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Where AI Can Help Health Systems Manage Complexy & Specialty Pharmacy Operations · Becker’s Healthcare Podcast

• 0:00
  - Well, hello everyone. This is Erica Spicer Mason
• 0:02
  - with Becker's healthcare. Thank you so much for
• 0:05
  - tuning into the Becker's healthcare podcast series.
• 0:08
  - My guest today is Kim Zumakis,
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  - the CEO of Vital one, which works with
• 0:13
  - hospitals and health systems on pharmacy management,
• 0:16
  - specialty pharmacy services, and three forty b programs.
• 0:19
  - Kim brings more than twenty five years of
• 0:21
  - health care leadership experience, including a leadership role
• 0:24
  - at one of the country's largest integrated cancer
• 0:27
  - care networks.
• 0:28
  - So today we'll discuss where AI could help
• 0:30
  - health systems manage complex and specialty pharmacy operations
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  - and what leaders should consider as they put
• 0:36
  - it to work.
• 0:38
  - Kim, so great to have you with us
• 0:39
  - on the podcast. Thanks again for being here
• 0:41
  - today.
• 0:42
  - Thank you. Great to be here.
• 0:44
  - So glad to have you. And to get
• 0:46
  - us started, I thought it might be helpful
• 0:47
  - to first touch on some operational challenges that
• 0:50
  - you're seeing in the space here.
• 0:52
  - What is an operational challenge in managing complex
• 0:54
  - and specialty pharmacy across a health system that
• 0:58
  - leaders may oftentimes underestimate?
• 1:01
  - Yeah. It's a great question because I think
• 1:03
  - this is one of the areas that that
• 1:05
  - our clients grapple with the most. And, certainly,
• 1:07
  - as I talk to other, health system pharmacy
• 1:09
  - leadership across the country, they're all struggling with
• 1:12
  - it. And really the biggest challenge is because
• 1:15
  - three forty b specialty
• 1:17
  - contract pharmacy, meds to beds, all of the
• 1:20
  - ecosystem
• 1:21
  - that that flows through,
• 1:23
  - the pharmacy workflow is very complex, and the
• 1:25
  - handoffs between the data
• 1:27
  - live in different systems. Reconcile... Reconciliation is often
• 1:31
  - manual.
• 1:31
  - Compliance monitoring has to be done,
• 1:34
  - pretty manually. There's still a lot of even
• 1:37
  - very sophisticated systems that are doing part of
• 1:39
  - this on spreadsheets.
• 1:41
  - So it's really reliant on
• 1:43
  - on,
• 1:44
  - data interconnectivity,
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  - which just is not as smooth as I'm
• 1:48
  - sure, they would all like it to be.
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  - And that's really where the value leaks out
• 1:52
  - and where skilled pharmacy teams burn hours and
• 1:55
  - hours on work that isn't clinical, that isn't
• 1:57
  - patient facing,
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  - and,
• 2:00
  - you know, really takes away from what pharmacy
• 2:02
  - should be, which is a strategic asset for
• 2:03
  - the health system.
• 2:05
  - But those pieces have... Of connectivity
• 2:07
  - have to happen,
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  - especially as we see the evolution in in
• 2:11
  - both the rebate world and three forty b
• 2:13
  - across the country.
• 2:15
  - Mhmm. Yeah. Kim, you know, pharmacy is just...
• 2:18
  - As a strategic asset, as you mentioned, it's
• 2:20
  - something that we hear so much nowadays at
• 2:23
  - Becker's in our conversations with leaders. So
• 2:26
  - definitely hear you on that and the complexity
• 2:28
  - piece as well.
• 2:30
  - I know when we're talking about complexity, especially
• 2:32
  - in administrative processes,
• 2:35
  - AI
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  - comes up in conversations
• 2:37
  - very often nowadays. So can you walk us
• 2:40
  - through a pharmacy workflow where AI
• 2:42
  - makes a really meaningful difference for teams that
• 2:45
  - are doing this work?
• 2:47
  - Yeah. Absolutely. And and we're seeing kinda two,
• 2:50
  - really important ones. The the first and foremost
• 2:53
  - boast is three forty b compliance monitoring. As
• 2:55
  - you know, there's
• 2:57
  - a lot of noise out there in the
• 2:58
  - industry, a lot of manufacturer,
• 3:01
  - pushbacks on three forty b, even when health
• 3:04
  - systems are are using three forty b for
• 3:06
  - exactly what it was defined for,
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  - which is what, we see with all the
• 3:11
  - clients that we work with. But staff are
• 3:13
  - trying to pull reports, review records, make sure
• 3:16
  - that the information is in the EMR,
• 3:18
  - manually checking for things like, is this a
• 3:20
  - qualified claim?
