AH065 - The Bridge to Value-Based Care: Unified Claims Processing™, with Dr. Sunil Budhrani

Transcript

Lightly edited for clarity.

[00:28] Justin Venneri: Hello, and thank you for listening to this week's episode of Astonishing Healthcare. Dr. Sunil Budhrani, our Chief Innovation and Medical Officer, is back in the studio with me today for an update. This is Justin Venneri, Senior Director of Communications at Capital Rx, and your host, of course. And we're building on episodes 54, Judi Health™, and 7, which unbelievably, Sunil, was your original episode with us: You Can't Have Value-Based Care Without Pharmacy.  

So that was a little over a year ago and value-based care comes up all the time, so I'm excited for it. Sunil, thanks for coming back on the show.

[00:57] Dr. Sunil Budhrani: Great. It's a pleasure to be here again and discuss this very important topic with you today.

[01:02] Justin Venneri: So we started off with you on Episode 7, as I mentioned a moment ago, talking about not being able to have value-based care without pharmacy as one component of it. And I think you've or we've learned a lot since then. So where should we start off? Do you want to dive in with the four Ps in case anyone listening may not have listened to that prior episode? It's a pretty good reminder, I think; you can frame things up for everyone.

[01:26] Dr. Sunil Budhrani: Yeah. So, when we had this conversation some time ago -- it feels like yesterday at the speed that we move at in this company -- we talked about value-based care often in medicine as being, you know, the important components involving a payer, provider, and patient. But when we last conversed, one of the missing links of that was pharmacy and the PBM's component in a value-based care model. And that was the great title that the team came up with, was You Can't Have Value-Based Vare Without Pharmacy.  

So we really have four Ps here that are involved in the ecosystem surrounding a patient's care. So that's where we left off in our last podcast, understanding its payer, provider, patient, and pharmacy, and how those pieces are necessary to be looked at to be able to provide holistic care to the patient.

[02:15] Justin Venneri: Got it. So since then, we've launched Judi Health. That was 1/1 this year, and we'll get into that a little bit more. Can you talk to us a little bit about what we've learned since that original episode, since launching Unified Claims Processing? Explain that to me like I'm five and give us some examples on your updated thinking about how to get to a true value-based care world.

[02:39] Dr. Sunil Budhrani: So, as I mentioned, where we left off, it was understanding that there are four variables in the success of value-based care. The payer, the provider, the patient, and pharmacy. The next iteration of the story for us here at Capital Rx is Judi Health.  

And Judi Health, in my opinion, is the glue, it’s the highway and infrastructure, to bring those four Ps together. That's why I was very much looking forward to this conversation, because it's almost like the next episode in the series to how do you get to VBC world – value-based care? The value-based care standards that we think about encompass quality of care, provider performance, the patient experience, and cost management. And the four Ps are the ingredients. But Judi Health is the highway to get there.  

So since we last spoke, we went out on this journey to start building the infrastructure to expand beyond pharmacy and go into medical to connect the four Ps -- payer, provider, patient and pharmacy -- and be able to create a unified claims platform, a term that we've coined here, to connect those four Ps to deliver on that quality of care, look at provider performance, and incentivize for outcomes -- incentivize for a proactive healthcare system, not a reactive one -- enhance the member and patient experience, and also manage costs.  

Judi® is, I believe, the opportunity to do what I've been saying in healthcare all along, which is to achieve higher quality of care at lower cost. But it's only achievable if you have a chassis like a Judi Health system to be able to do so. But also, a system that will allow you to be able to empower providers to be able to be rewarded for outcomes. A proactive healthcare approach versus a reactive healthcare approach.

[04:43] Justin Venneri: So what does it mean for a member or a plan administrator or plan sponsor to have what you refer to as this single point of access or this chassis that everything can run on?

[04:55] Dr. Sunil Budhrani: Well, let's start with the member and patient experience.  

I always say it is the role, it is a responsibility, for a payer, whether you're a health plan or a PBM, is to empower the relationship, strengthen the relationship, between the provider or clinician and their patients. Payers and PBMs should not be getting in the way of that relationship. So, through a Judi Health unified claims infrastructure, we provide the transparency for patients to navigate the healthcare system more holistically, to understand their pharmacy options, to understand their medical options through a transparent chassis. That allows patients to understand the cost of their care, the better choices and places they can go for their care, and be informed about their decision-making.

