AH062 - Navigating RxDC Reporting: Some Tips for Success, with Spencer Kramer

Transcript

Lightly edited for clarity.

[00:27] Justin Venneri: Hello, and thank you for listening to this episode of Astonishing Healthcare. This is Justin Venneri, your host and director of communications at Capital Rx. And joining us in the studio today is a director on the account management team on the PBM side of the business. He's a key member of the client services leadership team: Spencer Kramer. Thanks for joining me!

[00:47] Spencer Kramer: Thanks for having me.

[00:48] Justin Venneri: We're going to be talking about RxDC, or the prescription drug data reporting component of the CAA. I think this is probably about the most fun discussion I could have with someone about this topic. So I'm excited to have this discussion with Spencer because we've been working on this for our clients on a team here at Capital Rx for the last two years running now.  

And I just thought it would be super helpful to have a podcast episode on it that we could put out there and, you know, just try to share what we've learned along the way and what we now know about this process. So before we get started, Spencer, how'd you get into account management here at Cap Rx? What's your background, and maybe tell us a little bit more about your role?

[01:26] Spencer Kramer: Yeah, absolutely. I have an unconventional background compared to most people at Capital Rx. I've been at Capital Rx for five and a half years now. It's been a great ride so far. Before joining Capital Rx, I studied public health at The Ohio State University and earned my master's in Healthcare Administration from Hofstra University. I worked as a project manager for the emergency medicine service line in opioid management steering committee at the large health system New York State and moved on to work within the hospital administration at an academic New York City hospital.  

So, collaborating with hospital executives, healthcare providers every day. I was focused on continuous improvement efforts within different areas of the health system and hospital. That said, my finger has always been on the pulse of the New York City health tech scene. I was looking for something different, and I found Capital Rx and decided to reach out and learn more. I was hired as one of the first account managers at Capital Rx. Quickly ramping up my PBM and pharmacy industry knowledge.  

I learned the operational and technical aspects of our platform, Judi®, and helped establish internal processes like RxDC for compliance purposes. So I managed legacy client relationships and complex PBM commercial clients. And I grew into my role, which I'm currently in now, as Director of Client Services and Account Management, leading a team of nonclinical account managers overseeing health systems, large employers, and public entities, collaborating with internal teams to continuously improve operations. I'm just excited and feeling like we're truly just getting started here.

[03:05] Justin Venneri: That's great to hear. It's a wealth of interesting experience you bring to the account management role here at Capital Rx, kind of understanding different stakeholders and the different priorities out there in the ecosystem. I could see how that would be helpful for you.

[03:19] Spencer Kramer: Definitely.

[03:20] Justin Venneri: So RxDC, like I mentioned, or like I alluded to, not exactly the most exciting or sexiest topic, but it's really important, and it's timely. We talk a lot about data and how plan fiduciaries and other stakeholders really need to be able to get their data and know what to do with their data once they have it. And I think RxDC is part of that. So can you start off high level? You know, what is this and what's important to know about it?

[03:45] Spencer Kramer: Yeah, absolutely. Let's dive in, get into the weeds a little bit. So, as I'm sure a lot of our listeners have learned from some of our Capital RX leadership here, talking about the Consolidated Appropriations Act, the RxDC is a requirement. It's called the Prescription Drug Data Collection Reporting Requirement, or RxDC for short. So essentially, in 2022, after many years of discussion, the CMS and the departments required all plan issuers, TPAs, and employer group plan sponsors to submit annual medical and pharmacy prescription drug benefit information in a very structured way. And this data helps to identify major drivers of prescription drug and healthcare spending increases, to understand the impact of drug rebates on premiums and out-of-pocket costs, and ultimately aims to improve transparency in the healthcare system.

[04:38] Justin Venneri: And I know there's lots of articles out there covering this, and we can link some of them in the show notes, but what are some of the key things in the actual pharmacy data that are being reported on here that must be disclosed or submitted to the departments on an annual basis?

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• AH048 - High-Cost Orphan Drugs, Securing Claims Data, and More, with Dr. Eric Bricker

[04:54] Spencer Kramer: Yeah, absolutely. We have a standard process where we send our clients an annual survey asking them to indicate how they would like to be submitted for the upcoming submission. We do this to ensure we're capturing any necessary changes if a client has a change in their name, structural changes, or changes to their legal information. Just want to capture that to confirm reporting accuracy. Since this is a plan sponsor and fiduciary requirement. The survey is due two months before the reporting submission deadline, and this year our survey was due on April 4. So we received all of our book of business and client answers and we're actively working to collect all those and identify any, you know, missing information that we need and following up with our clients to ensure that we're accurately reporting.  

In addition, I would say the main key date to be aware of for RxDC is the annual submission CMS deadline of June 1st. So for the calendar year 2024, the reporting submission is due within the CMS Health Insurance Oversight System RxDC module by Sunday, June 1st. So it's important that everyone, all plan sponsors, everyone that is involved with RxDC knows that date; bookmarks it, which should contain all that information based off of what happened in 2024 calendar year.