• 3:22
  - And then on the back end of that,
• 3:23
  - they have manufacturers that are denying,
• 3:26
  - claims that are that are completely appropriate and
• 3:28
  - should be being processed, which is a whole
• 3:30
  - another,
• 3:31
  - oftentimes manual workflow.
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  - The exciting thing is with with AI and
• 3:35
  - the advancements in technology,
• 3:38
  - there are ways for the system to continually
• 3:40
  - surface
• 3:41
  - exceptions that need the attention,
• 3:43
  - allow the teams to prioritize
• 3:45
  - them, not taking the human element out of
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  - that, which I believe passionately is is so
• 3:50
  - important,
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  - but allows the team to spend their time
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  - resolving issues instead of looking for issues,
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  - allows them to have real time data,
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  - and numbers in front of them that that
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  - takes the administrative burden off of pharmacy teams
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  - trying to calculate that. And then importantly,
• 4:05
  - just tracking those denials and responding to them
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  - is gonna be absolutely critical going forward as
• 4:11
  - as everyone knows,
• 4:12
  - under the rebate pilot that's
• 4:14
  - launching in January. There's a lot more drugs
• 4:16
  - being added to that, a lot more risk
• 4:19
  - of losing revenue going forward that frankly,
• 4:21
  - hospitals and health systems should be entitled to.
• 4:25
  - Yeah.
• 4:26
  - And, Kim, thanks for the overview.
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  - As you were speaking, I I thought about
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  - how many organizations that are introducing AI to
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  - streamline some of this work
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  - are also concerned that certain tools could potentially
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  - introduce even more complexity, which I know is
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  - going against the very reason they're adopting the
• 4:43
  - tech adversities.
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  - So how does what you just outlined, how
• 4:48
  - does this change when AI is built into
• 4:50
  - a workflow rather than something that's added on
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  - as a separate tool?
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  - Yeah. And I think that, frankly, that's most
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  - of the conversations
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  - we're having
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  - is the last thing that the pharmacy team
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  - wants is yet another,
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  - separate and distinct platform that they have to
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  - work with or tool that they have to
• 5:07
  - work with.
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  - They've got their EHR.
• 5:10
  - They've got the,
• 5:12
  - the various different systems that are tracking and
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  - monitoring things. They've got prior auth. They have
• 5:16
  - all of these,
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  - disparate pieces that's requiring,
• 5:20
  - so much reliance on accurate,
• 5:23
  - connectivity that if you can actually have a
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  - platform that uses,
• 5:28
  - the right kind of AI, which is, you
• 5:29
  - know, AI preparing and prioritizing people deciding,
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  - which is our big
• 5:34
  - model here at Vital One.
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  - Then you have the ability to have all
• 5:38
  - of those systems that the pharmacy
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  - is using feeding into one location
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  - to really make that data visible,
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  - available, and allow them to focus on,
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  - what is most important. But if you don't
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  - have all of those feeds coming together,
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  - then it's, absolutely going to be a situation
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  - where the the workflow can't track,
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  - whether payments are being made, whether they're being
• 6:01
  - done correctly.
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  - You don't have the audit trail on the
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  - back end,
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  - and just having to go through that, as
• 6:07
  - I mentioned,
• 6:08
  - earlier in those disparate systems is probably,
• 6:12
  - the the biggest area that I think AI
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  - and technology is gonna make the lives easier
• 6:16
  - of, of pharmacy leaders across the country.
• 6:20
  - Yeah. A lot of potential here to
• 6:23
  - ease some of these very,
• 6:25
  - parts of the workflow.
• 6:27
  - I'm curious,
• 6:28
  - you know, when you're thinking about
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  - AI and use in these areas,
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  - are there particular decisions that still need a
• 6:35
  - pharmacist or a clinician's judgment? You know, how
• 6:37
  - are you making... How are you helping organizations
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  - make that call?
• 6:41
  - Yes. Absolutely. And every time I hear someone
• 6:44
  - say that, you know, AI is gonna replace,
• 6:47
  - the pharmacy teams or frankly,
• 6:49
  - many other clinical teams out there, I cringe
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  - a little bit because what it what it
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  - should be doing is augmenting
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  - and helping to prioritize
• 6:57
  - and flagging issues,
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  - for then those who are qualified to be
• 7:01
  - able to make those decisions. For example,
• 7:04
  - clinical appropriateness
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  - or whether,
• 7:06
  - there's sufficient documentation
• 7:08
  - to support,
• 7:10
  - a claim or a prescription,
• 7:12
  - patient counseling,
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  - qualifications,
• 7:15
  - compliance sign off to be able to provide
• 7:17
  - to HRSA if you're audited.
