The Astonishing Healthcare Podcast

This special episode of the Astonishing Healthcare podcast features Congressman Jake Auchincloss, who discusses his efforts to reform pharmacy benefit managers (PBMs) and address systemic issues in the U.S. healthcare system to bring down costs. Representing Massachusetts' 4th district and growing up in a family of medical professionals and scientists, Rep. Auchincloss draws on his experience to advocate for policies that promote competition, innovation, and improved access to affordable care. He highlights his Pharmacists Fight Back Act (H.R.9096), noting that he looks forward to reintroducing the widely supported, bipartisan bill that aims to protect independent pharmacies, employers, and plan members, and he shares optimism about the potential for meaningful PBM reform to become law.

Auchincloss stresses the importance of challenging entrenched corporate practices to create a healthcare system that prioritizes price transparency, patients, and encourages technological innovation - such as new drug development or medical devices - in key areas affecting millions of Americans. For example, why not make curing Alzheimer's, which is expected to impact upward of 60 million people by 2025, our 'moonshot'?

Highlights

• Mandatory NADAC reporting (cost-plus, with a fair dispensing fee) and banning spread pricing, steering, and other traditional PBM business practices will help stabilize retail pharmacies and protect payers and patients from misaligned incentives.
• The federal government should promote competition in areas where there's an obvious and immediate positive impact, such as the development of generic and biosimilar drugs.
• Improving technology for "hospital at home" and long-term care for the elderly should be a focus.
• Price controls won't work for drugs, and there's more work to do on price transparency for medical care.
• Value-based contracts make sense - GLP-1s are a good example/potential application. We should be paying for performance.
• Congress should promote community health centers more because "they are really meeting people where they're at with the services that they need."

Related Content

• The Role of Pharmacy Benefit Managers in Prescription Drug Markets Part III: Transparency and Accountability (Rep. Auchincloss at 4:31:00)
• AH052 - ERISA Insights: Challenges & Compliance in Modern Healthcare, with Nick Welle
• RELEASE: AUCHINCLOSS INTRODUCES BIPARTISAN PHARMACISTS FIGHT BACK ACT TO CRACK DOWN ON PREDATORY DRUG PRICING
• What is NADAC & How Does It Differ From AWP?

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

Episode 80 of the Astonishing Healthcare podcast focuses on care navigation! Our guest, Andy Kageleiry (VP, Judi Care), explains the role of care navigation in helping health plan members (i.e., healthcare consumers) find care and navigate the complex U.S. healthcare system. He also discusses the importance of care navigation from the perspective of a plan sponsor. While everyone in the healthcare industry talks about patient-centered care and controlling costs, patients are left to navigate fragmented systems that work against them. Andy cuts through this contradiction and explains how care navigation can help as a core piece of the health benefits puzzle.

Andy provides an overview of the basics, highlighting the spectrum of care navigation solutions and how smart technology can enhance them. He then dives into how AI can transform care delivery by removing barriers before patients encounter them and delivering more personalized experiences.

Key Discussion Highlights

• True integration isn’t just about convenience; it’s about creating a seamless experience that anticipates and eliminates roadblocks before they occur.
• Having a unified front door to care, encompassing medical and pharmacy benefits, and unified claim processing on the backend, enables the delivery of new solutions that improve the member experience and help drive utilization of the benefits that plan sponsors carefully choose for their members.
• Leveraging data and AI, we can provide relevant information in conversational ways to help plan members find the care they need, when they need it.

