In this episode of the Astonishing Healthcare podcast, Justin Venneri speaks with Bonnie Hui-Callahan, PharmD, CDCES, Senior Director of Clinical Programs at Capital Rx, about the significance of clinical programs within the pharmacy benefit management (PBM) space. Bonnie explains how clinical programs serve as an "added layer of service" similar to after-school programs. They enhance the core functions of PBMs (claim administration) and help plan sponsors reduce costs, improve quality of care, enhance patient safety, and address prevalent health conditions within their populations.

The conversation delves into the different types of clinical programs offered by Capital Rx, categorized into five key areas: utilization management, cost containment, patient safety, population health, and personalized care. Bonnie emphasizes that while many programs, such as opioid safety and medication therapy management, are standard across PBMs, there are also unique, in-house, and vendor-partnered solutions tailored to specific health conditions. She also highlights the potential benefits and importance of integrating pharmacy and medical claims, offers some key questions plan fiduciaries can ask, and reviews the results of a recent poster presentation by her team at the 2024 Pharmacy Quality Alliance meeting!

Related Content

• 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
• Pharmacy Benefits 101: Prior Authorizations

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

In this episode of the Astonishing Healthcare podcast, Will Tafoya, Senior Vice President of Operations and the leader of Capital Rx's contact center, shares his views on building and leading an award-winning customer care team, which is available 24/7/365 to serve millions of pharmacy plan members. Will's passion for customer care and his team shines through, as he explains why hiring PTCB pharmacy technicians and other individuals with healthcare experience is so important, the benefits of a virtual call center (vs. brick-and-mortar), how customer care interfaces with clinical or other teams, and much more.

Since member service and support are central to Capital Rx's new Never Move Again™, as as AJ Loiacono describes in Episode 33 - Never Move Again™, a Paradigm Shift in Pharmacy Benefits, Will and host Justin Venneri dive into topics including:

• Client-specific training (e.g., cultural training)
• Why JUDI®, Capital Rx's enterprise health platform, is a "one-stop-shop" for Will's team
• The importance of considering how members will react to AI and automation
• Measures of success, including average speed of answer (ASA) and handle time

Finally, Will shares that advice that's been most influential to him over his 30+ years in contact center leadership. (Hint: it's something we should never stop doing!)

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

In this episode of the Astonishing Healthcare podcast, AJ Loiacono, co-founder & CEO of Capital Rx, joins Justin Venneri to discuss Never Move Again™, the recently launched "unbundled" pharmacy benefit administration solution for large employers. It turns out larger employer groups, TPAs, and other groups with 50,000+ lives are very similar to health plans, which value the flexibility and transparency an unconflicted administrator provides. Supported by JUDI®, our single scalable enterprise health platform and a world-class call center, plan fiduciaries now have an option that addresses the pain points of CAA compliance and the friction of switching PBMs over time.

• The program's transparent, flat-fee structure ensures no incentive to push more expensive drugs, leverage hidden markups, or otherwise profit at the plan's expense - aligning with the fiduciary duties under ERISA.
• JUDI Health is the solution's core, providing a fully integrated system that allows clients to use their preferred services - point solutions, other vendors, rebate aggregators, or even pharmacy network options.
• Never Move Again™ is a return to the original, independent role of PBMs, offering a more ethical and efficient future for U.S. healthcare.

Additionally, and please forgive the shameless plug, AJ joined Josh Golden, SVP of Strategy here at Capital Rx, who we spoke with earlier this year about future-proofing your pharmacy benefit plan (AH008), on September 19, 2024, at 2:00 PM ET for an educational webinar explaining our new offering: Build a Lasting Pharmacy Benefit Strategy with Never Move Again™.

Related Content

• Capital Rx Launches Never Move Again™, Enabling Self-Funded Plan Sponsors to Perpetually Access the Best Drug Prices Without Ever Having to Reimplement a Plan
• ViVE 2023 Highlights: What's Behind the Price Tag of Medication
• AH032 - Prescription Rebates: Agreements, Guarantees, and More, with NPC's John O'Brien, PharmD, MPH, and Julie Patterson, PharmD, PhD

Learn more about Never Move Again™ HERE.

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

In this episode of the Astonishing Healthcare podcast, we dive into the National Pharmaceutical Council's recent employer survey on rebates and rebate guarantees published in the AJMC, Prescription Rebate Guarantees: Employer Insights ((7/19/24). NPC CEO John O'Brien, PharmD, MPH, and Senior Research Director Julie Patterson, PharmD, PhD joined Capital Rx's Co-Founder and CEO AJ Loiacono in the studio for the discussion, which covered everything from how and why rebates have become so important to employers and traditional PBMs and what "pass-through" means to "the spreadsheet" and the difficulty in comparing traditional and more modern PBMs and how rebates impact a plan's net total cost.

AJ and John highlight how PBMs manipulate drug prices through rebate incentives, resulting in higher costs for employers and patients, and Julie reviews the results of their survey, explaining why employers must "break the addiction to rebates." They emphasize the importance of transparency and the role of employer benefits consultants in PBM procurement and evaluation as well (at Capital Rx, we value objective, helpful advice on benefit design for our employees). Check out the survey and be sure to sign up for NPC's newsletter to follow their work - it sounds like there's a lot more to follow!

