AH058 - Building Judi®, the Healthcare Infrastructure of the Future, with Liya Lomsadze

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, your host and Director of Communications at Capital Rx, and today I'm excited to have the pleasure of chatting with one of our Product Directors, Liya Lomsadze.  

It's been so much fun collaborating with Liya on product updates. For example, anything related to new Judi® features that come out. Last year, we highlighted 12 of those for the 12 days of Judi, and we're really excited to dive deeper into some of those platform features today.  

So, Liya, thanks for joining me in the studio.

[00:58] Liya Lomsadze: Pleasure to be here.

[00:59] Justin Venneri: So we were just joking about it. I was like, oh, you've been to Capital Rx, like three years. And I'm like, wait a minute. You're like, no. [Laughing]  

Can you tell us a bit about your background and your path to Capital Rx, how long you've been here, and your current role as a Director on the Product team?

[01:14] Liya Lomsadze: Yeah, absolutely. So I've been at Capital Rx for five years now, which does feel like an eternity, but it's been a great adventure.  

Prior to Capital Rx, I was working primarily on the provider side of healthcare, so at large health systems here in New York and doing primarily sort of data analytics and trying to make our health system run a little bit more smoothly from the provider side. But it's been so illuminating, seeing things from the payer side, certainly, through the lens that we have here.  

And I started out here on the clinical operations team and doing data analytics with all our wonderful pharmacists and learning all about that kind of like clinical perspective on what we're doing and then had an opportunity to transition to the Product team and work on primarily our adjudication areas, right? So I got to work on the Medicare Part D launch that we pulled off in 2023. And then in this past year, I've had the opportunity to focus on the Unified Claims product, so bringing medical claim adjudication into Judi and into our scope, which has been a very fascinating journey.

[02:16] Justin Venneri: That's awesome. And so all of the features that come out come through the product team, right? Essentially?

[02:24] Liya Lomsadze: Yep. We collaborate with other parts of the engineering org to make sure that we understand what are the right features to build? How do we want to go about building them? We participate in the testing and the rollout and the entire kind of lifecycle of a feature from the very beginning when, you know -- depending on what you're working on, maybe Medicare comes out with a new requirement and now we have to figure out what that means, who it applies to, does it apply to us? And how we would actually enact any kind of compliance with it in Judi itself, all the way through to writing out the requirements, documenting everything, working with our engineers to figure out what it's going to take to build it into Judi, QAing it, and then getting it out the door and monitoring kind of the lifecycle of it as it's out in production.

[03:09] Justin Venneri: Makes sense. Can you give us a little bit of an overview of how far Judi’s come -- Judi being our adjudication platform, of course -- in just the last year, two years? You mentioned the -- I remember overnight on January 1st, we were super excited for the Medicare claims to start processing. That was awesome. And then, you know, since then a lot's happened as you alluded to: pulling in medical now and we've done that for ourselves, unified claims processing under Judi Health™.  

So can you just talk a little bit about that acceleration of advancement of the platform?

[03:41] Liya Lomsadze: Yeah. So every year now it feels like things are just getting both deeper and wider. So when, when we started out, when Capital Rx or at least when I got here, right, we were really primarily focused on administering the pharmacy benefits of small employers and unions. And since then we have really brought up a ton of new functionality to support all kinds of other lines of business, right? So primarily, you know, Medicare Part D, Medicaid, Exchange, and that's allowed us to gain so much more visibility into this particular pharmacy benefits ecosystem to see all the different kinds of benefits that could be provided.  

And then we've also been growing in a bunch of other directions outside of pharmacy alone. So some of that is new tools for folks who are pharmacy benefits specialists who are working in Judi and trying to do their job better, faster, more accurately. We've got things like DORA that we love, that self-service reporting tool, that allows anybody in Judi to get access to their data. And then of course we've got experiments, or at least they started out as experiments, into the eligibility TPA space.  