[06:23] Justin Venneri: And this may be silly. That's a weekend, right? So do you have to have it in Friday by end of day or is it…  What happens if it falls on a weekend? Does it matter to CMS or the departments?

[06:32] Spencer Kramer: It doesn't matter to CMS. I did want to mention there are several challenges with the reporting, so the earlier, the better to ensure that there's no issues with reporting or to avoid any escalations or penalties. So it's just important for all plan sponsors, health insurance providers, and TPAs PBMs to stay updated on these deadlines and to ensure timely and accurate reporting.

[06:56] Justin Venneri: That makes sense. So the initial info that we collect is the higher level info, and then the information within the files that are submitted that includes that list of the top 50 drugs dispensed to the plan's members, the rebate data, et cetera. Right?

[07:12] Spencer Kramer: Exactly. Yep, all that information. We pretty much collect demographical information, and then our team sort of spits out the actual data that needs to be submitted.

[07:23] Justin Venneri: And so we've been going through our process with our clients, as you mentioned, and I have to hope everyone out there listening to this is on top of this, as they should be. Where have you seen the most friction, Spencer, or frustration with the process or within the process? Is there a type of client or plan, or is there a vendor partner side issue? What would you say is the top one or two things that you've seen that cause friction in this process?

[07:48] Spencer Kramer: That's a great question, Justin. And the RxDC process has really posed several challenges over the years. Primarily I would say due to the complexity of the data submission, which includes multiple parts like plan lists, data files, and narrative response files. One of the main challenges is coordinating these submissions, especially with multiple vendors, can be stressful and confusing from a plan sponsor perspective.  

I think another challenge is creating accounts. Initially, when this requirement kicked off, there were some delays in getting those accounts set up. So there were some extended deadlines, and CMS kind of provided some forgiveness. But the creation of the account adds to the administrative burden, which is if you're newer to the process, it can take a few weeks.

In addition, I would say one of the other challenges - the lack of compliance relief for recent reports, meaning errors or delays that can result in potential penalties. That adds to the stress for plan sponsors that are responsible for accurate reporting. Because this has been going on for a few years now. CMS is pretty strict on that deadline. So in addition, we've seen some friction or frustration in the process for those Plan sponsors and TPAs that have multiple groups and or accounts and need to break out the data further. So it's just emphasizing the importance of getting ahead of this early on in the year so that you avoid any delays in the process and really leaning on your vendors and PBMs, such as Capital Rx, to help guide them through the process to avoid delays.

[09:22] Justin Venneri: That makes sense. There are different approaches, right? I think aggregate or other submission. Can you describe that in a little bit more detail?

[09:30] Spencer Kramer: Absolutely, yeah. At Capital Rx, we allow our clients to be included in our Book of Business aggregate submission, which includes a P2, the plan list file, specifically the P2 file, and pharmacy prescription drug only drug list files or D files, as well as the narrative response file. So they can be included in that or they can opt out, which is our alternative approach. Some plan sponsors prefer that they like to do their own submission, they like to have the data at their disposal, and we provide them with their D files for the client to include in their own submission.

So for both options, we have the ability to customize and create breakouts, but we need to better understand not just how the client's group structure is set up on our end, on Capital Rx end, but how they would like to be included in their reporting. So there's consistency with what has been previously submitted and aligns with their other vendors that are submitting. And I think it just needs to be aligned to ensure that there's no inconsistencies or issues with the data.

It's important that plans and vendors think about reporting implications when they're setting up their group structures as well when they're implementing with their PBM. And that's something Capital Rx does a really good job of with our clients. Because really, if the group structure is not set up appropriately, it will require significant custom reporting and a bigger lift for a requirement like RxDC.

[10:59] Justin Venneri: On that note, just a random thought popped in my head. Is this another situation where plan sponsors might need to hire an additional resource on the team to manage something like this? Or is it. Are you seeing people just delegate the responsibility to one of the team members on the plan side to work through this process? Or are they like really heavily relying on vendors like the PBM or...

[11:19] Spencer Kramer: Yeah, I've seen over the years some clients, plant sponsors hire outside consultants or firms to help them with not only RxDC but a lot of the Consolidated Appropriations Act requirements. And I think we're seeing more of that as the requirements increase. Increase. It's a mixed bag in terms of our clients and what they use, and how they like to delegate their work.

[11:44] Justin Venneri: Okay. And you mentioned starting early earlier in the conversation, so I assume that's one of them. But I'm going to ask anyway, and I'll ask you for more. What would be your top two or three recommendations for plan fiduciaries out there to avoid issues - some of the friction you've mentioned with RxDC and other CAA-related reporting this year and in future years?

[12:05] Spencer Kramer: Yes. Public statement announcement for prospects, prospective clients as well as current clients:

• Start early! Review the prior year’s submission to ensure everything is complete and accurate. Early preparation helps with identifying any gaps or issues that need to be addressed. I would say check for updates. Don't just depend on your PBM or vendor for those updates.  

• Stay informed about any changes or updates to the RxDC reporting requirement as well as CAA requirements. Although there were no changes in 2025 other than additional crosswalk information, you should regularly check resources like the RxDC website and the Regtap website for any new information.

