Capital Rx Insights (October 2024)

We know plan sponsors are wrestling with rising healthcare costs, which have been primarily but not solely driven by pharmacy spend over the last handful of years. That's why Capital Rx teamed up with Workplace Intelligence in early October for a Q&A and LinkedIn Live event featuring our Chief Innovation & Medical Officer, Sunil Budhrani MD MPH MBA , and Senior Vice President of Strategy, Josh Golden : How to Uncover and Manage Your Healthcare Costs.

Dan Schawbel , Managing Partner at Workplace Intelligence, moderated the "fireside chat," and the trio dove into the reasons healthcare costs are rising, outlined priorities for 2025, highlighted specific areas of waste, and offered several suggestions to rein in costs.?

Related Content?

• How to Uncover and Manage Your Healthcare Costs?
• Pharmacy Benefit Procurement: How to Ensure That Savings Materialize?
• Will Biosimilar Rebates Pass-Through??

A. J. Loiacono spoke at HLTH 2024 -- "Owning the Boardwalk" -- the panel discussed how companies can stay resilient and thrive in highly consolidated industries, hurdles new entrants face in healthcare, and why constant innovation is critical even amidst rapid growth. AJ’s insights highlight how Capital Rx became a "one of one" organization and the pathway toward further success.

Astonishing Healthcare

If you haven’t yet, visit our Astonishing Healthcare Podcast page or subscribe on Apple, Spotify, or YouTube Music!

AH038 - Navigating Flu Season! A Quick Update on Vaccines and Such, with Libbi Green, PharmD

Formulary Operations Manager Libbi Green , PharmD, joined the podcast for a timely discussion about flu season, this year's flu vaccines, the timing and importance of vaccinations, how the flu vaccine performed last season, predicting flu trends, and the availability of different vaccine formulations to accommodate patients' varying needs.

Libbi also explains the role of pharmacies and healthcare providers in administering flu shots, emphasizing the importance of accessibility and preventing serious illness and hospitalizations, what's important for plan sponsors to consider for their populations, the vaccine production schedule, and what advancements we may be able to look forward to.

AH039 - Transition Benefits and the Relationship Between Communications and Product Management

Samantha Custer , Director of Member Experience, and Jake Mulkey , Product Manager, discuss a niche, important aspect of Medicare Part D plans: Transition Benefits. What goes on behind the scenes to enable a plan member to receive uninterrupted care? What role does modern software - i.e., JUDI? - play in providing members with a temporary supply of their medication and meeting notification requirements? What makes for a great relationship between product teams and other business units?

To answer these questions and more, Sam and Jake explain everything from how processes can be built into the adjudication process in JUDI in real time to the exchange of data and reporting surrounding the notifications that must be sent to plan members, per CMS requirements. Sam also explains how flexible JUDI is and that if CMS issues changes to any one part of the process, they can be adhered to "quickly and easily," or if commercial clients want to leverage the setup, it's no problem. Jake shares his views on building products in a modern platform and some things he's learned over the years that make for a good working relationship between product and other teams.

AH040 - Celebrating Women Pharmacist Day 2024

In this special episode of the Astonishing Healthcare podcast, four women pharmacists across Capital Rx's teams join host Justin Venneri to celebrate Women Pharmacist Day 2024! Amy Stockton, PharmD (our guest for Episode 6); Symara Schmidt, PharmD, BCGP, PMP , PharmD, BCGP; Lauren Carroll , PharmD, BCACP; and Marissa Badzik-Miller, PharmD , PharmD, discuss the significance of Women Pharmacist Day, highlighting the progress women have made in the pharmacy field and how and why they are celebrating this unique holiday within American Pharmacists Month.

The conversation delves into personal stories about their careers, including advice they'd share with their younger selves, how they balance their roles at work and home, the importance of mentoring the next generation of women pharmacists, the impact pharmacists have on patient care, and their hopes for the future!

AH041 - ERISA Litigation Outlook and Meeting CAA Requirements: What Can Plan Fiduciaries Do?

Three of the top experts in our industry weigh in on rising litigation against employers and pharmacy benefit managers (PBMs). What can employers sponsoring ERISA-covered health and welfare plans can do to show they are making an effort to establish processes and assess how "reasonable" the fees they pay are? Chris Deacon , Founder of VerSan Consulting; Jonathan Levitt , trial attorney and Co-Founding Partner at Frier Levitt; and Julie Selesnick , Senior Counsel in the employee benefits and ERISA Group at Berger Montague, discuss:

• Relevant provisions of the Consolidated Appropriations Act of 2021 (CAA)
• The recent lawsuits filed against Johnson & Johnson and Wells Fargo (implications and outlook for more litigation)
• How plan sponsors can approach things like getting their data to make informed decisions
• Conflicts of interest inherent in certain vendor relationships and the PBM procurement process

This episode builds nicely on previous conversations, including AH030 - Plan Sponsors Need a Source of Truth; Get Your Data Now & Find It, with Jeff Hogan.