Now with our unified claims launch (Judi Health), the experiment, you know, knock on wood, is going pretty well, but it's a huge departure from what we've done before and it's a lot of new functionality that Judi didn't have before either.

Content Related to Judi's Features & How Technology Advances Pharmacy Benefit Administration:

• 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
• Pharmacy Benefits 101: What is a Formulary?

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[04:56] Justin Venneri: Yeah, it was interesting to hear AJ and Sunil talk about how just you using the platform to administer the pharmacy benefit and then figuring out all the stumbling blocks and inefficiencies and then evolving it to do things better, faster, more accurately led to all of these other opportunities and things we could build.  

And I'll link a bunch of stuff in the show notes of other episodes, but I love that you mentioned DORA and I know how much Ryan Kelly, our Chief Technology officer, he's a huge fan of the names we've given all these modules that we've built out for Judi.  

So let's dive into some of the features, what they do and how they help plan sponsors or plan administrators or the user of a health plan. We're not going to go through all 12 that we highlighted in the blog or in the 12 days of Judi last year, but I definitely want to dig in while we have schedules overlapping for once and see what you can tell us about Prior Authorization and the Prior Authorization tool, which -- it's received several updates over the last couple of years, but two big updates in 2024.  

Can you tell us what those were and why those features are important?

[05:56] Liya Lomsadze: Yeah, let's do it. So, kind of two major items that we'd want to highlight about the Prior Authorization Tool that went out last year.  

First, we brought up the ability to review Medicare and Medical PA cases in PAT. Just like when we brought up Medicare Part D on the pharmacy claim adjudication side of the world, entering this new line of business brings a whole new set of regulatory compliance challenges, and your tools need to be tailored to actually meet those requirements, because now you're in such a heavily regulated space under so much scrutiny.  

So bringing Medicare on board required a ton of new functionality around, you know, making sure that we're tracking things like the completion of the cases themselves, the timing of them, making sure that we can produce all of the data that is required by CMS when we inevitably get audited, just as any new PBM gets audited. And all of that is so important to both the folks who are actually doing the work day to day reviewing cases for Medicare beneficiaries and to Capital Rx and the plan sponsors who rely on us or do their own work in Judi to make sure that they're meeting all these regulatory requirements.  

The Medical PA piece is also kind of an interesting thing because especially now in our kind of unified framework, there is a piece of the medical pharmacy universe where certain drugs, particularly these high cost injectables, could either be covered under your pharmacy benefit or under your medical benefit.

[07:24] Justin Venneri: Okay.

[07:25] Liya Lomsadze: And reviewing these things and understanding what is the appropriate way to handle them, it can be very helpful to have the same individuals who are doing the work do it for both sides. So bringing that functionality on board was also super helpful.  

And then the second big feature that came out in the Prior Authorization Tool this year is our supervisor dashboard. So, we get thousands of PA requests and each one of those PA requests has to go through a very particular lifecycle, has to go through all the different steps that it takes to reach completion. And it is so important if you are a manager, supervisor, to understand where your volume is. Are things getting stuck somewhere? Do we need to staff a certain team more? Do we have a problem somewhere where we need to shift our resources? And the supervisor dashboard is really the one stop shop to give you a snapshot of all of your PA requests, where they are in their journey, and you can find where you may need additional support for your team.

[08:18] Justin Venneri: Got it. Thanks. I can see how that would be super helpful given the volume, especially for the things like a new class of drugs, like GLP-1s. Or like on the med-pharmacy side, it's really interesting. You know there's a lot of cost there. You know, there's lots of friction there, but how do you make that a smoother experience and process those faster so people can get the medication they need?

[08:36] Liya Lomsadze: Yeah, absolutely.

[08:37] Justin Venneri: How about we talk a lot about implementation, that process, what we try to do to make it smoother and more seamless? Jean Beman and Jillian Lonson are amazing with the benefit design aspect of it and trying to set things up the right way for our new clients and make sure those benefits are designed. And obviously the implementation team just came off super busy season.