• 7:20
  - All of those activities
• 7:22
  - are absolutely critical. They continue to
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  - be, made by a qualified pharmacist and or
• 7:28
  - their clinical teams. What I do see,
• 7:31
  - these teams get really excited about,
• 7:34
  - is the technology that allows that to, again,
• 7:37
  - bring all those disparate systems together, that allows
• 7:40
  - it to flag and identify and organize data
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  - and allows them to do reporting and analytics
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  - around the data that's feeding from these various
• 7:49
  - systems. And so,
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  - those pieces, one, are giving comfort to to
• 7:53
  - CEOs and CFOs because now there's more data,
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  - that the pharmacy ops of leaders can actually
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  - provide.
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  - But secondly, it's giving more, more bandwidth to
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  - those teams that are... Should be focused on
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  - clinical outcomes and and patient counseling and things
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  - like that,
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  - rather than, you know, kinda chasing data in
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  - a system and trying to figure out whether
• 8:14
  - or not they get paid. So as long
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  - as humans are owning the outcome, and I
• 8:18
  - think that's gonna be the case for long
• 8:20
  - term,
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  - but but allowing
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  - AI and technology to augment,
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  - what they're doing. I think that this is
• 8:27
  - gonna be a a really great, evolution for,
• 8:30
  - for the pharmacy within hospitals and health systems.
• 8:34
  - Yeah. It brings to mind that concept of
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  - enabling teams to work at the top of
• 8:38
  - their license rather than... Exactly. Absolutely. Yeah. Absolutely.
• 8:42
  - Yeah. Well,
• 8:43
  - Kim, I'm curious too. You know, it's something
• 8:45
  - we hear from leaders is
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  - essentially how overwhelming it can be to receive
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  - the number of AI partnership pitches that they
• 8:53
  - get on a daily basis, the number of
• 8:54
  - options out there for technology partners.
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  - What do you think health system leadership ask
• 9:00
  - when they're evaluating an AI partner for this
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  - kind of work, especially when we're talking about
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  - accuracy,
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  - integration, and oversight?
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  - Yeah. And, you know, we, we did a
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  - forum recently with with a lot of the
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  - chief pharmacy officer leaders across the country and
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  - really kinda dug into,
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  - you know, how are they looking at this
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  - and what are they thinking,
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  - as it relates to,
• 9:21
  - how to evaluate
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  - AI. And, you know, the first thing is,
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  - has this been designed and built,
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  - by people with pharmacy expertise? Pharmacy is such
• 9:31
  - a unique,
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  - aspect of health care, and there are so
• 9:35
  - many regulatory
• 9:36
  - pitfalls and compliance risks. And and frankly, these
• 9:39
  - are big dollars when you're looking at specialty
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  - pharmacy
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  - and, you know, at other complex areas. Those
• 9:45
  - drug prices can be,
• 9:47
  - monumental and and a risk there is is
• 9:50
  - not getting paid correctly. And so, you know,
• 9:52
  - first and foremost,
• 9:54
  - making sure that the, the platform or the
• 9:57
  - tool that they're using,
• 9:59
  - was built,
• 10:00
  - with knowledge of pharmacy.
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  - Secondly, understanding,
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  - what is
• 10:07
  - the longevity
• 10:07
  - of what you're getting? What is the, you
• 10:09
  - know, the backup when something goes wrong?
• 10:12
  - What's the paper trail,
• 10:14
  - that exists to support whatever decisions are made,
• 10:17
  - so that if you do get questioned either
• 10:18
  - by, you know, leadership or by, governmental entities
• 10:22
  - or frankly manufacturers challenging things,
• 10:25
  - that you're able
• 10:26
  - to respond to those.
• 10:28
  - Integration
• 10:29
  - is absolutely critical.
• 10:31
  - It has to work with the other systems.
• 10:33
  - It has to be able to to bring
• 10:34
  - in data. Anything you're doing has to be
• 10:37
  - able to bring in data from the existing
• 10:38
  - systems,
• 10:39
  - that are in your ecosystem,
• 10:41
  - or you're just gonna add additional workflow on.
• 10:44
  - And then most importantly, you know, compliance oversight
• 10:47
  - as, you know, a healthcare lawyer who practice
• 10:50
  - for twenty years. That's the question that's always
• 10:52
  - on my mind is just how do we
• 10:53
  - make sure,
• 10:54
  - that there are people
• 10:56
  - and governance at the top of
• 10:59
  - any AI or or technology implementation,
• 11:03
  - to ensure that you can support the decisions
• 11:05
  - that are being made.
• 11:07
  - You know, we've all heard the horror stories
• 11:08
  - out there, over the past, several months about,
• 11:12
  - the mistakes that AI can make and and
• 11:14
  - really understanding where those pitfalls could be and
• 11:17
  - then what's the backup
• 11:19
  - double check that's in in place to make
• 11:21
  - sure that they don't result
• 11:23
  - in payment errors and other things like that.
