Robert Andrews — a former congressman and the CEO of the Health Transformation Alliance, a cooperative of self-insured companies — predicts AI will be able to personalize formularies for patients within five years.
“Formularies are really built upon economic, commercial relationships between PBMs and drug manufacturers,” he said. “Sometimes that overlaps with the goal of making healthier patients, sometimes it doesn’t. Why shouldn’t it always?”
Mr. Andrews describes himself as “a gospel of AI,” believing it has the potential to tailor drug formularies and maximize health outcomes for an employer’s plan members.
“Some drugs are really helpful for some people, and others aren’t,” Mr. Andrews said, referencing comorbidities.
But it is unclear whether drug manufacturers have an incentive to move toward personalizing formularies.
“Maybe, maybe not,” Mr. Andrews said. “I think the smart ones … are going to figure this out. And what they’re going to say is, ‘You know what? I’d rather sell fewer doses of the drug but have more of a positive impact and share in that positive impact.'” This could result in a higher market value more per dose.
The move toward personalization could come as value-based care is on the rise. It would also be far from AI’s only foray into the health insurance space. Tensions have been brewing amid the Trump administration’s planned use of AI in Medicare prior authorization decisions.
Other use cases, including ways to promote customer satisfaction, have also come to the forefront.
