AH080 - Health Benefits 101: The Importance of "Smart" Care Navigation, with Andy Kageleiry

Transcript

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[00:28] Justin Venneri: Hello and thank you for listening to another episode of Astonishing Healthcare. This is Justin Venneri, your host and in the studio with me today is Andy Kageleiry, Vice President with our Judi Care unit.  

We're going to be talking about Care Navigation in the context of a broader health benefits strategy, so that's why it's part of Our Health Benefits 101 series. Andy, thanks so much for joining me today.

[00:46] Andy Kageleiry: Appreciate it, Justin.

[00:46] Justin Venneri: Before we get into the questions, how about you take a minute, tell us a bit about your background, your role here at Judi Care, your path to Amino.

[00:53] Andy Kageleiry: Happy to. I spent the last 15 years in healthcare. First half of my career I worked as a data science and strategy consultant to healthcare companies, and in the back half of my career I've worked for high growth technology startups, mostly in the pharmacy space, including Good Rx and then most recently on the management team at Amino before we were acquired by Capital Rx.  

In addition to pharmacy, one of the through lines of my career has been how do we use data to help make healthcare a little more efficient, whether that's matching people to the right medication or helping find the right doctor.

[01:23] Justin Venneri: Yeah, it's great, and we are so happy to have you guys as part of the team. Now this episode really does build on, you know, the press release, the announcement, but also John Asalone and AJ's podcast episode, just highlighting the rationale for the deal.  

Related Content

• Capital Rx Acquires Care Navigation Company Amino Health
• Health Benefits 101: The Importance of a Transparent PBM Model
• AH054 - Judi Health™: Going Beyond Pharmacy and into Medical Claims, with AJ Loiacono and Dr. Sunil Budhrani
• Pharmacy Benefits 101: Building an Award-Winning Call Center from Scratch

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So maybe starting high level, what is care navigation? How would you define it in the context of today's digital health landscape? What do people need to know?

[01:43] Andy Kageleiry: I like to say if you've seen one care navigator, you've seen one care navigator. The truth is there's a total spectrum of what care navigation can be, all the way from a simple directory product that's offered by every insurance carrier, all the way to a very heavily peopled-powered process, where you have a human concierge or human care navigator helping you manage a case or find care.  

But on the simple end, right, if we think about 80% or 90% of the use case for care navigation, it's finding a doctor, it's finding a facility, it's finding a primary care physician or a pediatrician for your child. And in those cases there's a couple different options. And most people are going to that carrier directory, or they're looking on Google or Facebook groups or somewhere online, right? And what's missed from that process is there's so much rich data that exists today, particularly on the experience, on the outcomes that a provider has, on the quality of their care. And the job of a care navigator is to help democratize that.  

So that's what we did at Amino. We invested heavily in layering on quality transparency and cost information to arm the member with the ability to find high quality care with objective information.

[02:50] Justin Venneri: Okay. And on that spectrum, everything from - I think that's why people refer to care navigation as a digital front door, right. It's like, how do you get into the healthcare system and find the right care to become a patient, so to speak? When we say unified care navigation, what does that mean in the context of, you know, the spectrum of care navigation?

[03:08] Andy Kageleiry: Yeah, I love that question, Justin. Historically, care navigation primarily focused on guiding on the medical side. And there's some good reasons for that.  

First and foremost, medical has always been and continues to be a greater share of health plan costs that employers face. Second, there's historically been more complexity to that care. Appointment after appointment, specialist after specialist, going to different systems. And so having a human who can help with case management, or software that can help make those decisions about who to see next, has been a great solution.  

And third, there's a pretty paradigm difference between guidance on the medical side and the pharmacy side. If you're prescribed generic Lipitor, if you're prescribed atorvastatin, and you go to the independent pharmacy on one side of the street or the retail chain pharmacy on the other, you're going to be dispensed the same generic medicine. If you go to see a dermatologist at health system A or a dermatologist at health system B in your town, you could get wildly different care quality, and the cost can be quite different.  

So a lot of the trends here, however, are changing. And we believe, and I think the industry is showing, that unifying care navigation across both the medical and the pharmacy side is becoming really important. As your listeners know, pharmacy costs are increasing both in magnitude and share of what plan sponsors are facing in terms of total cost. It's driven by GLPs and specialty meds. I'm sure it's been covered on this podcast before.

[04:33] Justin Venneri: Oh yeah.

[04:33] Andy Kageleiry: Second, plan sponsors are adding more programs to make sure the right patients are taking those medications. So, there's adding more and more complexity to actually navigating the pharmacy benefit itself. And third, people expect more personalization in everything that they do, and that includes care navigation. And so that requires taking sort of a full view.  

For us at Judi Care, we believe unifying both medical and pharmacy for navigation is the future. So that's a single system that knows your full medical and pharmacy history, ideally driven off claims in real time and your plan design so you can make a significantly better recommendation.  

