Transforming Care Management and Disease Management Workflows with Agentic AI - with Raheel Retiwalla of Productive Edge
🎯 Summary
Podcast Summary: Transforming Care Management and Disease Management Workflows with Agentic AI
This episode of the AI and Business Podcast, featuring Raheel Retiwalla, CSO of Productive Edge, focuses on the immediate and transformative impact of Agentic AI on healthcare’s most complex operational areas: Care Management and Disease Management. The discussion centers on how these systems augment existing staff, connect fragmented data, and drive real-time action to improve outcomes under the increasing pressures of value-based care.
1. Focus Area
The primary focus is the application of Agentic AI within healthcare payer and provider workflows, specifically targeting Care Management, Disease Management, Behavioral Health, and Complex Case Management. The discussion emphasizes using AI agents as infrastructure-level augmentations to streamline processes like utilization tracking, medication adherence nudging, and care plan generation, rather than replacing human roles.
2. Key Technical Insights
- Agentic Augmentation over Replacement: Agentic AI is positioned not as a replacement for care managers or rules-based systems, but as a layer that surrounds and supercharges existing platforms by providing real-time aggregation, insights, and activation capabilities.
- Maturity Curve for Deployment: A clear framework for adoption is outlined: starting with Summarization/Aggregation, moving to Recommendation/Nudging/Activation, and culminating in Execution of tasks, allowing organizations to achieve quick wins without immediate, full-scale overhauls.
- Connecting Signal to Action: Agents excel at mining unstructured data (like clinical notes or EMR signals) to identify rising risk (e.g., for diabetes or hypertension) and immediately connecting that signal to the relevant, existing workflow or stakeholder (e.g., nudging a provider or reprioritizing a care team’s to-do list).
3. Business/Investment Angle
- Addressing Core Business Pressures: The momentum for agentic AI is driven by converging pressures: increased financial risk tied to outcomes in value-based care, chronic staffing constraints leading to high turnover, and the rising complexity of chronic conditions and SDOH.
- Immediate ROI in Low-Friction Areas: Early, successful use cases (like tracking authorization counters or medication adherence) demonstrate immediate value by preventing care disruptions, improving Star Ratings, and enabling consistent guidance across different operational silos.
- Efficiency in Compliance and Planning: Agents significantly reduce the manual overhead associated with creating and updating service plans by instantly providing necessary state-based rules, compliance regulations, and guidelines, thus unlocking scaled value from existing investments.
4. Notable Companies/People
- Raheel Retiwalla (Productive Edge): Chief Strategy Officer, providing expert insights on the practical deployment and strategic value of agentic AI in healthcare operations.
- Productive Edge: The sponsoring organization, highlighted as a digital transformation consultancy specializing in helping payers and providers leverage data for operational streamlining.
- US Payers & International Health Plans: Mentioned as active adopters, with specific examples provided for Medicare/Medicaid populations and international clients focusing on utilization management.
5. Future Implications
The industry is moving toward a highly personalized, omnichannel engagement model where AI agents act as the connective tissue between disparate data sources and activation channels (SMS, app, email). The future involves agents proactively managing long-term tracking for complex areas like behavioral health and automating the preparation for high-value human interactions, such as complex case management reviews.
6. Target Audience
This episode is highly valuable for Healthcare Executives (C-Suite, VPs of Operations, Strategy Leaders), Payer and Provider IT/Digital Transformation Leaders, and Healthcare Consultants who are seeking actionable strategies for deploying AI to solve immediate operational bottlenecks and scale value-based care initiatives without massive infrastructure replacement.
Comprehensive Narrative Summary
Raheel Retiwalla argues that Agentic AI is the critical technology needed now to address the operational crisis in care and disease management, which is being exacerbated by the shift to value-based care and persistent staffing shortages. He stresses that the goal is augmentation, not replacement, freeing up stretched care teams from mundane data-chasing to focus on high-value patient interaction.
Retiwalla provided concrete, operational examples of agentic AI in production across US payers. One key use case involves utilization tracking, where agents monitor service limits (like physical therapy visits) in real-time, alerting care managers and nudging members/providers before limits are breached, thus avoiding denials and care disruption. Another example centers on medication adherence, where agents synthesize signals from pharmacy data and EMRs to provide care teams with prescriptive next steps (e.g., “Member needs two refills, here is the outgoing script”).
The discussion extended internationally, showing how agents can mine unstructured data from admission/discharge notes to identify early signals for chronic disease risk (like diabetes), connecting those signals to existing enrollment workflows at opportune moments (e.g., when the patient is already engaged with a provider). This allows for proactive enrollment and stakeholder feedback across the care continuum.
A significant portion of the conversation addressed the distinction between traditional rules-based systems and agentic AI. Retiwalla clarified that agents complement, rather than eliminate, rules engines. Agents are superior in the pre-rules phase (validating submission quality) and the post-rules phase (assisting specialist clinicians in complex manual reviews, such as prior authorization decisions, by aggregating necessary guidelines and data).
Finally, Retiwalla presented a clear roadmap for adoption: start with summarization (e.g., preparing case management review packets), move to activation (nudging members via omnichannel approaches), and eventually reach execution. This phased
🏢 Companies Mentioned
💬 Key Insights
"start with significant opportunities, start in summarization, aggregation already. Then you can move into, hey, it already summarized and aggregated and understands the underlying data, it can recommend things to you, right? And in some cases, it can go and nudge you and activate the right channel with the nudge. And lastly, it could actually go ahead and conduct the execution of a task in certain contexts where you, of course, have the human with the right to the content."
"there is a majority. You start with summarization, aggregation, you're moving to recommendation, then you're moving to nudging and activation, and then you move to execution, which is where agents can really play a role."
"you can essentially augment those [pre-rules and post-rules engine steps] with agents. And the reason why they're very good at it is because they understand those rules, they understand some of the coverage determinant rules, they understand health guidelines, they're able to look at the incoming authorization requests and are able to actually provide guidance based on how you essentially make those decisions using the right type of data."
"what's more powerful is the thought of agents as not just a way to actually understand and do millions of tracking, but to know what to do with that and how to actually activate those signals across a more omnichannel perspective."
"Similarly, a second use case we're tackling is medication adherence. So from a pharmacy perspective, you're seeing patterns of missed renewals, reversals, long gaps... this particular agent monitors signals from pharmacy, EMR, and even app usage. Then it spots risk, it can nudge the care team with the relevant context, like, hey, this member needs two refills, he has the last thought notes, here's the outgoing script. Be more prescriptive in providing the exact things that the care manager needs to do."
"As value-based care accelerates, organizations are realizing that they cannot scale their way. And this is very authentic AI is showing its value. It's not about replacing the care managers or the service coordinators or the care coordinators or the mental health specialists. It's about augmenting them."