So, now I'm going to transition to what's in it for the plan sponsor, the employer, the HR team? When we develop tools on the patient side to allow them to understand and have visibility in their care. Similarly, on the other side of the coin, Judi provides an opportunity for the plan sponsor to get greater visibility, just like we did in pharmacy, into the medical path, medical understanding of their employee populations, obviously in an anonymous way, but to understand how they can improve the health of their patient populations, have more visibility and be able to provide them resources that will help them in their journey towards health.  

You can only do that when you have a transparent architecture that allows that kind of access and understanding into your patient population.

[06:54] Justin Venneri: Got it. And the platform approach and what it enables in the future. We have a cool infographic of sorts on this that I'll add to the transcript, the call notes, if you will, and of course we'll link out a couple of things per usual, related content, in the post that goes along with this episode. But could you discuss that platform approach and what you think the future state could look like if it's built on the right platform?

[07:19] Dr. Sunil Budhrani: Yeah, the typical platform that supports a health plan or PBM generally involves some kind of plan setup and member management, some kind of network configuration or management, claims processing and ability to test claims, and also some kind of data output regarding all of these interactions that occur between clinicians and members and reporting of that information. That is kind of your generic way of thinking about what a platform does.  

But the problem is pharmacy, medical, and then vision and dental all have independently the same functionality of these four components -- plan setup, network, claims processing, and reporting. This is the problem that occurs in healthcare. You have these same activities occurring in four different islands: medical, pharmacy, vision, and dental. It's not until you can bring those pieces together then you can deliver value to the patients and members, the employers, all the stakeholders that are involved in the care of patients.  

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But when we think about Judi, we don't think about limiting it just there. When all the same activities are occurring with medical, pharmacy, vision, and dental, those activities being planned set up network management, claims processing, and then reporting data. It's not until you put it under a single roof, under a Judi Health roof, in one instance, that's what we think about as a Judi Health enterprise platform. Our focus is creating an infrastructure chassis that supports all of those activities, but allows a plug-and-play Model that we term as a Never Move Again™.  

So we create a chassis that lets you then plug in other functionality, like modeling and underwriting, implementation management, formulary management, clinical program management, prior authorization capabilities, an award-winning call center, and then other areas -- data exchange and eligibility, payments, government operations, and documentation -- that then you create a highway for the future of healthcare, connecting everything and anything that happens outside the hospital, delivering on a promise of value-based care.  

The integration of all these departments under one system creates a single source of truth. It increases efficiency and accuracy and reduces error and operational costs. But here's the key thing, I always say our not-so-secret sauce is we expand flexibility, we're nimble, and we're interoperable to improve client satisfaction. It is only when you build a system from scratch, like we have been doing here, that you can really leverage predictive analytics and artificial intelligence to not only predict disease but understand how to avoid and provide treatment modalities in an earlier time frame to keep people healthy.

[10:35] Justin Venneri: Okay, and that future state where you can layer the predictive analytics and the artificial intelligence on top of the source of truth, why Is what you just described the pathway to value-based care? Does it really address or meet the standards?

[10:50] Dr. Sunil Budhrani: So, as we discussed in our first episode of the conversation of four Ps, where we agreed that patients, providers, pharmacy and payers represent key elements to a holistic view of value-based care, you need a glue to bring those pieces together.  

So by having a Judi Health infrastructure to bring those pieces together, you then have a data repository regarding the patient's healthcare experience. With that data repository, you can really do predictive analytics and use AI in a more meaningful way to uncover the patient's pathway and predict disease. If we get to a state where we can better understand through information and data the patient's healthcare journey, we can then start thinking about rewarding providers based on outcomes.

The current fee-for-service model, which is the predominant financial structure, the more I do to patients, the more I generate revenue and income. But we know being a 20% GDP nation invested in health care, this is not sustainable. A more you do, the more you get paid model in health care does not promote disease prevention and health. But that system only exists because we do not have the information for pharmacy, medical, vision, dental and other areas to holistically reward providers in a meaningful way to encourage outcomes-based care.  

With a system like Judi bringing all these various components together, we now are moving significantly towards a financial model of rewarding health versus doing more.

[12:41] Justin Venneri: So as a physician who's expressed frustration with the traditional PBM model, with the traditional care model like you just explained, what's the most interesting thing you can say with confidence -- we've done this for five months now, right? How come it is so clear to you that this is the path toward achieving this value-based framework that's been elusive for years?

