In this episode of the Astonishing Healthcare podcast, Spencer Kramer, Director, Client Services at Capital Rx, joins us in the studio to discuss an important aspect of plan sponsors' annual reporting requirements: Prescription Drug Data Collection - aka RxDC. We review key dates and where plan fiduciaries can find important data and updates, and Spencer shares his experience working with Capital Rx's clients and some suggestions to a) yield a smooth RxDC submission process and b) make use of the detailed data that plan sponsors are entitled to!

As a requirement of the Consolidated Appropriations Act of 2021, RxDC demands detailed annual data submissions by plan issuers, TPAs, and others. Spencer explains the importance of starting early, understanding the data submission components, tackling coordination complexities, and ensuring accuracy. You'll want to be working with a partner here, not "just a vendor." Spencer emphasizes the importance of cooperation and maintaining detailed records to avoid friction and streamline the reporting process.

Related Content

• AH030 - Plan Sponsors Need a Source of Truth; Get Your Data Now & Find It, with Jeff Hogan
• The Consolidated Appropriations Act & Prescription Drug Data Collection (RxDC): New Rules & Regulations Equal New Responsibilities
• AH048 - High-Cost Orphan Drugs, Securing Claims Data, and More, with Dr. Eric Bricker

Visit CMS.gov for RxDC-Related Resources

• https://www.cms.gov/marketplace/about/oversight/other-insurance-protections/prescription-drug-data-collection-rxdc

For more information about Capital Rx and this episode, please visit Capital Rx Insights.

On this episode of the Astonishing Healthcare podcast, we discuss how modern technology - Judi® - brings efficiency to the labor union market with Capital Rx's Mike Miele, FSA, MAAA (Senior Vice President of Insured Services), Christie Peperato (Manager, Payment & Operations), and Kelly Smith (Product Manager). Who knew that Capital Rx has an hours banking system? Why did we build one? Well, every hour a union worker works may be tracked and "banked" for benefits eligibility purposes. So, those hours and the accuracy of the reporting matter... a lot. And as Christie describes, it's been a manual, "painful" process forever.

After Mike explains the unique needs of union clients and what hours banking is all about, Christie and Kelly dive into how this newly developed system alleviates the pain by automating the tracking of work hours and eligibility for health benefits and having everything, including payments, processed in one system. By removing the manual burden on union office managers and making it easy for contractors to submit the data, managers and plan administrators can focus on what matters most: taking care of members' needs. Want to help name the new system? Drop us an email. 😆

Related Content

• 12 New Judi® Features Innovating Pharmacy Benefit Administration
• AH055 - Pharmacy Benefits 101: Stop-Loss Insurance, with Mike Miele, FSA, MAAA
• Capital Rx Unveils Healthcare's First Unified Pharmacy and Medical Claims Processing Platform

Please visit Capital Rx Insights for more information, including this episode's transcript, or to get in touch!

For this special episode of the Astonishing Healthcare podcast, Andrew Barnell, CEO of Geneoscopy, joins Justin Venneri in the studio for an insightful discussion about colorectal cancer (CRC) screening in observance of National CRC Awareness Month! Andrew explains how he and his "very talented" sister, Erica Barnell, MD, PhD, co-founded Geneoscopy to develop diagnostic tests using RNA biomarkers extracted from stool samples. Their newly FDA-approved test, ColoSense™, provides a non-invasive alternative to traditional colonoscopies.

Barnell highlights the rising incidence of CRC in younger adults, which prompted guideline changes to lower the recommended screening age to 45. He stresses the urgent need for increased screening awareness and greater access to screening tools, noting that employers can help overcome barriers to screening through education and by encouraging engagement in wellness programs. Other topics covered include:

• Over 135,000 people are diagnosed with CRC every year, and despite CRC being one of the most preventable cancers with good long-term survival rates following treatment, 50,000 people die from it annually.
• Preventive screenings are increasingly covered with no patient out-of-pocket costs, but insurers' expenses are rising.
• Increasing early screening is crucial: 30-40% of eligible individuals remain unscreened, particularly in the 45-49 age group.
• Geneoscopy's decentralized clinical trial and overall use of technology to conduct its pivotal FDA approval study virtually, which increased patient diversity and efficiency.
• Regulatory challenges remain: FDA approval is just one step; Medicare coverage and guideline inclusion are key hurdles.
• Bringing targeted therapy approaches to autoimmune diseases like IBD to improve patient outcomes and reduce costs is Geneoscopy's next goal.

