The Astonishing Healthcare Podcast

In this episode of Astonishing Healthcare, Alfonso Martinez, Director of Product Management at Capital Rx, joins Justin Venneri to discuss the transformative role APIs - application programming interfaces - play in the healthcare industry and the flexibility they offer plan sponsors and benefits administrators to be imaginative. He explains how APIs facilitate seamless integration, automate critical workflows, and empower real-time data access and exchange, significantly enhancing user experiences.

Alfonso reviews several practical use cases and explains how an open platform like JUDI® is revolutionizing pharmacy benefits management without being too "salesy." Additionally, they touch upon the future potential of APIs in achieving value-based care by breaking down data silos and enabling integrated analytics, processing payments, and much more!

Related Content

• Capital Rx’s JUDI® - The Beauty of an Open Platform
• Capital Rx’s Enterprise Health Platform Enables Healthcare Organizations to Meet The CENTERS for MEDICARE & MEDICAID SERVICES’ M3P Requirements
• AH007 - There’s No Value-Based Care Without Considering Pharmacy, with Sunil Budhrani, MD

Please visit Capital Rx Insights for more information, including this episode's transcript!

Executive Vice President and CEO of the National Alliance of State Pharmacy Associations (NASPA), Krystalyn Weaver, PharmD, JD, joins host Justin Venneri for a discussion about pharmacists and expanding their scope of practice. She shares her insights on the role pharmacists can play in the healthcare system and highlights several positive developments recently, including Iowa changing the scope of practice to be a standard of care model and Tennessee passing a law that allows pharmacists to prescribe in a "slew of categories" without requiring additional regulations.

Additionally, Krystalyn shares her thoughts on the importance of making progress at the federal level to allow pharmacists to be reimbursed by Medicare (ECAPS), the AMA's stance against the expansion of pharmacists' responsibilities, how to relieve the pressure on the pharmacy business model, what some pharmacies are doing to diversify their businesses and succeed, and much more.

Related Content

• AH023 - Compliance Matters, with Heidi McKinnon, PharmD, CHC
• Iowa governor signs legislation that modernizes the state Pharmacy Practice Act
• Under new law, pharmacist scope of practice expands in Tennessee

Please visit Capital Rx Insights for more information, including this episode's transcript!

We dedicated this episode of Astonishing Healthcare to discussing the ongoing challenges within the pharmacy benefit management (PBM) industry, as unveiled by a recent front-page New York Times article (subscription required). Capital Rx Senior Vice Presidents Josh Golden and Ryan Duffy join host Justin Venneri to share their reactions to the article and opinions about where the spotlight should be at this time. The article brings several issues to the forefront, including new "layers" of profit opportunity for traditional PBMs, which come at the expense of health plans/payers.

Ryan and Josh also stress the importance of PBM transparency and alignment with plan sponsors' (and members') interests. They also explain why HR leaders and benefits administrators must be vigilant and prepared for a shift toward more accountable PBM models. Potential regulatory reforms and their implications are also examined, providing insights into how to navigate and optimize pharmacy benefit management in today's complex healthcare landscape.

Related Content

• AH015 - PBM Legislation, Contracting, and More, with Lloyd Fiorini
• 5 ways to improve your PBM procurement process in 2024
• Your PBM is the Problem
• Capital Rx CEO: PBM industry needs to be repaired, not ditched

Please visit Capital Rx Insights for more information, including this episode's transcript!

On this episode of the Astonishing Healthcare podcast, Capital Rx's head of compliance, Heidi McKinnon, PharmD, CHC, joins Justin Venneri for a discussion about a few of the critical issues she's tracking today that are either currently impacting or could impact the pharmacy benefits industry. With over 20 years of experience, she expertly navigates topics like the role of AI in detecting fraud, risks associated with compounding GLP-1 medications, and the nuances of digital pharmacy operations (vs. retail or mail order).

Heidi underscores the need for a sound compliance framework to support business growth and meet evolving regulatory requirements. She also explains the importance of relaying the "compliance is a good thing" message from the top down.

Related Content

• How to Manage Pharmacy Benefit Spend in a GLP-1 World
• AH021 - Managing Pharmacy Costs in a GLP-1 World, with Bridget Mulvenna

Please visit Capital Rx Insights for more information, including this episode's transcript!

In this episode of the Astonishing Healthcare podcast, Ben Schuster, Senior Director of Rebate Administration at Capital Rx, joins Justin Venneri for a dive into the world of pharmaceutical rebates. From the basics of what rebates are and how they flow through the supply chain to the intricacies of rebate guarantees and contractual definitions, Ben shares his thoughts on the importance of understanding how various factors can impact the amount of money plan sponsors receive and rebate eligibility (e.g., for GLP-1s).

With market dynamics rapidly changing, Episode 22 offers valuable insights into the evolving landscape of drug rebates and highlights the need for transparency and strategic decision-making in navigating the complex pharmaceutical supply chain.

Related Content

• Pharmacy Benefits 101: Pharmaceutical Rebates
• Will Biosimilar Rebates Pass-Through?
• Pharmacy Benefits 101: Traditional vs. Pass-Through Models

Please visit Capital Rx Insights for more information, including this episode's transcript!

