AH006 - Pharmacy Benefits 101: Clinical Care Teams, with Amy Stockton, PharmD

February 23, 2024

Capital Rx

On this episode of The Astonishing Healthcare Podcast, Amy Stockton, PharmD, who manages the clinical care team at Capital Rx, discusses what, exactly, her team of pharmacists in a non-traditional, managed care setting does (hint: it's a lot behind the scenes). She highlights the clinical programs the team supports, including low-cost alternative, pharmacogenomics, and medication therapy management (MTM), to name a few, what it's like working with frontline customer care, how technology - i.e., JUDI® - is leveraged, and the day-to-day responsibilities of a clinical care team member.


Lightly edited for clarity.

Justin Venneri: Hello and thank you for joining this episode of the Astonishing Healthcare podcast. This is your host, Justin Venneri, Director of Communications at Capital Rx, and I'm excited to have Amy Stockton with us who manages our clinical care team here at Capital Rx. We're going to be discussing what exactly clinical care teams do and are responsible for. Amy, thanks so much for joining us today.

Amy Stockton, PharmD: Awesome. Thanks for having me today, Justin. I'm really excited to have this opportunity to tell you about the awesome team of pharmacists I work with.

Justin Venneri: Likewise. Can't wait to hear it. Actually, let's start off with a little bit about your background, just to frame the discussion for people. Where were you before Capital Rx and what led you here?

Amy Stockton, PharmD: Sure, I actually started in retail as a lot of pharmacists do. I was with two different companies, one where I was an intern during pharmacy school, and then after I graduated, I worked for another company where I started off as a floater, then was a staff pharmacist, and then moved up to PIC, or pharmacist in charge. After that, I moved to a PBM where I was the prior authorization pharmacist and eventually moved into managing a small call center for them as well. We were a small team, so I wore a lot of hats there. We did some PNT work and some other things as well. I came to Capital Rx in late 2020, started actually as a clinical care pharmacist on the evening shift, and then took over the manager role in August of 2021. And I've been here ever since.

[01:54] Justin Venneri: Awesome, and we are happy to have you. So, a lot of people don't realize how much the pharmacists do behind the scenes in the managed care -- sort of the payer side -- of the business. It's generally viewed as an alternative pathway for career development for pharmacists. Can you share a little bit about what role the clinical care team at Capital Rx plays?

Amy Stockton, PharmD: Absolutely. Yes. And you're right, it isn't something that was on my radar in pharmacy school. I think it's becoming a little more common, but I wasn't even aware this was a career opportunity when I was a young pharmacist starting out. I think as far as clinical care teams. Different organizations probably have different definitions of what those teams do. I think we're a little unique here. We are all pharmacists, and we impact multiple teams and multiple areas within the organization, which is really unique. One of our main goals is to support and administer our clinical programs.  

So, our pharmacists receive inbound calls and make outbound calls for our high touch clinical programs, such as Rx Smart Save Level Two, which is our low-cost alternative program; Rx Ally, which is our opioid management program; and Rx Helix, which is our pharmacogenomics program. We also support our wonderful front-line customer care team. They take all the incoming calls, which could be from members, prescribers, or pharmacies. We don't counsel, but we do assist with questions that require clinical knowledge.

Some typical questions we receive are drug shortage questions. We often do clinical type overrides. We handle formulary alternative questions and, of course, we help with prior authorization related questions as well. All the clinical care pharmacists are cross trained in prior authorization. So, while that's not our main duty, we do support that team during peak volume times.  

And then another really unique opportunity we have is we take part in the Capital Rx residency program. We provide a rotation within the clinical care team, which is also another really unique situation. PBM residency was not an option when I was in pharmacy school, and we love having those residents come and learn from us, and we learned something from them, too. So, it's a really great setup.

[04:15] Justin Venneri: That's awesome. So, it sounds like, for the plan sponsors out there, or for health plans, or just in general, your team supports a lot of different functions, especially when it's something that a pharmacist is necessary to help with. How would this vary at other PBMs?

Amy Stockton, PharmD: Sure. Lots of PBMs also have pharmacies, so a lot of their call volumes involve counseling, benefit questions, prescription questions. We don't have pharmacies here at Capital Rx, so we only take the calls that need clinician assistance from our front-line customer care team. And I had mentioned some of those before, such as drug shortage issues.  

Many PBMs have clinical care teams focused mainly on MTM, or Medication Therapy Management. While that is a clinical program that we have, that's not our exclusive focus. I think something that's really unique for us is we work hand in hand with other stakeholders within the company to make our processes more efficient. And we have a lot of input into how clinical programs are developed and set up, so some creative ability as we have to ensure that the workflows make sense for us when we're on the phones administering those programs, and then also from a management perspective and a reporting standpoint. And I would say as a newer tech healthcare company that is growing so rapidly, there are lots of opportunities for growth in the clinical realm. So, we're looking forward to supporting more clinical programs as they come down.

[05:51] Justin Venneri: Okay, and do you support health plans and commercial clients alike? How does that differ?

Amy Stockton, PharmD: Sure. Yeah. For our PBM clients, it is typically full support. They typically do need our call center, front-line customer care staff, so that trickles up to us when clinical questions come about. So, it is a typically a full support type situation.  

[With] the PBA clients, we have the ability to make more of a selection, so they may not necessarily need clinical support. They may have their own help desks, but if they do elect various clinical programs, then we can administer those programs and take those calls.