Related Content

• Multitarget Stool RNA Test for Colorectal Cancer Screening. Barnell EK, Wurtzler EM, La Rocca J, et al. JAMA. 2023;330(18):1760–1768. doi:10.1001/jama.2023.22231
• Pharmacogenomics (PGx) 101: What You Need to Know for Rx Programs

Reference Materials/Other Links (courtesy of Geneoscopy)

• Projected Impact and Cost-Effectiveness of Novel Molecular Blood-Based or Stool-Based Screening Tests for Colorectal Cancer. Ladabaum U, Mannalithara A, Schoen RE, Dominitz JA, Lieberman D. Ann Intern Med. 2024 Dec;177(12):1610-1620. doi: 10.7326/ANNALS-24-00910. Epub 2024 Oct 29. PMID: 39467291.
• Colorectal Cancer—Patient Version. National Cancer Institute (NCI)
• Productivity savings from colorectal cancer prevention and control strategies. Bradley CJ, Lansdorp-Vogelaar I, Yabroff KR, Dahman B, Mariotto A, Feuer EJ, Brown ML. Am J Prev Med. 2011 Aug;41(2):e5-e14. doi: 10.1016/j.amepre.2011.04.008. PMID: 21767717; PMCID: PMC3139918.
• Follow Geneoscopy on LinkedIn

For more information about Capital Rx and this episode, please visit Capital Rx Insights.

On this episode of the Astonishing Healthcare podcast, Bloomberg Intelligence's Jonathan Palmer (Sr. Equity Analyst & Team Lead, Healthcare) joins us in the studio for a discussion about the work his team does and the evolving landscape of health tech. Palmer notes interest in Hinge Health's potential IPO and how the market's receptivity to tech-enabled healthcare companies has improved recently. While these companies face pressure to demonstrate profitability amid evolving market dynamics, there's optimism about innovation on several fronts. He also explains the impact of health policy uncertainty and questions about what the FDA, FTC, DOJ, and CMS will do on investors' ability to place bets: ambiguity causes market hesitation, and investors gravitate toward safe havens.

The discussion also covers areas of focus for 2025, including:

• Palmer's favorite Vanguards of Healthcare podcast episodes and why he enjoys speaking with private company CEOs and venture capital leaders
• Biopharma Innovation, including GLP-1s, oncology readouts
• MedTech Advancements like surgical robotics, cardioablation, and evolving insulin delivery systems
• Capital Spending Concerns as US providers and China's healthcare sector are under scrutiny
• Healthcare Services: online pharmacy growth and Medicare Advantage trends

Reference Materials Courtesy of Bloomberg Intelligence

• North America Managed-Care Policy Outlook
• N.A. Health-Care Tech, Distribution: 2025 Outlook

Related Content

• Vanguards of Health Care: How Capital Rx is Fixing America's Broken Drug Pricing
• AH057 - How First-Movers are Taking Control of their Health Plans in 2025, with Jeff Hogan
• AH047 - What Project 2025, RFK Jr., and Dr. Oz Could Mean for the Business of Healthcare Under Trump
• AH046 - What's Hot In and Around the Pharmacy Supply Chain, with RSM's Tom Evegan

For more information about Capital Rx and this episode, please visit Capital Rx Insights.

On this episode of the Astonishing Healthcare podcast, host Justin Venneri speaks with Liya Lomsadze (Director, Product Management) at Capital Rx. Liya highlights her journey from data analytics on the provider side to leading the product development of Capital Rx's Unified Claims Processing™ product, Judi Health™. They dive into several recent updates to the Judi® platform, highlighting Judi's overall agility and how it aids in the administration of benefit plans for Capital Rx's clients. During the discussion, they also explore:

• Improvements to the Prior Authorization (PA) Tool, including a new supervisor dashboard for PA requests.
• Judi's ability to ingest historical claims data for seamless onboarding of new clients.
• The potential expansion of Unified Claims Processing to include other insurance (e.g., vision and dental).
• Capital Rx's new Medicare Prescription Payment Plan (M3P) and Judi's ability to meet evolving CMS requirements.
• Judi's Formulary Management Tool, which aims to improve how claims are adjudicated by making formulary data both accessible and functional.
• How Judi Health aims to streamline member care and improve the patient experience.