• 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

Can you talk to me a little bit about Judi’s ability to load incumbent PBM claims data and any other features that are helpful during implementation?

[09:07] Liya Lomsadze: Yeah, so you're absolutely right. We have the best implementation team in the game. And Jillian and Jean are, you know, some of the smartest people I've ever worked with. They can set up the best benefit configuration that will result in the most seamless onboarding onto Capital Rx, if that's your new PBM. And then at the end of the day, if we don't know which of our new members who've come on board on 1/1 are utilizers of which drugs, it won't matter.  

So, a lot of these structures that are in place that plans can choose to enact, such as continuation of therapy, to make sure that folks are not disrupted while we wait, kind of, for the pieces to all come together, right? Because it takes time to get the data out of the other PBM to port it over. All of those things take time.  

But if we know on January 1st that Liya Lomsadze is on a high cost drug and she will need a refill soon, and it does require a PA, but maybe she needs the refill before we can get a letter out the door, before we can get in touch with her provider, before we can do any of this, right? As long as we know that she's filled this drug before, this is something she's chronically on, Judi can automagically look back at this historical claim that we've loaded onto my profile, and we can make sure that the very next fill comes through and pays appropriately without necessarily stopping for something like a PA. And then we can initiate all the communications that need to happen to make sure that next time I go to refill, I have taken the steps, or my provider has taken the steps, to go through all the appropriate clinical review processes.  

But the ability to intake and ingest and QA the ingestion of these historical claims files is so important because that is the context that helps us identify who needs that additional maybe grace fill to smooth their way onto the Capital Rx network, the Capital Rx formularies, and then who maybe doesn't. Maybe somebody who's truly like, I've just had this drug prescribed to me for the very first time, then, you know, yeah, maybe we should just go through all the clinical scrutiny right now.

[11:09] Justin Venneri: Just out of curiosity, again, this is like really efficient for pharmacy benefit design, implementation, adjudication, and just generally the pharmacy benefit experience. It seems like a lot of the design of Judi -- I'm not trying to be too salesy here -- it's intuitive to me that this would work for medical too, or would work for other types of benefits like vision or dental. Do you anticipate the ability to ingest data the same way from previous providers of those types of insurance also onto the platform?

[11:40] Liya Lomsadze: That would certainly be my hope. It's been two months and with only really one carrier. So, I don't know how much this generalizes, but it's not clear to me yet whether this is as much of a norm in those other kinds of coverage -- medical, dental, vision. So it may not on honestly, but it should be. The more we know the more we understand about your prior experience, the more we can appropriately figure out what should be going on when we have you here, right?  

And probably the other big thing that I hope we'll be able to tackle in the future on both the pharmacy and the unified side of this equation, is the processing and the ingestion of historical prior authorization approvals. Because the claims are doing an enormous amount of work for us, don't get me wrong. They are super, super important.

But the other key to making this experience, when you change PBMs or you change health plan carriers, less disruptive is that we should get all of the prior authorizations that were granted by your prior PBM or your prior health insurer, and we should honor them, if that makes sense.

[12:38] Justin Venneri: Of course. Yeah.

[12:39] Liya Lomsadze: So that you don't have to go through this legwork twice.

[12:41] Justin Venneri: That makes total sense. And then, of course, I'm sure the data exists in 2, 3, 4, 5, 7 different systems or whatnot. Probably in the EMR. It's right in the patient's health record, too, in the doctor's office, etc. Data is everywhere. Gotta pull it together.

[12:55] Liya Lomsadze: Yeah. But rather than asking you, so, you know, hey, maybe, like, can you scan for me that letter that you got six months ago from your old insurer and, like, show me what it says so that I can make sure I'm not making you jump through this hoop again.

[13:09] Justin Venneri: Agreed. So, we've talked about prior authorizations here. We've talked about data ingestion and implementation. There's a newer program this year. We've done a webinar on our new product, the Medicare Prescription Payment Plan (M3P). Jason Barretto's discussed that on the podcast, and we have a live demo on it this month. Can you share your thoughts quickly on what makes that situation unique and what should plan administrators, plan sponsors, who might not be using it currently know about it.