In this episode of Astonishing Healthcare, we discuss glucagon-like peptide-1 (GLP-1) agonists, but it's not another "these drugs are going to blow up every plan" sort of discussion. Bridget Mulvenna, a former pharmacy program director and our guest on Episode AH002, shares her experience and opinions about how plan sponsors can work through the decision-making process to cover GLP-1s for weight loss. She also offers some suggestions for consideration and stresses the importance of leveraging data to understand the needs of each plan's members.

Plan sponsors must work closely with pharmacy benefits managers (PBMs) and dive into how coinsurance, prior authorization, third-party point solutions, and other tools or strategies work. The potential impact on the plan's financials and members' experience, as well as the future exposure, must be evaluated today because the GLP-1 drug pipeline is full, and the potential exists for even more new indications on both new and existing GLP-1s.

Related Content

How to Manage Pharmacy Benefit Spend in a GLP-1 World

GLP-1s are No Laughing Matter

Please visit Capital Rx Insights for more information, including this episode's transcript!

What do you get when schedules line up and AJ Loiacono and Antonio Ciaccia are the guests on a podcast? An episode you must listen to if your work or interests are in any way centered on drug prices. NADAC - national average drug acquisition cost - was the focus of our discussion on this episode of the Astonishing Healthcare podcast. Recent methodology changes and a new survey participant have combined to drive meaningful deflation in generic drug prices. AJ and Antonio dive into why this is significant and other factors stakeholders should consider.

NADAC serves as a crucial price benchmark, providing visibility and some level of understanding - a "source of truth" - of drug pricing in the United States. Average wholesale price (AWP) and other indexes fail to reflect actual acquisition cost/supply chain economics but have prevailed for years. Is it the pharmacy benefits managers (PBMs)? Is it the wholesalers? At Capital Rx, we have always preferred to leverage NADAC whenever possible despite its imperfections. Nothing is perfect in the pharmaceutical supply chain regarding drug pricing, and NADAC remains the best, most reliable option. Tune in to discover what's happened and what to watch for next!

Related Content

What is NADAC & How Does It Differ From AWP?

Why Use NADAC-Based Pricing Over AWP

Medicaid.gov - Drug Pricing (where NADAC lives)

Please visit Capital Rx Insights for more information, including this episode's transcript, AND we'll add links to any new studies or documents that may interest you if you're a student of drug prices or a fan of NADAC.

On this episode of the Astonishing Healthcare podcast, Casey Stockman, PharmD, Vice President of PBA Services, joins host Justin Venneri and shares her insights on the complexities of high-cost cell and gene therapies (CGTs), glucagon-like peptides (GLP-1s), and much more. Given the advancements in drug development and million-dollar-plus price tags for many of the CGTs, it is crucial for health plans to navigate the challenges of covering these therapies. Casey discusses outcomes-based agreements, annuity or mortgage models for payment plans, and the concept of risk pooling.

She addresses concerns surrounding GLP-1s, specifically the expanded FDA approval for reducing major cardiovascular events, affordability and overall uptake of GLP-1s among Medicare patients, and the potential impact of rising utilization on total medical expenses. Casey also emphasizes the benefits of modern technology, such as JUDI®, in solving real hurdles for health plans by improving the coordination of benefits for dual-eligible members and having the flexibility to meet regulators' intent.

Last, Casey shares an astonishing journey from provider to payer to patient.

For more information and this episode's transcript, visit Capital Rx Insights!

On this episode of the Astonishing Healthcare podcast, a trio of pharmacists on the Capital Rx team join Justin Venneri and share their experiences and insights related to the residency and fellowship programs (i.e., post-graduate training) that pharmacists often choose to participate in. Allison Gallant, PharmD, Caitlyn Tung, PharmD, MBA, and Nicole Bergman, PharmD, discuss the details of well-designed programs that foster personal and professional growth, the array of traditional and non-traditional settings pharmacists can practice in, what the residency program at Capital Rx - a pharmacy benefit manager (PBM) - looks like, the difference between accredited and non-accredited programs, and much more.

Whether you're a pharmacy student, recent graduate, or pharmacy executive interested in how to train the next generation of pharmacists, this episode is for you.

For this episode's transcript and much more, please visit Capital Rx Insights.

Thank you for listening!

In this episode of the Astonishing Healthcare podcast, we tackle one of the more polarizing issues in healthcare: prior authorization (PA for short). Sara Izadi, PharmD, Capital Rx's Chief Clinical Officer, Lorece Shaw, PharmD (Director of PA), and Product Manager Callie Burton-Callegari, join host Justin Venneri for a candid discussion about PA. They cover everything from basics like what a PA is, who decides the criteria, and common reasons for denials to why they are necessary and how technology - AI & ML - can help improve PA workflows.

Last but not least, the team shares the most astonishing things they've seen around PAs, including a personal story!

For related content, check out:

• Pharmacy Benefits 101: What is a Formulary?
• Are Your Prior Authorizations Actually Working?
• Capital Rx's JUDI® Redefines the Role Tech Plays in the Administration of Medicare, Medicaid, and Commercial Pharmacy Programs (highlighting our new PAT)

For this episode's transcript and much more, please visit Capital Rx Insights.

Thank you for listening!