[12:48] Justin Venneri: If there have been changes in the past, are they updated? I would assume in a timely fashion because it's a reporting requirement. But it's, you know, a government site, right?

[12:56] Spencer Kramer: Correct. Which are publicly available on the RxDC website and Capital Rx includes that information in their FAQs and overview documents that we send out to our book of Business clients as well as our consultant partners.

[13:12] Justin Venneri: Got it. Okay.

[13:13] Spencer Kramer: And then I would say last note is to keep track of your submission. Plan sponsors should maintain thorough records for their survey submissions and reports. So it's ensuring that they have copies of all documentation to verify and reference as needed. This helps with streamlining the process and really ensures compliance. And because we haven't really heard of any findings of the CAA RxDC just yet, if we ultimately do hear back, they'll be prepared and have the data to be able to respond.

[13:45] Justin Venneri: Yeah, it's interesting because I wanted to ask you to sort of kind of dig in a little bit on the actual content of these files that I started going into. A little bit. This is the plan's data. Right. And so they keep track of everything. They have good records on the submission, they start early. What else could they do here? What's the best way to use that data for any other purposes?

[14:05] Spencer Kramer: Correct. This is the Plan Sponsors’ data. It's very important to emphasize that, you know, this is a fiduciary and plan sponsor requirement. Plan sponsors and their partners should track and analyze this data annually because it has pretty valuable information such as top 50 most frequent brand drugs, most costly drugs by spending increase, Rx, you know, pharmacy Rx totals, rebates by therapeutic class, and rebates for the top 25 drugs.  

So at Capital Rx, our account management teams provide most of this data regularly and upon request. But plan sponsors should really also leverage this RxDC data to enhance their own understanding of their plan and utilization so that they can really be the best fiduciary that they can be and make data-informed decisions.  

Although it may seem burdensome and a lot of data, I really think it's crucial and we're closely monitoring CMS and department findings from prior submissions and, you know, should we hear back on those findings, we'll definitely proactively inform our clients of any insights or implications.

[15:15] Justin Venneri: I know I don't have the answer to this question. I don't know if you've heard anything, but. And it's come up in past podcast episodes and I think people talk about it a lot. Have you heard any buzz about what or when the government might release some data around these report submissions at some point?

[15:30] Spencer Kramer: I have not. No. That's definitely something that I'm interested in figuring out. My finger's always on the pulse of that. So I'll definitely let you know. I'll let everyone know once, once we get some understanding of that.

[15:43] Justin Venneri: Definitely curious. And so here we are all of a sudden at the end of the conversation. And I know you're going to do it too, but I want to make sure to give a shout-out to our RxDC working group, Katie Winblad, and everybody else on the team that's been super helpful in pulling all this stuff together.  

What's the most astonishing or surprising thing that you've experienced along the way, working with the team here, working to ensure that the RxDC data is getting submitted appropriately year in and year out?

[16:13] Spencer Kramer: Yes, I knew I was going to get this question, so I wanted to answer it a little bit differently.

[16:19] Justin Venneri: Everybody, everybody gets the question - got to come with a good answer!

[16:23] Spencer Kramer: Yeah, indeed. I was looking forward to it. But yeah, shout out to the RxDC Task Force - Compliance, Analytics, Rebate, Regulatory Change Management, Legal. Everyone has played such a crucial part in standing up this requirement, and so that we can keep our clients happy.  

But yes, I've seen some pretty astonishing things while working at Capital Rx, including RxDC. So instead of sharing just one, I think I'd like to just share a few valuable lessons at my time with the company so far with an account management twist.

Justin Venneri: Okay…

Spencer Kramer: So you know, I've really learned that clients would rather wait for the right answer than get the wrong or incomplete one quickly. Relationships are everything. Building internal relationships is crucial. Your colleagues and subject matter experts are your lifeline. So connect often and ask thoughtful questions.

Organization is key. Gather all client issues in one place. Tackle the easy ones first. Coordinate discussions for the complex ones, and don't be afraid to ask clients for clarification. I know at Capital Rx, we try to get into the weeds and understand so that we can better deliver. You know, it really helps you become a better partner rather than just a vendor, if you will, you know.  

And then continuous learning is essential. So stay informed about your company's communications, product offerings and industry news. That goes for the account managers on Capital Rx's end. And I would hope that our clients are keeping a pulse about Capital Rx so that we can deliver better insights.  

And most importantly, we have to have fun. This is a complex industry, but we have to find the good in the work that we do and contribute to a culture of engagement and optimism. I'm a healthcare optimist, so I'd like to think that we're improving healthcare and trying to create the electronic infrastructure the e industry needs and creating enduring social change. I could talk about this all day, but really, Capital Rx is changing the game. Every day is astonishing to me working here, and I truly believe we're just getting started. So thanks for having me.

[18:36] Justin Venneri: It’s been a fun discussion about a generally rather dry topic, right? So yes, I'm glad you were able to come on and look forward to hopefully having you back on. Or maybe we can rope in some of the rest of the team next time.

[18:48] Spencer Kramer: Indeed. Thanks so much.

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