The Astonishing Healthcare Podcast

This episode of the Astonishing Healthcare podcast explores the intersection of pharmacy and Medicaid in a relatable and understandable way. Jessin Joseph, PharmD, MBA, Senior Director of Pharmacy Benefits Administration (PBA) Services at Capital Rx, joins Justin Venneri for a discussion that starts with his journey from pharmacy school to Kentucky Medicaid, twists through acronyms like NADAC, AMP Cap, and M3P; and ends with why states are using or interested in preferred drug lists (PDLs) and single PBA solutions.

Jessin highlights the changing rebate landscape for Medicaid (and Medicare) plans, the financial implications of M3P for plans, and the importance of transparency, education, and collaboration in providing care to a vulnerable population.

Please visit Capital Rx Insights for additional content, including this episode's transcript!

In this episode of the Astonishing Healthcare podcast, Lloyd Fiorini, General Counsel & Chief Compliance Officer at Capital Rx, shares his expertise and experiences from over 25 years in the pharmacy space. He acknowledges that employers and benefits consultants face challenges in a rapidly evolving, complex healthcare landscape. Lloyd covers several topics impacting health plan sponsors and fiduciaries, including the implications of the Consolidated Appropriations Act (CAA) and avoiding penalties and personal liability through effective procurement processes, and the Inflation Reduction Act (IRA) and how disruptive M3P (the Medicare Prescription Payment Plan) implementation could be. 

Beyond the CAA and IRA, Lloyd discusses some potential changes in the industry driven by recent lawsuits and legislation; and for all the hockey fans out there, there's a prediction at the end!

Related Content

🏒 Replay: PBM Legislation: Navigating State and Federal Regulatory Changes and How They May Impact You

🏒 Self-funded plans ignore the CAA at their peril

🏒 For more information about M3P and Capital Rx's solution: Click Here

Please visit Capital Rx Insights for additional content, including this episode's transcript!

The astonishing potential of artificial intelligence (AI) for personal and professional use, and in healthcare in particular, is what we explore in this episode of Astonishing Healthcare with Christian Ward, Chief Data Officer at Yext, and Carrie Liken, Head of Yext's Healthcare Industry Practice. They discuss the trends they see in search that reflect changing behavior and ultimately influence how people will find information online. Health systems and other healthcare providers must structure their data on the backend and get things lined up properly to ensure accurate search results in a GEO world.

The conversation delves into how to ground AI and prevent the 'hallucination' of information, as well as creative ways to use AI as its capabilities expand to include more senses! Christian and Carrie emphasize the need for organizations to embrace AI and employ a collaborative adoption strategy now rather than taking a wait-and-see approach. They also describe the impact of AI on healthcare journeys and how patients can be directed to the most appropriate resources, thereby reducing waste in the system.

For more information and to get in touch with Christian and Carrie:

Please visit Capital Rx Insights for additional content, including this episode's transcript!

In this episode of the Astonishing Healthcare podcast, Robert Longyear, Co-Founder of Avenue Health, joins Justin Venneri to discuss virtual care and remote patient monitoring, including the role nurses and pharmacists can play as care models evolve and the importance of timely information exchange.

Robert shares his personal journey in healthcare and how his experiences have shaped his mission to improve patient care. He explains Avenue Health's role in launching remote patient monitoring programs for chronic diseases, such as hypertension and diabetes, and the importance of leveraging nurses and other healthcare professionals in providing virtual care. They also discuss challenges in the healthcare staffing space, including clinician burnout and moral injury, and Robert's book, A Virtual Care Blueprint. The conversation concludes with a discussion on the future of virtual care, the power of information exchange, and the need for innovation in the healthcare industry despite the most astonishing thing Robert continues to encounter: resistance to change.

For more information about Robert's book and to get in touch:

Please visit Capital Rx Insights for additional content!

This episode of the Astonishing Healthcare podcast features the CEOs of Prime Therapeutics, Mostafa Kamal, and Capital Rx, AJ Loiacono. They join Michael Passanante, SVP of Marketing & Communications at Capital Rx, to share the story behind the strategic alliance between the organizations and their vision to reimagine pharmacy and provide better care to patients across the country leveraging next-generation technology: JUDI®. 

The CEOs emphasize the importance of platform modernization in pharmacy and healthcare more broadly. Prime chose Capital Rx for an alliance and investment due to its complementary capabilities, alignment of core values, and, of course, JUDI, Capital Rx's enterprise health platform. Mostafa and AJ explain the benefits modern health tech can bring to pharmacy plan administration and to plan members, such as rapid deployment of solutions, scalability to navigate the complex regulatory environment, a better overall care experience, and much more.

Visit Capital Rx Insights for this episode's transcript and additional content!