Chris, Jon, and Julie also share their opinions about the similarities - or lack thereof - of the health plan lawsuits to the 401(k) and pension litigation of the early 2000s, the reality and frustration of relying on traditional PBMs and carriers for data (and what to do about it), and why Julie has a "fainting couch!"

Capital Rx Press & Knowledge Exchange?

In response to some great questions from a channel partner regarding GLP-1s, our clinical team helped pull together a “What We Know Now, For Now” series of articles:?

Part 1 covers?how major pharmaceutical incumbents and reimbursement authorities believe payment and reimbursement for anti-obesity drugs is likely to evolve.

Part 2 discusses?how, and to what extent, payers will materially differentiate between patient segments and what share of the market could be reimbursed (vs. cash).

Part 3 explores?how competition in the market could create downward pressure in pricing and what room there is for innovative pricing/value-based models.?

Ryan Kelly, Capital Rx’s Chief Technology Officer, and Josh Golden, SVP of Strategy, were named to the Class of 2024 BenefitsPRO Luminaries?in the Innovation & Technology and Education & Communication categories, respectively. This is a huge honor and shows just how impactful both have been -- not just to Capital Rx but to the industry at large.

Capital Rx Earned Full URAC Reaccreditation in Pharmacy Benefit Management, reflecting our company’s unwavering commitment to achieving and maintaining the highest quality, member engagement and experience, and operational standards for PBMs in the industry.?

What is NADAC & How Does It Differ From AWP? highlights NADAC’s overall utility as the best available drug price index. It’s publicly available, based on pharmacies’ acquisition costs, and has exhibited an overall deflationary trend over time, whereas AWP is not based on actual supply chain economics and enables PBM gameplay like spread pricing.

HIStalk Interviewed A. J. Loiacono, CEO, Capital Rx - the discussion/Q&A covered the underinvestment in healthcare technology (e.g., claim processing), eliminating the conflicts of interest inherent in traditional PBM models, and how Capital Rx leverages cutting-edge technology -- JUDI? -- to enhance claim administration and price transparency.?

Channel Partners,? ?

Before we get into some tips for brokers relating to pharmacy benefit implementations, I first want to state that the top brokers/consultants in the business are not afraid of moving groups to a better PBM, provided you’re selecting a PBM that has mastered the art of implementing smoothly.?So, please don't be that broker/consultant that elects to take an average renewal from a carved in deal or stays with a PBM your group is not satisfied with simply because it is easier for you!?

? Four Tips for Implementation:?

1. Assuming you are keeping the plan design as close to the current set up as possible, ensure that you complete onboarding documents with as much detail as possible to take that lift off your client?
2. Inquire about Continuation of Therapy (CoT) if there’s any concern about disruption for members on chronic medications?
3. Request to meet your account management team and see how early in the implementation process they are involved (spoiler alert, at Capital Rx they are with you from the beginning)?
4. Stay engaged with your client through the full implementation to ensure the PBM's answers are complete and address any concerns fully?

For more, you can read Pharmacy Benefits 101: Successful Implementations at your convenience! I’m always happy to chat – reach out if you have questions.

Brian || [email protected]

Most Read News at Capital Rx

• Texas sues PBMs, manufacturers over insulin 'conspiracy' ( Fierce Healthcare ; 10/3)
• CMS proposes risk adjustment changes, broker fraud crackdown for 2026 plan year ( Fierce Healthcare ; 10/4)
• The end of a shortage of popular weight-loss drugs may mean many people lose access to them ( CNN ; 10/9)
• Four health systems form Longitude Health ( Healthcare Finance News ; 10/11)
• CVS and Walgreens are ailing. Here’s why ( NPR ; 10/16)
• The Powerful Companies Driving Local Drugstores Out of Business ( 纽约时报 ; 10/19)
• Walmart will start delivering prescriptions to customers’ doorsteps as CVS and Walgreens struggle ( CNBC ; 10/22)
• Maloy and Colleagues Introduce Bill to Investigate How PBMs Unfairly Audit Pharmacies (Maloy; 10/28)

We’re Hiring!

If you are looking or know anyone looking for a new role in the PBM industry, please visit our careers page or click the image below.

We Celebrated American Pharmacists Month and Pharmacy Week, along with #RxTechDay2024 and #WPD2024, in October. Our licensed team members deserve thanks for their devotion to the managed care pharmacy profession and for providing the best client and member service in the industry!

It's never too late to celebrate, click the image below and join it...

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