Last, Liya praises one of Judi's most loved features - can you guess what it is? Hint: if, then.

Related Content

• Capital Rx Receives a US Utility Patent Covering its Enterprise Health Platform - Judi®
• Pharmacy Benefits 101: Prior Authorizations
• How Our Favorite New JUDI Features Aid Pharmacy Benefit Administration
• AH027 - What is Pharmacy Benefit Management? With Jillian Lonson and Jean Beman, Part 1
• AH028 - What is Pharmacy Benefit Management? With Jillian Lonson and Jean Beman, Part 2

For more information about Capital Rx and this episode, please visit Capital Rx Insights.

On Episode 57 of the Astonishing Healthcare podcast, host Justin Venneri welcomes Jeff Hogan, President of Upside Health Advisors, back to the show to discuss the major trends he observed in healthcare procurement and plan management in 2024 and areas of focus in 2025. Jeff highlights the evolving role of employer fiduciaries under the Consolidated Appropriations Act of 2021 (CAA), building on Episode 30 and re-emphasizing the necessity of real-time data access and process-driven strategic decision-making. He explains how employers must take greater accountability for healthcare spending, moving beyond reliance on traditional insurance networks (BUCAHs) and considering alternative care delivery models; and adds that provider organizations must adapt to align care delivery with consumer needs or risk obsolescence.

The discussion also covers the increasing use of analytics - including platforms like HOMA Health - or outside resources, like Nick Welle explained on Episode 52, to help plan employer plan sponsors manage costs and their vendor contracts, PBM reform, and point solution fatigue. Finally, Jeff outlines key priorities for 2025, including fiduciary compliance, confirming the removal of gag clauses from contracts, and greater transparency in broker compensation to ensure better alignment between healthcare purchasers and providers.

Related Content

• Replay - Strategic Well-Being: Rethinking Health Benefits to Empower Employees and Drive Impact
• AH030 - Plan Sponsors Need a Source of Truth; Get Your Data Now & Find It, with Jeff Hogan
• Best of '24! AH041 - ERISA Litigation Outlook and Meeting CAA Requirements, What Can Plan Fiduciaries Do?
• Signs it is time to change your PBM vendor, and how to overcome common hesitations

To learn more about Upside Health Advisors, click here, or you can find Jeff on LinkedIn.

Resources Mentioned

• Vizient - 2025 Trends Report: Strategy is (finally) back in the driver’s seat
• Peterson Health Tech Institute - Virtual Musculoskeletal Solutions (June 2024)
• ICER - Peterson Health Tech Institute: Assessment Framework for Digital Health Technologies (Sept. 2023)
• Peterson Health Tech Institute - Digital Diabetes Management Solutions (March 2024)

For more information about Capital Rx and this episode, please visit Capital Rx Insights.

On this episode of the Astonishing Healthcare podcast, Justin Venneri chats with Angela Kalantarova, PharmD, a senior clinical programs manager at Capital Rx, about recent updates to Medicare's star ratings. Angela shares her path to Capital Rx and experience working in managed care and on clinical programs, and she explains what's new for 2025: star measures for polypharmacy and concurrent use of opioids and benzodiazepines.

The conversation highlights the positive impact early interventions can have and how innovative enterprise health technology like Judi® allows for real-time insights. As CMS proposes changes, such as possibly removing the MTM - medication therapy management - measure or others like limiting initial opioid supply, having the flexibility to react quickly helps immensely. Angela also provides some strategic insights into how to navigate the evolving landscape and achieve superior ratings.

Related Content

• AH035 - Pharmacy Benefits 101: Clinical Programs, with Bonnie Hui-Callahan, PharmD
• Poster: Impact of Point-of-Sale Duplicate Therapy Safety Alert on Concomitant DPP-4 Inhibitor and GLP-1 Agonist Use
• AH005 - Star Ratings, MTM, & CMS Translation Requirements with Jay Tran, PharmD
• AH006 - Pharmacy Benefits 101: Clinical Care Teams, with Amy Stockton, PharmD

For more information about Capital Rx and this episode, please visit Capital Rx Insights.