[13:36] Liya Lomsadze: So the M3P requirement kind of dropped on all of us in this ecosystem last year from CMS. And my colleagues at Capital Rx have done an incredible job rallying around this with really minimal guidance and maybe not as much time as one would want to bring such an enormous program to fruition.  

But it was, I think, a challenge that Judi was really uniquely suited to solve because it has so many different elements from the outreach to the member, to make sure they know that they're actually eligible for this and how to enroll and what that'll take, to the tools that provide we have from our member facing side of the world with the web portal and the mobile app that let them interact with their payments and understand where they are in the process, to all of our invoicing capabilities to make sure that the plan sponsors get an accurate picture of what is going on when members are opted in.  

So it's kind of a perfect type of problem for the modular nature of Judi to address. But we have both full-service clients of ours for whom we run the entirety of their Medicare business through sign on for this as well as folks who just need that M3P support, and both are possible and both are supported.  

So it's a really lovely kind of choose your own adventure depending on what you need from us experience.

[14:54] Justin Venneri: That's great. And you mentioned formulary before, Formularies and the product team, you actually built a formulary management tool which helps centralize formulary workflows, among other things. Can you break down the other things and why that's useful?

[15:09] Liya Lomsadze: Yeah. So this was -- I still have such vivid memories from 2020 when we were building Judi kind of from the ground up. And of course the formulary is one of the main pillars that we need in order to adjudicate claims accurately. And we were having challenges that I think everybody in the industry has. There are tools that exist to manage and create formularies and those tools primarily, I would say, are geared towards creating the member and regulatory facing outputs of what a formulary is, right? So they can very effectively create a website where you can go in and search your drug and find out if it's covered or not. They can create the kinds of files that you need to submit to CMS to make sure that Medicare blesses your formulary before you enact it. But very few of them can also create a file that an adjudication system can understand and can use to adjudicate claims properly.  

So we had to do a lot of interesting workarounds to make the files that were coming out of the tool that we used machine readable and understandable to Judi. And it was immediately obvious that there's a gap here. There's a gap because formularies need to do much more than be accessible to members and plan sponsors and CMS and whoever else that wants to see them. Formularies also need to drive the actual adjudication logic and make sure that your claims are getting adjudicated properly. And a system like Judi needs that to look very different from you or me when we're just looking up whether our drugs are covered or not.  

So that is sort of the big, I think, hope and the differentiator or as our Formulary Management Tool evolves, is that it will be able to do it all and it will live within Judi. So, it will live in a place where it can create an extract that gets published to the adjudication side of Judi and gets used immediately to adjudicate claims.

[16:57] Justin Venneri: Okay. And we talked a little bit about Judi Health earlier and Unified Claims Processing. Instead of just sort of rehashing that, two questions on Judy Health. One is how do you think it's going so far? Snd what's your experience been like? Are you on it?

[17:12] Liya Lomsadze: Oh, I'm on it. I'm on it. I went, I scheduled an appointment --

[17:15] Justin Venneri: I'm on it too.

[17:16] Liya Lomsadze: Six months in advance. I went to my doctor on January 2nd. I was really trying hard to be the first claim in the door, but other people beat me. I was trying so hard to get like claim number one spot.

[17:27] Justin Venneri: That's funny. And then the second of the question is, what do you think? Or what do you hope it means for patients and the healthcare consumer experience?  

[17:35] Liya Lomsadze: So, we didn't end up in the situation that we're in, in healthcare in America today, because that was the right way that things should be done. We didn't separate medical from pharmacy from dental from vision because that's the optimal way for things to work. It's just a series of like historical artifacts that have all kind of led us here. So it is really cool to be trying to bring these pieces together.  

