does not have patience for error. With the implementation challenges and data privacy concerns, it would not be out of the realm for many industry stakeholders to find this transition too much of a hassle and headache, thus being laggards to adopt AI.
The vigorous growth of AI is inevitable, and it will be something PBMs will have to adapt to thrive in a new era of healthcare. If PBMs lean in and use this tech to make contracting more intelligent and patient-centered, they have unlocked maximum opportunity. If not, the industry is moving forward regardless, with transparency and smarter tools here to stay.
The Future of PBMs in 2025: AI, Regulations, and Transparency Initiatives | Pharmacy Times
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