On this episode of the Astonishing Healthcare podcast, we explore the nuances of stop-loss insurance with Capital Rx's Mike Miele, FSA, MAAA (Senior Vice President of Insured Services). With premiums on the rise due to high-cost claims reaching levels actuaries never thought possible, self-insured plan sponsors need new options and better tools to monitor their costs. Mike, who is a healthcare actuary by training, discusses everything from "What is stop-loss?" and who it's for to what's driving high-cost claims to new heights, the rise of a pharmacy-only stop-loss option, and options plan sponsors have to mitigate risk when "it's not a good time to be in a risk-taking business."

Mike comments on broader cost drivers, using GLP-1s as an example, preliminary book-of-business trends (2024 vs. 2023), the importance of surveillance on emerging claims, and more!

Related News & Content:

• Sun Life sees stop-loss problems spiking: Will it force employers to buy fully insured coverage? (BenefitsPro)
• AH031 - Dissecting Pharmacy Cost Drivers and the Value of PMPM, with Kristin Begley, PharmD, and Mike Miele, FSA, MAAA
• Capital Rx Unveils Healthcare's First Unified Pharmacy and Medical Claims Processing Platform

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

This episode of the Astonishing Healthcare podcast highlights the transformative potential of Judi Health™, the first unified claims processing platform that integrates medical and pharmacy claim administrative workflows and data to create a seamless experience for stakeholders, including patients, providers, and employers. Guests AJ Loiacono (Co-Founder & CEO of Capital Rx) and Dr. Sunil Budhrani (Chief Innovation & Medical Officer) emphasize the limitations of the traditional fee-for-service model and legacy infrastructure in U.S. healthcare, which incentivizes reactive rather than proactive care and can't handle the evolution and complexities of value-based care, respectively.

Building on Episode 7 (with Sunil) and Episode 9 (with Ryan Kelly, CTO), AJ and Sunil discuss how Judi Health’s innovative design can improve the system by enabling real-time data sharing across medical and pharmacy claims (and ultimately vision, dental, etc.), reducing administrative friction, and offering personalized care through population health strategies.

AJ Loiacono reflects on the journey of building Judi Health and the importance of firsthand experience in workflow optimization. Dr. Budhrani stresses the importance of transparency and collaboration among the stakeholders, underlining how Judi Health can break down silos to improve care delivery and outcomes. They offer practical examples of how Judi Health can work, such as diabetic-specific plan designs and improved workflows for cancer care.

The conversation closes with a reflection on the team members' strong personal and professional synergies and real-life experience with Judi Health since its launch on January 1.

Related Content:

• Capital Rx Unveils Healthcare’s First Unified Pharmacy and Medical Claims Processing Platform
• Setting a New Standard for the Future of Pharmacy Benefit Administration
• Replay - Build a Lasting Pharmacy Benefit Strategy with Never Move Again™
• Signs it is time to change your PBM vendor, and how to overcome common hesitations

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

On Episode 53 of the Astonishing Healthcare podcast, Bridget Mulvenne, VP of Business Development, joins Justin Venneri in the studio again to share highlights of her first full year of selling pharmacy benefit solutions ahead of her webinar on February 13: 5 Ways to Improve your PBM Procurement Process in 2025 (click here to learn more and register). They discuss the evolving healthcare landscape, regulatory pressures, expanding indications for GLP-1s, and the need for transparency in pharmacy benefits. Bridget shares stories from the field, explaining why focusing on drug manufacturer revenue and breaking the industry’s dependence on rebates are so important and how modern technology helps provide real-time data access and actionable insights to plan sponsors.

Previous AH episodes featuring Bridget:

• AH002 - A Former Pharmacy Program Director's View on Controlling Pharmacy Costs
• AH021 - Managing Pharmacy Costs in a GLP-1 World, with Bridget Mulvenna

Bridget also shares insights on the evolving landscape of GLP-1 medications and their growing number of FDA-approved indications beyond diabetes and highlights the challenges plan sponsors face with coverage decisions, balancing short-term costs with potential long-term savings. Discussing Capital Rx’s Never Move Again™ offering, Bridget emphasizes its flexibility and appeal to sophisticated plan sponsors.

Related Content:

• Pharmacy Benefits 101: Pharmaceutical Rebates
• Our Single-Ledger Model™ - Pharma Revenue Explained
• AH030 - Plan Sponsors Need a Source of Truth; Get Your Data Now & Find It, with Jeff Hogan

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