AH028 - What is Pharmacy Benefit Management? With Jillian Lonson and Jean Beman, Part 2

Transcript

Lightly edited for clarity.

[00:27] Justin Venneri: Hello and thank you for joining us for this episode of the Astonishing Healthcare podcast. I'm Justin Venneri, Director of Communications at Capital Rx and your host. And this is part two of our discussion with Jillian Lonson, Senior Director of Benefit Administration and Jean Beman, Manager of Benefit Operations and Administration here at Capital Rx on what really is pharmacy benefit management and what goes on behind the scenes. Jean and Jillian, I’ve got some more questions for you, so thanks for coming back.

[00:52] Jillian Lonson: Happy to be here.

[00:54] Justin Venneri: So, last episode we spoke high level about what a PBM is, and the core things that you two set up and your team helps set up for our clients to enable their members to pick up a prescription at the pharmacy. So, I’ll link that show along with some other resources in the show notes, and I think we can get right into some of the more detailed topics.‍

• AH027 - What is Pharmacy Benefit Management? With Jillian Lonson and Jean Beman, Part 1

Starting with you, Jean. Can we tackle a fear that we hear a lot in the field or that our team hears a lot from prospects and folks in the industry? Some common challenges employers, for example, face or need to solve for when implementing a PBM solution, especially relating to the configuration. Who do you work with to configure things, operationalize the benefit, etc., to ensure that things go smoothly?

[01:39] Jean Beman: Yeah, great question. So, the number one thing I think that is a very large fear with employers and moving in from a legacy PBM to a newer PBM is – consolidation is one of the key components to make Judi different from typical big box PBMs who are not capable of consolidating their account hierarchy. What I mean by consolidating is that they have a much larger benefit build in their previous incumbent PBM’s system. That makes it so that it is very inefficient. So, our goal is to reduce all those duplications to essentially enhance the efficiency of, overall, the build of the book of the benefits for the client. But also, later down the line, the plan maintenance is much less cumbersome.

[02:24] Justin Venneri: Got it. Jillian, anything you'd add?

[02:26] Jillian Lonson: Yeah, so I think Jean really hit the nail on the head. One of the key differentiators with Judi is that, to Jean’s point, we can take a client’s benefits from a legacy platform where they may require, for example, 250 plans to be built. Given the limitations, we can consolidate those 250 plans into, maybe 100 or less plans in Judi – really. Depending on the configurations we take a look at, that means less plans for the clients and us to manage and maintain, which ultimately creates downstream efficiencies throughout the life of the plan.

We have found that clients are pleasantly surprised by Judi’s ability to consolidate at a very granular level while still maintaining the same level of benefit designs. When it comes to who we work with during the process, it can vary. Typically, my team will work with a client and their consultant, if applicable, and any vendors we need to account for during the configuration process, such as accumulation, vendors, medical vendors, etc. Benefits work with all areas across Capital Rx to facilitate and execute on our side, which, based on my career experience, is something that sets us apart from other organizations. We operate holistically and are not siloed in any sense of the word. Every area is aware and informed along the way, which ultimately contributes to a seamless execution, which is really always our goal.

[03:55] Justin Venneri: Okay, and how crucial is thorough testing during the implementation process? What are some best practices for ensuring a smooth testing phase? Jillian, you want to take that?

[04:05] Jillian Lonson: Yeah, that’s a great question. So, testing validation is just as important, if not more so, than the actual configuration step. This is where my team ensures that what we built in Judi meets the client’s intent. Our primary goal when testing is to mirror as many scenarios as possible at the pharmacy, including anything that may be customer as well, so that there’s no member impact when a patient fills their medication at the pharmacy.

As a standard, my team tests over 700 unique scenarios for each plan design to ensure everything from the cost shares, the accumulations, plan maxes, clinical rules, formulary and network. Obviously, that’s just naming a few. There are many other pieces that go into the configuration, but our ultimate goal is to make sure that everything is set up accurately, well in advance of the plan start date. And then, once all of the configuration is complete and peer reviewed, we run our batch testing scenarios against the benefit. And once those are run, my team will then perform a validation check to ensure the actual scenarios that we enter into our batch align to the anticipated scenarios again in the batch. And then the testing goes through three additional layers of reviews via the account management and implementation teams to ensure alignment prior to closure of the plan.

[05:32] Justin Venneri: So, you’re really at any scenario – and by scenario, you mean a new patient pretend walking into the pharmacy?

[05:39] Jillian Lonson: Exactly. Yeah, so we try to mirror. Obviously, that’s going to be an endless amount of scenarios at the pharmacy, but we really try to account for every common scenario and those custom scenarios that we might come across in a day at the pharmacy. And we just want to make sure that, when that member walks out of the pharmacy, they paid the correct cost share, they got the medication they needed, the correct quantity within their plan limits, if they had a deductible, they paid part of their deductible.

So, that’s also something that we make sure that we set up on the plan so that the correct pharmacy dollars apply to the medical buckets, if applicable, and then vice versa. So, we need to make sure we’re integrated with the medical vendors so that when they send the medical dollars over, we accumulate those to the correct pharmacy buckets as well. So, there’s a lot that goes into it.

