AI Can Prevent Millions of Dollars in Losses Amid CMS Part D Regulatory Overhauls

The CMS Part D Redesign Program is set to introduce transformative reforms in the cost-sharing structure for members, health plans, and other stakeholders. These adjustments will hopefully increase affordability and accessibility for members, however, health plans will face significant financial challenges, which could potentially include increases in operational costs due to higher cost-sharing requirements for Part D medications.

In light of these changes, payers should refine their strategy and utilize new innovative solutions to ensure members’ medication regimens are clinically optimal and cost effective. This includes actions like effective and accurate prescribing, preventing expensive medical complications and hospitalizations, implementing deprescribing initiatives and formulary management programs to reduce unnecessary Rx costs, and continuously evaluating cost effectiveness and clinical efficacy.

Historically, these interventions required a meticulous and comprehensive member-centric approach, involving time-consuming identification of members needing interventions, analysis of members’ clinical risks and required interventions, which restricted the potential for savings generated. AI technologies can help payers augment these efforts and optimize drug regimens at a larger scale, with higher clinical accuracy, and greater financial impact.

A key opportunity with AI-based solutions like MDI Health is the ability to drive a much more personalized intervention for a bigger proportion of the population. For instance, within Medication Therapy Management (MTM) programs, members are only included in the program if they have met CMS's eligibility criteria, which is currently less than 10% of Part D enrollees. Among these eligible individuals, less than 20% complete the comprehensive medication review, leading to significant missed opportunities for clinical optimization. Thus, it's necessary to complement these programs with more comprehensive cost reduction technologies that will find untapped clinical and financial opportunities.

MDI’s algorithms are able to run personalized analyses on the entire member population, while analyzing everything from medications to conditions and demographics; previously not possible across an entire population, and instantly generate personalized recommendations for medication regimen changes that will prevent medical complications and are tied directly to cost reduction and revenue enhancement.

Another significant application is AI’s ability to analyze extensive data sets to empower payer organizations to effectively stratify members in need of intervention based on clinical risks and potential impact. AI systems, like MDI, prioritize members with the biggest clinical and financial opportunities, and generate clinical solutions to address the needs of each member, allowing for identification, intervention, and implementation to occur in a fraction of the time of previous methods. Enabling a more strategic approach to clinical and cost-containment programs.

“With these regulatory changes, medication-focused clinical programs have the potential to be a key tool for curving utilization spend. We know that there is a 58% chance a patient that is taking 5 or more drugs will experience an adverse drug event, marking a key domain for cutting medical spending” said Stephanie Stewart PharmD, MBA, Clinical Pharmacist Lead, MDI Health.

As prescription drug spending skyrockets, especially with the increased utilization of Type 2 Diabetes and weight loss medications, coupled with the upcoming Part D cost-sharing adjustments placing a greater financial burden on health plans, organizations are urgently looking to implement cost-containment strategies to offset the growing financial impact.

“We are seeing a significant surge in interest towards deprescribing initiatives, which will continue to grow as we approach 2025. Health plans that will successfully reduce unnecessary medications while optimizing clinical outcomes will be in a critical advantage in light of the forthcoming Part D changes” said Avishai Ben-Tovim, CEO, MDI Health.

“We’ve helped one of our partners achieve a 20% reduction in medications among high-risk members and we can already see the amplifying effect on total cost reduction,” he added.

The significant financial impact of the upcoming Part D changes poses a unique opportunity for health plans to innovate in a way that improves health outcomes while maintaining financial stability. Those driving the future of healthcare through the utilization of new technologies, including AI, to innovate how we care for members and manage the increasing cost of healthcare will be better equipped to manage the ever-changing healthcare landscape.

Schedule a meeting with MDI Health to explore spend reduction strategies in anticipation of the forthcoming regulatory changes.

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