So I'll give you an example. If you search in your navigator today for a GLP, you might be holding a script in hand looking for prices or how to access it. You might be curious if you're eligible for that medicine, or you might simply be looking for the right provider to help prescribe you that medicine and consult with you on that medicine. Unified navigation can look across that spectrum to route you to any of those, whether it's a real-time price check against your benefit, or to an obesity specialist or an endocrinologist who can help prescribe that medicine for you.

[05:36] Justin Venneri: So it sounds like everything, in a way, that spectrum of care navigation, is kind of shrinking and gravitating toward a more holistic solution that does cover this digital front door, like initial search, but also is complemented by the type of care you need on an ongoing basis to make sure that you're being routed to the right places and you can follow up, or the clinical care team is involved to help make sure that the prescription doesn't reject if there's maybe a prior authorization or something like that. So it kind of becomes a more comprehensive solution, right?

[06:04] Andy Kageleiry: It does. And I think that is true at two levels, Justin. One, it's true because as a single point that the member can go to, we want to be able to cover more surface area. Second, because plan designs are becoming more and more complicated as a way to control costs, there just becomes necessarily more coordination that we can provide value as a care navigator by seeing both sides of that spectrum. The GLP example is a good one, but there are of course many more examples you could imagine.

[06:31] Justin Venneri: It's a great segue to for my next question on from a payer or the employer's perspective, why should care navigation be a priority? It seems like it's all about costs and plan performance or experience and reduced friction. Sorry for asking a couple questions in one here. I do that a lot if you haven't noticed. You know, what kind of things should an employer or a plan sponsor really look for as they think about care navigation solutions?

[06:54] Andy Kageleiry: Well, of course, it's all the above, Justin. You nailed all the important ones. And I think first and foremost, a lot of employers, when they start to think about navigation, first think about control and cost. And you have to do that. But I would say it's necessary but insufficient to be a good navigator. Let me give you an example.  

First think about an employer without a navigator. Their ability to impact care decisions primarily happens around plan design, right? That's a very important part of this process. Employers have teams of people, they employ consultants who are dedicated just to this. They spend time and money on plan designs, whether that's choosing a plan, a PBM, designing the plans, choosing point solutions, you name it. But then from there you kind of just hope it works out. You get your claims filed back 30 days later, maybe weeks later, after the care was provided. You can make plan design changes on an annual basis, but you don't have any ability to actually help your members in the moment make decisions about care.  

So what a good navigator does, whether that's software platform that members access on their phone or a human providing recommendations, is sitting with the member when they're making those choices and helping them make decisions. So that's helping make decisions around who's the highest quality provider. It's guiding members to the point solutions that their employer has selected so carefully to help, whether that's bending the cost curve further or increasing engagement. It may help them make an appointment with a great provider and helps show just different options. And a lot of those can have to do with costs.  

So maybe the surgeon that you want that has great outcomes practices at both an academic medical center and an ambulatory surgical center, and the surgery center may be half the cost. We can help surface that information by making recommendations about where someone might seek that surgery or other care.  

So I remind my clients all the time, you're spending millions - and some of them spend tens or hundreds of millions of dollars on their healthcare benefit for their employees. Our job is to help increase engagement with that particular design by guiding members to the right care and reflecting their preferences in the way that we serve our guidance.

[08:48] Justin Venneri: That makes a ton of sense. And I know a couple of surveys, or at least one survey and another article has been published recently showing just the expectation for an acceleration of healthcare cost inflation yet going into next year. And the other one was the wild disparity in pricing. One procedure can be, you know, hundreds of percent different in cost at, you know, a different facility. And it's the same procedure. It's like in the same region. So I see how helping address those issues could be very helpful for the plan.  

Reference Articles

• Same Surgery, $220K Apart: Why Providers & Employers Need to Rethink Value Amid Price Disparities (MedCity News; 8/18)
• Business Group on Health. 2026 Employer Health Care Strategy Survey (August 2025)

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And one of the catalysts for this episode was a conversation we were having about demos and showing how the platform actually works. Could you walk us through an example of how effective navigation might change the patient's experience? So kind of flipping to the plan member side of the equation here, how does it impact their journey or at least the start of it?

[09:32] Andy Kageleiry: Yeah, so that can depend pretty wildly on the situation. So I'll give you a couple examples.  

First, let's think about a plan member who has an employer who sponsors a low-deductible PPO plan. For folks like that, they may not actually face price differences when they go seek low acuity care. So the plan may dictate that there's a $50 copay to see a specialist. And that's going to be true whether you go to the expensive provider in town or the low-cost provider.  

For those on a high-deductible plan, cost can really matter. And so just thinking about cost as a dimension, our job is to help steer folks to care that is going to be cost effective. But the most important thing about the experience is that it's not fragmented and from a member perspective that really matters. So we talked a moment ago about unifying medical and pharmacy and I think that's going to be increasingly important.  

At Amino, we also thought about making the entire experience more streamlined. So I think John on the last podcast talked about features we added, like digital appointment booking, the ability to help members actually book care in the platform, which is integrated with the provider's EMR and that can help you make a medical decision. And I think increasingly, and I think we'll talk about this today, is making that recommendation more personalized.