[06:42] Justin Venneri: Jean, anything you’d add?

[06:43] Jean Beman: Yeah, I just would say that, with testing, it really is the last stop out the door before a plan goes live to make sure everything is truly tied down and working. One thing that we regularly do is small scale test our templates to ensure that they’re up to date and, according to the formulary, clinical, and any other program updates that we may have throughout the year, so that we are up to date and ready to go and ready to run when we have a new implementation.

[07:07] Justin Venneri: Okay. And Jean, I’ll stick with you. Can you share a real-world example of effective configuration leading to significant efficiencies in PBM implementation or go-live?

[07:18] Jean Beman: Sure. Just moving from an older adjudication platform to Judi, it’s clear that Judi was designed with a lot more operational efficiencies in mind. I used to spend hours manually building than waiting hours and hours for batch testing to even load to run. And with Judi, we can not only bulk load entire benefits, but we can build manually, and it takes literally minutes. And our testing is returned for review from Judi, from a full build, looking at roughly about 700 different scenarios in a matter of 15 minutes or less. So, this, to me, is a hugely effective efficiency overall, just because of the thought in mind that was put into the adjudication system.

[07:57] Jillian Lonson: Yeah, and I think Jean really said it best there. Judi was built with operational efficiencies in the forefront. We know what works and what does not work, given our industry experience, and we always make sure to not reinvent the wheel on things we know that work well and create efficiencies around those processes where there may be areas for opportunity. And I think this really contributes to making the process smoother, seamless, and successful.

[08:22] Justin Venneri: And what are some key considerations that payers, plan sponsors, plan administrators, other stakeholders responsible for their benefit program – what should these folks keep in mind or prepare for when configuring a pharmacy benefit to ensure that it aligns with their specific needs or goals – DEI or otherwise? Jillian, want to go first?

[08:43] Jillian Lonson: Sure. I think my biggest piece of advice is don’t make it so complex that it becomes frustrating and challenging for members to understand their own benefits. We understand that it becomes frustrating and challenging for members to understand their own benefits. We understand that there are unique scenarios such as state requirements or regulatory requirements, and even decisions that are made to optimize plan spend. But where standards can be elected, to really try to mitigate and minimize member confusion is always my recommendation.

Throughout my experience, I’ve seen too many times where payers want a specific configuration, even after a consultation with our internal teams, and they decide to proceed with it. And then a week or two goes by once the plan goes live, and then we receive a request to terminate it due to member noise. So, I would just say, you know, where there’s standardization, we always love to make that recommendation.  

Obviously, Judi is an amazing platform. It can support pretty much anything, and if it can’t, we can build it to support it. But at the end of the day, if it’s confusing for me, configuring your benefits, then more than likely it’s going to be confusing for your membership to understand their actual benefits. And it’s a very sensitive scenario when you’re going to the pharmacy and you need something quickly, and you thought your cost share was this, and it’s actually not. And by the way, you can’t even get it there anymore. So, really, just having the member as a top priority is always my recommendation, and simple is best.

[10:12] Jean Beman: I would agree with that. I think really ensuring that you’re reducing the amount of member noise that you can on your plan, therefore reducing the complexity, is a really big deal. And really, being aware that setting limits on certain drug categories could inherently create roadblocks for individuals who need access, and to be mindful of the options available by looking at the overall population requirements.

[10:35] Justin Venneri: That makes sense. So, by keeping it simple or straightforward with the member in mind, you’re basically saying, Jean, like your example of limits on certain drug categories, whether it’s utilization management or something else, basically make it as easy as possible for a member that has a prescription from their doctor to actually get that medication when they’re in the pharmacy with relative ease.

[11:00] Jean Beman: Exactly.

[11:00] Justin Venneri: And so, how do you collaborate with clients and balance the need for customization? Because, I imagine they have all these scenarios in their mind of, “Hey, we’d like to do this or that to control access to provide a richer benefit in some cases.” What are, sort of, the average times needed to properly configure a benefit for a client?

[11:21] Jillian Lonson: My team, Benefits, we always take a consultative approach when we are collaborating with our clients, to really just ensure that the benefits are built most efficiently for everyone. Our goal is to always meet client intent, but we are not shy when it comes to more optimized approaches. Our clients are very open to exploring alternative solutions as we build that trust. Average turnaround times can vary based on the configurations required, but what I can say is that they are much, much smaller time frames than traditional PBMs, having been in the industry for – I don’t want to age myself, but 20+ years.

[11:57] Justin Venneri: Not to plug Judi, but I would have to assume that a big portion of the configuration turnaround time is attributable to what system you’re working in to configure something. Is that fair?

[12:09] Jillian Lonson: 1000%. And our product and dev team really keeps up with the changing times. So, as the industry evolves, Judi evolves before it. So, the system that we use is very efficient. I love Judi. It’s amazing. And that really does contribute to our reduction in turnaround times when compared to your traditional PBMs with legacy systems.