I think in the short term we at Capital Rx, right, we have an award-winning customer care center. We have all of those wonderful ancillary tools in Judi that we talked about, like DORA; we believe that your data is your own. We have an easily accessible, you know, intuitive set of tools for both plan sponsors and the folks who are actually doing the work and members to use to access their information. And plugging a new kind of claim into that ecosystem should be pretty powerful because I would love to -- or not I would love, but I can now depend on our wonderful customer care team to help me with all my issues, with my medical issues and my pharmacy issues. And that is a relief because before when I had some challenge with a medical claim and I was going down some rabbit hole trying to figure it out on my own, I did not have them with me.  

So I'm looking forward to seeing what bringing the power of all of our existing talented colleagues and the tool sets that we have in Judi to this problem space should already hopefully bring some sort of reward.

[18:58] Justin Venneri: Yeah. Relief would be a good one. I think there's enough negative experience stories out there and we'd like to have some tangible takeaways of the benefits of streamlining and concentrating patient data in one spot.

[19:11] Liya Lomsadze: Yeah. And then the other side of it, I think for me, but I think this will take longer to prove out, is on the pharmacy side. I think one of the things we've been very successful at is kind of deconstructing this really complicated, sometimes deliberately obfuscated, business into plan elections that plan sponsors can make sense of and they can understand the choices that they're making. We have written out pretty clearly in our claim UI, if you're looking at why did a particular claim price this way or reject or how did the cost share get calculated, we have our wonderful Reasons for Adjudication and Reasons for Rejection that tell you in human readable English what actually happened.

And bringing that kind of clarity to the really convoluted, complex space of medical claim adjudication is the other thing that I'm really looking forward to, because when you do have to deconstruct these things, I think it will help illuminate the areas where there is some misalignment or there is some confusion. And then hopefully we can also look at the full picture and say, hey, you know, I see that you're offering really awesome diabetic care on the pharmacy side. Is there anything going on on medical? Like, should we maybe, you know, connect these things somehow, make sure there's a complement on both sides? So those are the kinds of conversations that I'm hoping we can power in the future.

[20:25] Justin Venneri: All right, and last question. What's the most astonishing thing you've seen that you can share, of course, compliantly, either during your time here at Capital Rx or related to this discussion today broadly about product development, or tell us a good story, something surprising to you, or just astonishing.

[20:40] Liya Lomsadze: It's been really rewarding, I think, to see that some of the tools that we've created over time because we've just seen the need for it, or we've had to adapt to challenges really quickly.  

So this is a lot of people's favorite. I know, but Tags and Overrides, right, have been spoken about a lot, as they should be, and they're such a powerful and wonderful feature and they've let us be so responsive without having to really spend a ton of effort on it or a ton of development effort, honestly, on any given new challenge that comes up.

So thinking back honestly to like, you know, 2020, 2021, that was another time when these regulatory mandates were kind of falling on us all from the sky, right? Like overnight, everybody in the industry had to figure out how to pay for over the counter COVID test kits with approximately, I don't want to say zero guidance, there was some guidance, but it kind of came out of nowhere. And I think I want to say in like three days after that, we already had the logic up and running in Judi. We knew exactly which test kits we were going to cover, how many we were going to cover. We made sure the member wasn't getting charged for them, right? It wasn't this like, okay, well we gotta step back and it's gonna take three months of work and people are gonna have to be paying out of pocket, getting reimbursed. It creates this enormous overhead. We were able to stand it up in a handful of days and avoid all of that mess and avoid all of the --

[21:56] Justin Venneri: There was enough confusion, right?

[21:57] Liya Lomsadze: Exactly. There was enough confusion to not exacerbate it. And that's, cynically thinking about healthcare, I think that is honestly a great thing to bring to the equation, is to not exacerbate kind of the horror that it is. Yeah. At the very least. At the very least, of course, we're aiming higher than that.

[22:15] Justin Venneri: Absolutely. Well, Liya, thank you for taking the time today. I know you're super busy. I'll let you get back to it. Really appreciate you sharing your thoughts and I look forward to having you back on.

[22:23] Liya Lomsadze: Thanks, Justin. Pleasure to be here.

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