So whether that's guiding you to a point solution that your employer has already selected by helping you realize that that point solution exists, or in the future driving personalization off data like your own claims history, there are more ways in the future that we're going to be able to continue to make the member experience even richer across the spectrum in care navigation.

[11:04] Justin Venneri: You know, it's interesting, we also recently spoke with Carrie Liken again about AI mode, Google, just the enhancements to search broadly, but we were talking specifically about how it impacts the consumer healthcare journey and the way people find care locally. And I just think it's fascinating because when she was going through her examples and the little nonscientific studies she ran, she was really seeing how far she could get in that journey toward booking an appointment. And it wasn't specific to her plan, of course, it was just her using Google and AI mode to try to get down that path. But this is nice and in general it makes sense to be able to pull all the point solutions together,  because we all know there can be point solution fatigue and confusion around what resources people have, and then find the in-network benefits. That really reduces a barrier to care that's out there, right?

[11:47] Andy Kageleiry: That's right. And what I want us to be able to do, and what every care navigator should strive for is just solving more problems for the member. So for that member who's on a high deductible plan, helping them find something that's cost effective. For any member who's looking for a provider, helping them find someone who's high quality, has experience with the particular need that they have, helping them book an appointment, helping them save money on their medicines, there's all kinds of reasons that people need help when they're interacting with the healthcare system, and it's incumbent on navigators to bring those into their platform - again, whether it's digital or human powered - in a way that helps those members actually solve a problem.

[12:21] Justin Venneri: Yeah, I would think it would help with preventive care too. Just all the stuff that's fully covered that you may not use because just of convenience reasons or other non-financial barriers. It's like, you know, it's covered like just find the right doctor that's close to you and you can get in there and get your immunization or have your screening done for whatever.

[12:37] Andy Kageleiry: Absolutely.

[12:37] Justin Venneri: So we've covered a ton of ground here already. I do have a couple more questions for you. And of course the last one that I ask everyone. The core components of quote unquote smart navigation, what makes a care navigation platform truly smart and able to help overcome those barriers to care that we were talking about. What are like must have components that our listeners should be looking for if they're evaluating different options.

[12:58] Andy Kageleiry: Well, Justin, I think care navigation is going to feel truly smart once we've really personalized the recommendations to the individual.  

So for a long time we've talked about this holy grail of having a unified single medical record that hosts all of your diagnoses and the care that you've received. And we've sort of salivated at what we'd be able to build on top of that. And when we think about the unification of claims on the back end and the training of large language models and AI that can drive off of that, you get to a world where this kind of recommendation engine actually becomes realistic.  

So we think about something like social media. Everyone's social media feeds are personalized directly to them. That's been so much harder in healthcare because the data is fragmented, it's highly protected and regulated. But if you have claims on both the medical and the pharmacy side, you have AI, you have an opinion about which providers are good for which conditions and have the best outcomes, you can start to make incredibly powerful and individualized recommendations.  

So if we see someone seeking a certain type of care, we may be able to intelligently route them to the right place to pick up their script or the right follow up care. If they've seen their primary care multiple times for a condition, we might be able to recommend the right specialist for them to see next. I think this day is actually coming pretty soon and that's when navigation is going to feel incredibly smart.

[14:19] Justin Venneri: That's interesting and it will be exciting when we get to that point where everything is personalized.  

So what is the most astonishing thing you've seen or experienced over your career related to care navigation? And of course, I know you've seen a lot, so compliance hat on. Make sure it's a safe one to share. Tell us a good story to send us off.

[14:34] Andy Kageleiry: Well, we talked a minute about personalization and that future is coming soon. But we've already seen some very cool ways that AI can make an impact in guiding people to the right care. So I'll give you a couple examples that we've invested in our product in the last few months.  

So first is in our search bar. We used to have all of our search terms mapped to specific types of care that we would recommend that you see. So you'd search for rash on your arm and we would map that to dermatology. AI has given us the ability to be able to increase that surface area infinitely. Where you used to have to search “rash”, now you can search “my 4 year old has a rash on her arm.” And we will not only route that to a dermatologist, we can actually help route that to a dermatologist who specializes in seeing kids.  

Similarly, we've added generative AI into our product to help create a custom plain English summary on every single provider page based on what that person searched for.

[15:26] Justin Venneri: That's awesome.

[15:27] Andy Kageleiry: What we can do is we can explain to the user based on what they searched for, the experience that that provider has treating that specific condition, the outcomes that drive off of it. And we've always had this data under the hood. What we've been able to do with AI is actually explain that to the member, to the user, in plain English, and we've seen it really help people understand and make a decision about the care that they're seeking.  

So this is really the tip of the iceberg and you can see how this would start to let software become as powerful as the old people-powered navigators, because we can roll out recommendations and start to personalize it at scale.

[16:02] Justin Venneri: That is definitely exciting. Andy thank you so much for taking the time today. Really enjoyed chatting with you and learning more about care navigation, and I look forward to hopefully having you back on and seeing how things evolve.

[16:11] Andy Kageleiry: My pleasure. Thanks Justin.

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