Related Content

• Government Programs: The True Meaning of Customization (with Jason Barretto)‍
• Pharmacy Benefits 101: Successful Implementations

[12:37] Justin Venneri: Okay, and how important is ongoing optimization and fine-tuning of the PBM platform post-implementation? And what advice or suggestions do you have for payers to continually improve efficiency or scale with the business if that’s necessary?

[12:54] Jillian Lonson: Yeah, I think Judi does a really great job of accommodating 95% of clients’ needs, and there will always be those edge-case scenarios that we come across. So, you know, we partner very closely with our product and dev teams to build new logic as necessary.

I think, regardless of if we have recommendations for efficiency gains, we discuss those needs with this team who are very open to wanting to make Judi the best it can possibly be, as well as making our processes more efficient. At the end of the day, enhancement requests -- I don’t want to tout -- but they take weeks, not months or even years. I’ve worked at other organizations where they wouldn’t even look at my enhancement request for six to eight months. That really contributes to our overall success as an organization as well.

[13:40] Justin Venneri: What would an enhancement request look like versus a configuration request? I know when I spoke to Jason Barretto a while back about just government programs and meeting intent, I think there's commonalities and I think sometimes plain examples are helpful. Can you kind of break down the difference there for us between what an enhancement might be, which would take a lot longer in a legacy system versus shorter in Judi, or what a configuration might be?

[14:06] Jillian Lonson: Oh, Jean, you want to take that one?

[14:08] Jean Beman: Sure. A really easy example and looking at current function of everything that's going on with Medicare going into next year, something like adding M3P functionality in a legacy system would probably take minimum of months of just development just in the backend to get it complete. With our adjudication system and our development team, we were able to get M3P into our system before CMS had even fully finalized all of their documentation so that we were ready to go and ready to be flexible where needed, based off the final rules that were put down.

[14:44] Justin Venneri: And that falls in the enhancement bucket?

[14:45] Jean Beman: Definitely. Yes, definitely an enhancement because it's not something that previously existed in any adjudication platform.

[14:51] Justin Venneri: And then, so like a configuration of a benefit would be—

[14:53] Jean Beman: Configuration of a benefit, then, would just be actually implementing what a client had specifically elected and what's already there in our UI system. So, what you can see and physically elect for based off their benefit.  

As far as advice goes, really ensuring that your development team and operations team are on the same page with scalability and prioritization of product development is truly key. To Jillian’s point, our development team is very quick to respond and quick to prioritize different product items as we are enhancing and evolving continuously. And one of the most important key things that I think that taking it back that we really do best is really ensuring that we are not siloed and that everybody is on the same page. And that is something that is very different and very unique about Capital Rx.

[15:39] Justin Venneri: And last question. I'll start with you, Jillian. What's the most astonishing thing that you've seen or experienced -- that you can share, of course -- relating to benefit, configuration, implementation, or something else relatable?

[15:51] Jillian Lonson: Yeah, so this might seem simple, but honestly, it was the user interface of Judi.  

Coming from multiple years on a legacy platform where each day was a challenge to perform even the simplest of tasks, it was really quite daunting to me. I feel like this industry moves at such a fast pace that systems should be able to quickly adapt at the rate of those changes. And it's funny to say, but I didn't know what I was missing until I logged into Judi for the first time. I was completely astonished at how user friendly the interface was and how simple it was to perform even the most complex tasks.  

I always say that if I told my daughter, who's twelve, by the way, to build a benefit with our workflow that she would be able to execute with minimal oversight. It doesn't have to be complicated, but a system should be able to support those complicated things with ease. And that is exactly what Judi does. It really is a one stop shop and our product and development team is absolutely amazing at keeping up with the rapid pace of this industry, which truly is a differentiator in the market.

[16:55] Justin Venneri: Thank you. And Jean, I know in the last episode you mentioned bulk loading benefits. I'm curious, what's the craziest thing you can share that someone's asked us for during an implementation or that you've seen previously or heard of?

[17:08] Jean Beman: Something not configuration necessarily related but testing related: a couple of years ago we were running end to end testing for a client during implementation. And with end to end testing, it is extremely high volume in claims. So, we're looking at roughly anywhere between 100,000 to 200,000 claims, which is quite a bit. In my past life, if you were to try to run end to end testing like that, you would literally just break the adjudication system and you would probably break it for pharmacies at point of sale because it would be an overload on the system.  

With our capabilities, we have the ability to submit our testing so that it doesn't actually hit our true production environment. It's truly actually testing just from a test aspect. So, we have the capability not only to process those, and our adjudication system does not break, but we also likewise were able to process those, I believe, within less than a day, which was awesome to see that it had actually successfully processed.

[18:09] Justin Venneri: That is pretty cool. So, thank you for geeking out with me a little bit today on all of the things that that you do in the background to really help get our clients plans set up and configured appropriately and so that they can go live, and members have a smooth experience.

[18:25] Jean Beman: Thank you. Happy to be here.

[18:26] Jillian Lonson: Thank you for having us, Justin.

‍

‍

‍

If you would like to learn more about Capital Rx’s full-service PBM or PBA solutions, including our clinical programs, CLICK HERE to get in touch with our team.

‍

Want to stay apprised of the latest Capital Rx news? Sign up for our monthly newsletter!

‍