Related Content

• Capital Rx Acquires Care Navigation Company Amino Health
• Health Benefits 101: The Importance of a Transparent PBM Model
• AH054 - Judi Health™: Going Beyond Pharmacy and into Medical Claims, with AJ Loiacono and Dr. Sunil Budhrani
• Pharmacy Benefits 101: Building an Award-Winning Call Center from Scratch

Reference Articles

• Same Surgery, $220K Apart: Why Providers & Employers Need to Rethink Value Amid Price Disparities (MedCity News; 8/18)
• Business Group on Health. 2026 Employer Health Care Strategy Survey (August 2025)

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

In this episode of the Astonishing Healthcare podcast, Mike Miele, FSA, MAAA (SVP of Insured Services), joins us again for a lively discussion about a new product and the growth of level-funded pharmacy plans. What are level-funded plans? How does Capital Rx's "Capital Equilibrium" work? Listen in to hear how these plans, positioned between self-funded and fully insured models, offer employers budget certainty while maintaining flexibility and transparency. Mike highlights the scenarios where a level-funded plan can truly help - e.g., a municipality with a fixed budget and the role stop-loss plays (building on Episode 55), and he also notes that not all level-funded plans are equal, and plan sponsors should look for transparency around rebates and whether any savings - if a plan's performance is better than the guarantee - ultimately benefit the plan.

Related Content

• AH071 - A Look at What's Really Driving Drug Spend, and How it Impacts Us, with IQVIA's Michael Kleinrock
• Pharmacy Benefits 101: Pharmaceutical Rebates
• AH067 - Aligned Health Benefits and the Freedom to Unbundle, with Kristin Begley, PharmD
• How to Manage Pharmacy Benefit Spend in a GLP-1 World

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

In this episode of the Astonishing Healthcare podcast, Capital Rx's Dr. Sunil Budhrani (Chief Innovation & Medical Officer) and Mike Tate (Vice President, National Business Development) discuss the questions they are fielding from channel partners and prospects interested in Judi Health™ - the first unified medical and pharmacy solution. We explore advancements in unified claims processing and how it helps address healthcare's fragmented nature by integrating pharmacy and medical benefits data with preferred vendors to tackle specific needs (e.g., for women's health or chronic condition management). Sunil also shares early, updated data revealing a ~5% per-employee-per-month (PEPM) reduction in costs YTD with Judi Health compared to 2024.

Additionally, the conversation with Sunil and Mike covers:

• The importance of empowering patient-provider relationships
• The need for greater transparency and access to data to see what's driving costs
• How a platform that allows for flexibility and personalization helps lower costs and provides for a better member experience

Related Content

• Judi Health™ Earns Best Healthcare InsurTech Solution in the 9th Annual MedTech Breakthrough Awards Program
• Replay - Strategic Well-Being: Rethinking Health Benefits to Empower Employees and Drive Impact
• Health Benefits 101: The Importance of a Transparent PBM Model
• Replay – The Bridge to Better Healthcare: Uniting Medical and Pharmacy Services on One Platform to Achieve Value-Based Care

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

In this episode of the Astonishing Healthcare podcast, host Justin Venneri sits down with Lauren Carroll, PharmD, a Senior Clinical Programs Manager at Capital Rx, to discuss Rx Retro, a pharmacist-led program that focuses on medication deprescribing to enhance patient safety, reduce adverse drug events, and improve healthcare outcomes. Lauren shares insights into how Rx Retro leverages Judi® - Capital Rx's enterprise health platform - to identify and address drug therapy concerns through a series of alerts and outreach designed to promote the safest and most effective treatments for plan members. The conversation also highlights the broader implications of deprescribing for healthcare quality and cost savings, with Lauren noting that, "We are uniquely positioned to bridge gaps that exist in the healthcare system."

Highlights

• Deprescribing Defined: The process of discontinuing potentially inappropriate medications under a healthcare provider's supervision.
• Judi® identifies drug therapy concerns in real-time, even across multiple prescribers and pharmacies.
• Rx Retro's Two Levels: Level 1 involves fax notifications to prescribers, while Level 2 includes direct pharmacist outreach and patient counseling.
• Broader Impact: Rx Retro addresses clinical areas like polypharmacy, duplication of therapy, and high-risk medications in vulnerable populations, and can help with quality metrics and scores that impact plans' star ratings.