[13:04] Dr. Sunil Budhrani: Yeah, great question. About 18 months ago or so, we began on this journey to expand our Judi pharmacy capabilities into medical. And we continued to build a team and brought in additional talent when it comes to understanding the medical infrastructure space. And over time we were able to process and adjudicate and build these capabilities out in our system under one instance to be able to manage a claim.  

We then were able to choose best in class vendors like telehealth, women's health, fertility, chronic disease, diabetes to plug into our unified claims Judi chassis and successfully went live 1/1/25 as the first Unified Claims Platform in the country on our own employee population processing pharmacy and medical claims under one roof. This journey has taught us a lot that what many organizations in healthcare have never thought about or just could not do is possible.

And as we've gone live and gained further experience, our early data has demonstrated with a shared technology of unified claims doing medical and pharmacy, and shared services, where you have a clinical team, a finance team, we have a best-in-class call center, which is unheard of in the industry -- where it usually lies as two separate teams or two separate islands doing this function.  

So when you deliver a unified technology providing medical and pharmacy, and a unified share service providing clinical, account management, customer care, and finance, to name a few, you can deliver that promise of higher quality care at lower cost.  

So our early information is demonstrating that we are providing some of the best health care to our employees that we have ever received. And we're providing that while maintaining or even lowering the cost of care because it's all under the single Judi enterprise roof.

[15:21] Justin Venneri: And is that like on a PEPM or PMPM basis? How are you measuring or looking at that?

[15:27] Dr. Sunil Budhrani: Great. So again, this is preliminary data. We have created a solution that has taken many years for other companies to even try to put forth in only a handful of months. And frankly it is far superior to what you would normally do off the shelf because we were able to customize our offering.

But our overall cost of care, which really is something that People Ops and HR teams look at closely, are the same or lower than they have been in the past, which delivers on the promise that maybe you really can deliver higher quality care at lower cost under one unified roof, which excites us.

[16:08] Justin Venneri: Nice. Okay, last question again, coming at this from a physician executive perspective, still in the ER a couple times a month, right?

[16:17] Dr. Sunil Budhrani: That's right. I work in the emergency department two to four times a month. I always say that it's important when you are building healthcare infrastructure and leading healthcare initiatives at a population health level to play the ground game, I call it. And for me, spending time with other clinicians, nurses, and staff in the hospital setting provides me that opportunity to understand how we deliver care on a one-on-one basis to patients.

[16:44] Justin Venneri: Makes sense. So what's the most astonishing or interesting or encouraging thing that you've seen? Obviously, the cost savings and that cost trend looks super encouraging, but like, from an actual care perspective, I'm asking with this unified process, what's the coolest thing you've seen in the first five months of it?

[17:01] Dr. Sunil Budhrani: Judi Health for me brings together almost a culmination of my career in the sense that I've spent significant time in the hospital environment, in the payer world, the digital health world, and then now pharmacy. And Judi Health provides the opportunity for me to see what many people in healthcare say cannot exist.  

What I mean by that is often people say that if one part of health care gets better, the other one has to be sacrificed. If payers are doing well, a provider might not be happy, or if a patient's health is great, it may not be beneficial financially for a provider. All those reasons I talked about earlier when it comes to a fee-for-service model, incentives are not traditionally aligned in health care. And I believe that Judi Health provides an opportunity where you can see a multifactorial win, where everybody wins -- patients win, providers win, payers win, pharmacy win. Because we're creating a chassis of the future for health care, of transparency, of visibility that has never existed in health care through a unified claims processing engine.  

If you create a highway that makes all the transactions clear and visible without financial incentives to use that highway, then you have an opportunity for patients to understand what they need for their health, understand what they're paying for their health, and providers to also appreciate how to deliver better care and also meet their needs.  

So there's a real opportunity here where all the parties in healthcare, stakeholders, patients, providers, pharmacy and payers, the four Ps we started with in the earlier conversation last year, can actually all win by having a visible, transparent, nimble and flexible platform like Judi Health.

[19:01] Justin Venneri: Got it. Sunil, thanks for providing the update today and we look forward to having you back on for another update, hopefully at the end of this year.

[19:08] Dr. Sunil Budhrani: Sounds great. Thanks for the opportunity, Justin.

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