• 11:26
  - Yeah. Certainly a lot to consider, Kim. And
• 11:28
  - I appreciate you sharing,
• 11:30
  - you know, what's come up for you. A
• 11:32
  - combination of what you've seen work, but also
• 11:33
  - what you're hearing from other health systems and
• 11:35
  - pharmacy leaders and, and what is most important
• 11:39
  - for them as they're evaluating AI partners.
• 11:42
  - So for the leader who's just starting to
• 11:44
  - explore these opportunities,
• 11:46
  - what's the first conversation that you think they
• 11:48
  - should have internally?
• 11:50
  - And then what's one step you think they
• 11:51
  - could take heading into 2027?
• 11:54
  - Yeah. It's such a it's such a great
• 11:55
  - question because you are, you mentioned earlier, which
• 11:58
  - is absolutely correct. They are getting pitched, you
• 12:01
  - know, all day every day about, you know,
• 12:03
  - whatever the latest solution is that's out there.
• 12:06
  - And I think the, you know, the conversations
• 12:08
  - that should be happening,
• 12:10
  - with, chief pharmacy officers, with their c suite,
• 12:12
  - with their finance, leaders is,
• 12:15
  - first and foremost, what is the problem that
• 12:17
  - we're trying to address,
• 12:19
  - or what is the opportunity that we're trying
• 12:21
  - to obtain? So if we're leaving revenue on
• 12:24
  - the table, where do we think that is,
• 12:26
  - and how can this AI and and technology
• 12:29
  - solutions augment what our people are able to
• 12:31
  - do today.
• 12:32
  - And then as there are gaps and regulatory
• 12:35
  - challenges, which can cause
• 12:37
  - significant risk, what do we have today in
• 12:39
  - place that's done manually,
• 12:42
  - that's done on a spreadsheet that requires lots
• 12:45
  - of people
• 12:46
  - going from system to system to check things.
• 12:49
  - And if you could bring that all into
• 12:50
  - a central location
• 12:52
  - where you can then look at the data,
• 12:54
  - slice the data,
• 12:55
  - analyze the data, and and know that it's
• 12:57
  - feeding from the actual systems
• 12:59
  - where the data resides.
• 13:01
  - I think that that is something that's gonna
• 13:03
  - be absolutely critical.
• 13:04
  - And then really deep diving,
• 13:07
  - the partner that you're selecting.
• 13:09
  - Know, have they been in the space a
• 13:10
  - long time? Are they, you know, are they
• 13:12
  - a start up?
• 13:13
  - Are they going to be here for the
• 13:15
  - long haul as things change and evolve?
• 13:17
  - And as you think ahead to other,
• 13:20
  - solutions that you may be,
• 13:22
  - implementing in your organization,
• 13:24
  - how are these pieces all going to fit
• 13:26
  - together? And the really sophisticated chief pharmacy officers
• 13:29
  - are are asking all of those questions,
• 13:32
  - but it is new. It's, you know, it's
• 13:33
  - it's kinda new for everybody, and I think
• 13:35
  - they're all, in the same boat of trying
• 13:38
  - to figure out how do we how do
• 13:40
  - we, you know, maximize
• 13:41
  - this opportunity that's here in in '26 and
• 13:44
  - '27 around technology.
• 13:46
  - But how do we do it in a
• 13:47
  - way that doesn't jeopardize,
• 13:49
  - our up...
• 13:50
  - Our operations
• 13:51
  - or our revenue,
• 13:53
  - and instead is is a real value add.
• 13:56
  - And this is one area, you know, going
• 13:58
  - back to, you know, pharmacy should be a
• 14:00
  - achieved strategy for all health systems. This is
• 14:03
  - one area where I think that automation
• 14:05
  - is absolutely gonna be a health systems friend
• 14:08
  - and allow, you know, additional revenue generation
• 14:11
  - that will allow them to reinvest that into
• 14:13
  - their organization, which is really exciting time.
• 14:17
  - Well, Kim, it's been great learning from you
• 14:19
  - today. I appreciate you sharing some actionable next
• 14:21
  - steps for our listeners as they head into
• 14:23
  - the new year, and then also sharing your
• 14:26
  - thought leadership with us. I know you spent
• 14:27
  - a lot of time in this space and,
• 14:29
  - your expertise is appreciated here. So thank you
• 14:31
  - again for making the time for Becker's today.
• 14:34
  - Absolutely. Thank you. Really appreciate all that you
• 14:36
  - guys do to bring everybody together.
• 14:38
  - Oh, happy to. And of course, we'd also
• 14:41
  - like to thank our podcast sponsor for today,
• 14:43
  - Vital One.
• 14:44
  - Listeners, be sure to tune in to more
• 14:46
  - podcasts from Becker's by visiting our podcast page
• 14:49
  - at beckershospitalreview.com.