Related Content:

• AH035 - Pharmacy Benefits 101: Clinical Programs, with Bonnie Hui-Callahan, PharmD
• Pharmacy Benefits 101: Building an Award-Winning Call Center from Scratch
• AH006 - Pharmacy Benefits 101: Clinical Care Teams, with Amy Stockton, PharmD
• Pharmacy Benefits 101: What’s the Drug Management Program (DMP)?
• AH073 - How Low Cost Alternative Programs Can & Should Work, with Jackie Lolos, PharmD, and Haleh Campbell, PharmD

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

In this episode of the Astonishing Healthcare podcast, we discuss recent health policy news and how to bring greater transparency to health benefits programs with returning guest, Jeff Hogan, President of Upside Health Advisors. Building on our previous discussion with Jeff - How First-Movers are Taking Control of their Health Plans in 2025 - we shed more light on the “PBM boogeyman” narrative, explaining how opaque pricing structures and unhelpful provisions buried in contracts must be discovered. Jeff reviews attempts by states around the country to intervene and halt steering and other practices that negatively impact health plans and their members - from early medical reform efforts to recent PBM-focused legislation. He also notes Medicaid cuts are likely to have some "second-order effects" that impact commercial plans, and the mood in Washington, DC, overall is "dazed and confused," so we can't count on help at the federal level.

Highlighting the evolving role of PBMs and Capital Rx's expansion into medical benefit administration, it's apparent that the opportunity to reduce waste and take back control of benefits programs exists; however, "medical is worse," Hogan says. So, what is a plan sponsor or benefits consultant to do? Dig into those contracts - all of them (administrative services, broker, and stop-loss, to name a few) - and look at the provisions you're paying for! "This is where you discover the schemes that are occurring," he adds.

Lastly, Jeff notes an interesting trend with health systems and direct contracting that's worth a listen, especially if you liked AH075 - What Health Systems Need [From a PBM]: A Blend of Tech, Transparency, and Understanding, with Lindsey Butler, PharmD, and Chris England.

Related Content

• Capital Rx Unveils Healthcare’s First Unified Pharmacy and Medical Claims Processing Platform
• Signs it is time to change your PBM vendor, and how to overcome common hesitations (BenefitsPRO)
• Replay - Strategic Well-Being: Rethinking Health Benefits to Empower Employees and Drive Impact

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

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

In this episode of the Astonishing Healthcare podcast, host Justin Venneri speaks with Lindsey Butler, PharmD, Vice President & Clinical Pharmacy Consultant at Lockton, and Chris England, Vice President of National Business Development at Capital Rx. They discuss what health systems need from a pharmacy benefit management (PBM) partner, the challenges in today's market, and the opportunities for innovation and collaboration to advance care for the patients in the communities health systems serve. State-level regulatory changes are top of mind, and Lindsey explains what she's tracking and how she's approaching meeting her clients' unique requirements: How can the benefits program aid with talent acquisition and retention? Can a pharmacy program meet everyone's needs (from the C-suite to the pharmacy team)? Both guests share insights from their extensive experience, offering ideas for health systems to enhance their pharmacy programs and improve the health benefits and healthcare experience for employees and communities.

Highlights

• Arkansas and Louisiana are among the states leading PBM reform efforts, and fiduciary responsibility is in focus - Lindsey discusses ERISA lawsuits and the Arkansas bill, while Chris talks about the push to use NADAC for drug pricing.
• Health systems are grappling with the high costs of GLP-1 drugs and exploring ways to integrate wraparound support, such as nutrition counseling, to improve outcomes - it's interesting that most health systems do cover them for weight loss!
• Many health systems are leveraging - or considering opening - in-house pharmacies to reduce costs, improve medication access, and enhance continuity of care.
• Having a PBM partner with flexible technology allows for custom network and reimbursement structures that align pharmacy benefits with health systems' goals.
• Collaboration among providers, pharmacies, and health plans is essential to ensure that decisions benefit both a health system and the patients it serves.