Contact Information

• Sign up for the NPC This Week Newsletter: https://www.npcnow.org/subscribe-updates
• Check out the National Pharmaceutical Council on LinkedIn
• Connect with John O’Brien, PharmD, MPH on LinkedIn
• Connect with Julie Patterson, PharmD, PhD on LinkedIn

Related Content

• Pharmacy Benefits 101: Pharmaceutical Rebates
• AH002 - A Former Pharmacy Program Director's View on Controlling Pharmacy Costs
• Our Single-Ledger Model™ - Pharma Revenue Explained

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

In this episode of the Astonishing Healthcare podcast, Justin Venneri sits down with Kristen Begley, PharmD, Chief Commercial Officer, and Michael Miele, FSA, MAAA, Senior Vice President of Insured Services, for a discussion about some of the finer points of pharmacy benefit management (PBM) procurement and pharmacy program cost evaluation, including how misaligned incentives can drive costs higher than they should be for plan sponsors. They delve into the misleading nature of focusing on unit costs and high rebates and advocate for a per member per month (PMPM) model to gain a clearer picture of true costs and hold PBMs accountable.

Kristin and Mike suggest ways to update and improve legacy PBM evaluation methods, encouraging stakeholders to more carefully consider everything from the questionnaires leveraged to screen potential PBM partners to the true value of clinical programs for utilization management - such as prior authorization - and the actual number of units used to forecast spending.

Related PMPM Content:

• AH010 - The Power of PMPM: Holding PBMs Accountable for Total Drug Spend, with Kristin Begley, PharmD
• 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!

In this episode of the Astonishing Healthcare podcast, Jeffrey Hogan, President of Upside Health Advisors, returns to the show for a timely discussion with Justin Venneri about why the timing is perfect for health plan sponsors and fiduciaries to engage their partners to secure necessary disclosure requirements and access to their data: it's renewal season!

The Consolidated Appropriations Act (CAA) placed additional responsibilities on plan fiduciaries, including the need to make attestations. With gag clauses removed from contracts, the door is open. Jeff stresses the importance of analyzing the plan's data to make informed decisions and meet the fiduciary obligations. "The industry is craving trust," and fiduciaries need a trusted source of data and analytics to help them identify areas of waste and make changes that will benefit their plans. Whether it's pharmacy benefits, hospital spend, or the commissions paid to brokers/consultants, there's a unique opportunity to gain the insight needed and avoid the rising risk of liability right now.

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

Related Content

• AH004 - Data, Fiduciary Responsibility, and Reversing Trend with Jeff Hogan
• The Consolidated Appropriations Act & Prescription Drug Data Collection (RxDC): New Rules & Regulations Equal New Responsibilities
• Self-funded plans ignore the Consolidated Appropriations Act at their peril

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

In this episode of the Astonishing Healthcare podcast, Nick Van Hook (VP, Commercial Markets) joins host Justin Venneri to discuss the pharmacy benefits selling season and the importance of building relationships and trust in B2B sales, especially in healthcare. They start with Nick's career journey - from pursuing a professional golf career and not knowing what a pharmacy benefit manager (PBM) is to consulting and, ultimately, Capital Rx - and then dive into the top questions and issues Nick fields and must address while building personal connections and closing deals with larger employers, including health systems and universities, where he tends to focus his time.

Nick shares his insights on current market trends, such as the significant impact specialty drugs and GLP-1s are having on employers' overall plan spend. He also explains drug mix and how Capital Rx differentiates itself by leveraging JUDI® to maintain independence and administer aligned pharmacy benefit programs that meet clients' needs without the conflicts of interest that arise from owning dispensing assets and engaging in spread pricing., for example.

Related Content:

• The Upside of a Single-Ledger Model™ in Pharmacy Benefits
• AH010 - The Power of PMPM: Holding PBMs Accountable for Total Drug Spend, with Kristin Begley, PharmD
• AH021 - Managing Pharmacy Costs in a GLP-1 World, with Bridget Mulvenna & How to Manage Pharmacy Benefit Spend in a GLP-1 World (Blog)

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

In this Part 2 episode of Astonishing Healthcare, Justin Venneri continues the discussion about what a pharmacy benefit manager (PBM) does with Capital Rx team members Jillian Lonson, PMP®, Sr. Director, Benefits Administration & Operations, and Jean Beman, Manager, Benefits Operations & Administration. They dive deeper into the weeds and geek out on topics including benefit configuration, enhancements, and testing to be sure everything is set up correctly! They also explain how JUDI® is different and makes several aspects of the process far simpler than they've experienced in the past with legacy software solutions.

Jillian and Jean also share their perspectives on the common challenges employers, for example, face when configuring and implementing a new PBM. They offer advice to ensure things go smoothly, emphasizing the importance of considering member experience. Last, Jean explains how JUDI's design enables the deployment of enhancements such as a new Medicare Prescription Payment Plan (M3P) solutions with relative ease.

Related Content:

• AH027 - What is Pharmacy Benefit Management? With Jillian Lonson and Jean Beman, Part 1
• Government Programs: The True Meaning of Customization (with Jason Barretto)
• Pharmacy Benefits 101: Successful Implementations

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

In this episode of the Astonishing Healthcare podcast, Jillian Lonson, PMP®, Sr. Director, Benefits Administration & Operations, and Jean Beman, Manager, Benefits Operations & Administration, join host Justin Venneri for part one of a two-part discussion about what pharmacy benefit management (PBM) entails. They describe the basics and then peel back the layers of what PBMs do to ensure that a prescription processes correctly - per your pharmacy benefit - so you can pay the correct amount at the pharmacy counter or receive your medication in the mail.

Jillian and Jean also share their professional journeys within the PBM industry, highlighting how their roles and teams are central to configuring and testing plan benefits so that formularies, the network, and clinical programs are set up correctly. This informative episode sets the table for a deeper dive into the configuration and testing that go on behind the scenes!

Related Content:

• AH001 - Building a PBM: Tech, Navigating Growth, and Delivering Value with AJ Loiacono
• What Is the Role of a Pharmacy Benefits Manager (PBM)?
• Pharmacy Benefits 101: What is a Formulary?

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

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!