CareFirst BCBS transformed medication adherence outcomes by replacing manual, campaign-based outreach with embedded clinical automation and AI. By partnering with CaryHealth, they integrated measure strategy and AI-driven engagement directly into their operational infrastructure. 

The results were significant: Medicare percent days covered improved by an average of 8.5 percentage points across chronic conditions, while targeted Medicaid HEDIS® measures increased by an average of 4.28 percentage points.  This improved adherence yielded an estimated $28 per member per month in avoided medical costs and allowed automated workflows to close up to 50 percent of pharmacy gaps without manual intervention.

In this session, presenters will explore the strategic redesign of pharmacy-driven quality, covering everything from cohort construction to AI governance. They will provide a candid look at managing member abrasion and complex edge cases while these technologies scale. Attendees will leave with a practical framework to shift from episodic outreach to continuous, infrastructure-level execution that improves performance while allowing clinical teams to focus on high-risk members.

Learning Objectives:

• Evaluate how embedded clinical automation can be leveraged to improve performance on Medicare Stars and Medicaid HEDIS® medication adherence measures.
• Design governance and optimization strategies to scale AI-enabled outreach successfully while minimizing member and provider friction.
• Apply a practical framework to redesign and modernize pharmacy-driven quality workflows in your own organization.