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 saw an average 4.28-point increase. This improved adherence yielded an estimated 28 dollars 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 scaling these technologies. 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.

Key Takeaways:

•  Automation Drives ROI and Quality: Embedded clinical automation is a primary lever for improving medication adherence, yielding both measurable quality gains in Medicare/Medicaid and significant financial impact.
• Governance is Essential for Scalability: Successful AI-enabled outreach depends on a foundation of continuous optimization and robust governance to navigate diverse member populations and complex edge cases without friction.
• Strategic Resource Allocation: Intelligent workflow design allows health plans to refocus clinical expertise on high-risk members while maintaining and sustaining high HEDIS and Stars performance.