Related Content

• Pharmacy Benefit Procurement: How to Ensure That Savings Materialize (eBook)
• AH021 - Managing Pharmacy Costs in a GLP-1 World, with Bridget Mulvenna & How to Manage Pharmacy Benefit Spend in a GLP-1 World (Blog)
• AH029 - Selling Pharmacy Benefits: Building Relationships & Meeting Clients' Needs, with Nick Van Hook
• Pharmacy Benefits 101: The Importance of the Network

To get in touch with Lindsey: Lindsey Butler, PharmD, CSP

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

On this episode of the Astonishing Healthcare podcast, Carrie Liken (now with Snowflake) returns to the show to discuss the exceptionally rapidly evolving search landscape and Google's new AI Mode. Are websites dying as AI-powered search ascends in popularity? According to Carrie, it looks that way. She and host Justin Venneri discuss the transformative impact of AI on healthcare search and patient journeys. They explore how tools like Google’s new AI Mode and ChatGPT are reshaping how consumers find healthcare information, reducing reliance on traditional websites. Carrie shares insights from her "mini research studies," highlighting the challenges and decisions healthcare organizations face in adapting to the new world.

Highlights include:

The Decline of Traditional Websites: AI Mode summarizes information directly on search results, reducing the need for users to visit websites and challenging healthcare organizations to rethink their content strategies.

The Importance of Data Strategy: Carrie emphasizes that a robust data strategy is essential for organizations to succeed in an AI-driven world.

The Role of AI in Patient Journeys: AI tools can guide patients through initial research and even help locate care providers, though booking appointments still requires human interaction.

The Future of AI Agents in Healthcare: Carrie envisions AI agents automating tasks such as appointment scheduling and care coordination to significantly reduce friction in the healthcare system.

Related Content & Reference Materials

• Maybe we should write an obituary for the website (3/20/25)
• AI Mode is the training ground for AI Overviews (and yes, websites are still dying) (6/7/25)
• AH070 - Inside Capital Rx's Acquisition of Amino Health: Creating the Health Benefits Platform of the Future, Today

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

The latest episode of the Astonishing Healthcare podcast dives into the functionalities and real-world impact of Rx Smart Save, a low-cost alternative program designed to reduce medication costs for both patients and plan sponsors. Jackie Lolos, PharmD, and Haleh (Halls) Campbell, PharmD, join Justin Venneri in the studio for a discussion highlighting the innovation and care behind this clinical program.

Jackie and Halls outline how the two levels of Rx Smart Save work, with Level 1 empowering members to independently switch to lower-cost, clinically equivalent medications via notifications on the Capital Rx app or web portal. Level 2 increases access with a proactive, high-touch approach, where a team of pharmacists and specialists assist members, prescribers, and pharmacies throughout the process. Halls also shares a quick case study demonstrating how one retiree saved $75 per prescription by switching from an injection-based migraine treatment to a tablet, and Jackie explains how modern technology aids the process..

Related Content

• AH035 - Pharmacy Benefits 101: Clinical Programs, with Bonnie Hui-Callahan, PharmD
• Pharmacy Benefits 101: Building an Award-Winning Call Center from Scratch
• AH006 - Pharmacy Benefits 101: Clinical Care Teams, with Amy Stockton, PharmD
• Signs it is time to change your PBM vendor, and how to overcome common hesitations (Capital Rx / Benefits Pro)

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

On Episode 72 of the Astonishing Healthcare podcast, Marsha Perry, Capital Rx's Head of Benefits and Compensation, joins host Justin Venneri in the studio for a conversation about the intricacies of employee benefits, beyond pharmacy benefits! At a high level, she shares her thoughts on setting up a "well-rounded and affordable" benefits package, what should be in the benefits guide, and how to drive app usage and engagement in underutilized programs (a little humor and sharing personal stories almost always helps 😀).

Additionally, Marsha offers some specific examples of "benefits people [often] forget they have," and she dives into the importance of dental benefits (a surprisingly underutilized benefit). Lastly, but not least, Marsha shares her opinions on covering GLP-1s and the importance of maintaining a solid relationship with the finance team.

Related Content

• Replay - Strategic Well-Being: Rethinking Health Benefits to Empower Employees and Drive Impact
• AH021 - Managing Pharmacy Costs in a GLP-1 World, with Bridget Mulvenna
• Replay: The Future of Health Benefit Design: How Judi® Powers Seamless Care and Better Outcomes

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