Navigating and understanding government programs in healthcare can be a daunting task. In this podcast episode, Jason Barretto, Vice President of Government Program Operations at Capital Rx, joins Justin Venneri to shed light on the complexities of regulatory compliance and the importance of meeting the intent of legislation and regulations, including the CENTERS for MEDICARE & MEDICAID SERVICES’ Medicare Prescription Payment Plan (M3P) requirements and new Prescription Drug Event (PDE) requirements.

Jason emphasizes the importance of collaboration with health plan partners to ensure alignment and minimize the need for "requesting grace" from governing agencies. Additionally, he explained the significant impact the M3P requirements will have on health plans, pharmacies, and PBMs. He highlights the disruptive nature of this program and introduces Capital Rx's comprehensive end-to-end solution to support health plan pharmacy directors in managing the new requirements. Lastly, he shares a story about an astonishing conference call, which he had to stay on with little to add.

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Visit Capital Rx Insights for this episode's transcript and additional content!

Per member per month (PMPM) cost plays a crucial role in healthcare, particularly in pharmacy benefit management. On this episode of the Astonishing Healthcare Podcast, Kristen Begley, PharmD, Chief Commercial Officer at Capital Rx, emphasizes the significance of PMPM guarantees and how they help hold pharmacy benefit managers (PBMs) accountable for total drug spend. The PMPM calculation provides a simplified way to evaluate drug spend by dividing the total plan spend by the number of members. This enables plan sponsors and other industry professionals to easily assess the value and effectiveness of their vendors and predict future costs.

Furthermore, PMPM guarantees prompt PBMs to act in the best interest of both the plan sponsor and the members, ensuring the selection of the most appropriate, cost-effective drugs, for example. Drug mix, formulary decisions, prior authorizations, and clinical programs also strongly influence PMPM and should be carefully considered. Last, Kristin shares the most astonishing thing she's seen, and it's amazing how costly the things people can miss are.

Related PMPM Content

PMPM - Is It the Best Way to Measure or Track Anything?

PBM Procurement: A PMPM Guide for Plans Sponsors eBook

Visit Capital Rx Insights for this episode's transcript and additional content!

Capital Rx Co-Founder and Chief Technology Officer Ryan Kelly joins Justin Venneri for a discussion about the opportunity to bring efficiency to an industry reliant on "horrendously and horribly inefficient" technology and the benefits that modern technology can bring to the administration of a pharmacy benefit program. Some benefits include centralizing all operational workflows and health information in one platform (JUDI®) and data security in the wake of recent cyberattacks. 

Ryan also shares his thoughts on AI use cases and how to achieve true value-based care. He explains what frustrates him to no end and the most astonishing thing he [continues to] see in the industry (hint: it should have died long ago, but it's still used and sometimes favored).

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Prime Therapeutics and Capital Rx Create Technology Alliance

Capital Rx’s JUDI® - The Beauty of an Open Platform

Capital Rx Earns Surescripts® Certification & SOC 2 Type 2 Report

Visit Capital Rx Insights for this episode's transcript and additional content!

In this episode of the Astonishing Healthcare podcast, Justin Venneri interviews Josh Golden, who brings his extensive experience as a healthcare consultant and Senior Vice President of Strategy at Capital Rx to the discussion to highlight key questions that plan sponsors should ask to future-proof their pharmacy benefit programs. It is crucial to understand how PBMs make money and how much a plan sponsor is paying their PBM. The answer to the first part helps explain PBMs' behavior, and the answer to the second aids plan sponsors in their decision-making process.

Josh explains the importance of a recent class action lawsuit as it relates to fiduciary responsibility and the pharmacy benefit plan and describes the conflicting fiduciary duties between plan sponsors and traditional PBMs. He also delves into the need for vigilant gatekeeping to control costs and ensure appropriate utilization of expensive medications and why states will continue to lead the way on PBM reform. Josh concludes with a truly astonishing, data-based observation regarding wasteful spending (hint: it can add up quickly)!

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In this episode of the Astonishing Healthcare podcast, Dr. Sunil Budhrani, Chief Innovation and Medical Officer at Capital Rx, discusses the intersection of value-based care and pharmacy. He explains the concept of value-based care in a clear and relatable way and describes how it has evolved over the years. Dr. Budhrani, who remains an active ER physician, shares his experiences from different roles across the healthcare system and highlights the fragmentation and silos that hinder the progress toward a true value-based care system.

He emphasizes the importance of sharing data and integrating pharmacy in value-based care programs to go beyond just scratching the surface, to address the needs of underserved communities and pay physicians for improving patient outcomes and helping to reduce healthcare costs. How do we consider quality, equity, and cost and bring the payer, provider, patient, and pharmacy (the 4 Ps!) together? How important are social determinants of health (SDOH) and aligning incentives? Listen to this episode of the Astonishing Healthcare podcast to find out! 

Visit Capital Rx Insights for this episode's transcript and much more content from the Capital Rx team.