[06:31] Justin Venneri: Got it. I recently spoke with Jay [Tran], you know, on our team as well. It's always nice to be able to tie content together. We discussed MTM a little bit. Could you just give an example? It occurred to me that many people listening to this may not understand exactly what that interaction would look like, just so they can put kind of a real-world example to that acronym.

Amy Stockton, PharmD: Yeah, sure. And Jay is excellent. He really heads this program up. So, MTM, or Medication Therapy Management, is – we identify patients through their filling and claims history, and then we reach out to them and see if we can help customize their medication more specifically to their needs. Sometimes we're looking at polypharmacy. Can we reduce the number of medications that they're taking? We're looking at safety. We're looking at what may interact with other medications they're taking. Just kind of a comprehensive view of how we can help them manage their medication therapy a little bit better.

[07:36] Justin Venneri: Okay, great. And then to do this job, to sit in this seat, what credentials or specialized training do the members of your team have?

Amy Stockton, PharmD: Sure. All our team members have a pretty solid background in retail pharmacy. It's something that we think is really important because you're able to see the other side. When we're helping pharmacies, we understand what they're facing, the issues that they're seeing, because we've all been there as well. So, I would say almost all of our team members have had retail experience prior to coming to Capital Rx and working for the Clinical Care team. We don't specifically require certain types of roles prior to hiring people, but we do look for team members who have experience that may complement the team members we already have.  

The reason for that, I mentioned earlier, is we're often involved in development, and we have a say in efficiency items and things that we're working towards. So, we're looking for subject matter experts (SMEs) with different experiences who can contribute their knowledge when we come across these opportunities, or sometimes when we need to solve a challenge.  

We do have some pharmacogenomics certified pharmacists that are involved with Rx Helix, which is the pharmacogenomics program. We have several team members with MTM certifications, and we find that this experience translates well to supporting the call center as well. Pharmacy schools generally don't teach phone skills to pharmacists. It is something we teach on the job, but we find that those who are MTM certified often have a little bit of a head start.  

We do have some pharmacists that have had residencies, but that is, again, not something we require. And then a lot of our pharmacists have a prior authorization background as well. And since all our clinical care pharmacists are cross trained to support, this comes in handy. We do have a pretty comprehensive training program, and it is broken down into call center clinical programs and then prioritization, and we follow the training period with a shadowing period. So, we pair them up with other pharmacists. They can listen in on calls and then have somebody there to support them as they start taking their own calls. And then eventually they go on to their shift on their own.

[09:54] Justin Venneri: And what does a typical day look like for a clinical care pharmacist to Capital Rx?

Amy Stockton, PharmD: Yes, we wear a lot of hats, so our day is very varied and busy. Our main priority, of course, is the calls, whether it's from the customer care team or from clinical programs. And they can be on a variety of topics from a variety of sources. So, we have to be prepared for anything. You pick up the phone and you're never really sure exactly what's coming at you from the other side. And of course, when you have people on the phones, you're trying to get to the answer, the resolution, as quickly as possible, because that person is waiting for you to resolve their issue.

We aren't quite big enough to staff around the clock, so we do have an after-hours process. If a pharmacist is needed, we are available at all times, of course, around calls. We're assisting the Prior Authorization (PA) team, and we are currently experiencing high volume in the PA queue. So, our support there is really critical right now. So, when the pharmacists hang up the phone and they are finishing up their notes on each call, then they're going right back into the queue to decision prior authorizations.  

I would say one of our big focuses right now is our opioid safety program, and we're working on the expansion of that. We want to really ensure that our members are using opioids safely, and then also our low-cost alternative program, which helps our members obtain lower cost medications. So those programs also require quite a few outbound calls, depending on the case. So, we do make a lot of outbound calls as well. So, we juggle a lot of things in our day. I would say it's never boring here. That's part of what I like. I like the variety and, yeah, I’m really proud of the team for all of the things that they can handle. They're very multi-talented.

[11:39] Justin Venneri: Okay, and how do you measure success in the role or for the team? And then what do clients care about most as a follow on to that? Is it the Net Promoter Score (NPS)? Is it time to answer or something else?

Amy Stockton, PharmD: Sure. Yeah, I can talk about that a little bit. So, of course, Capital Rx believes that our NPS score is very important, and we do indirectly support it by supporting our Customer Care team, because if we're handling calls successfully, then they're successful, and vice versa.  

We do have metrics and the pharmacists are held to them. We have what we call an SLA, which is a Service Level Agreement, and that means that we have to answer 90% of our calls within 30 seconds. I will say for the clinical care team, in a typical month, 6 to 8 seconds is our Average Speed to Answer or our ASA.  

The reason for that is, again, the pharmacists aren't just answering the phones, so often times they have to quickly finish what they're doing and then pick up the call. So, there is a 6 to 8 second ASA, which is still excellent, much better than much of the industry. And then, of course, during the times that we are working prioritizations, there are prior authorization metrics and quality levels there as well.  

We do have some team goals, and our biggest one is that, if we identify any issues, we have to research and escalate them to the appropriate team for resolution within 6 hours. We follow all cases from the time we receive them to resolution. And when I say cases, I'm talking about calls that come in. Each call creates a case, and so often the cases can be closed out right after the call is finished. But in some situations, we may need to do some further research and make sure that they get resolved.  

So, the pharmacists are very resourceful, patient-oriented professionals. They have to know where to find the info they need very quickly. Again, they support many teams, so they have to be very well-versed on all the questions that might come up to make sure that we are able to handle the calls efficiently and correctly. And most pharmacists, if you ask them why they went to pharmacy school, it's to help people. We don't do that as directly as most of us do in retail, but we do take that very seriously here.

[14:01] Justin Venneri: That makes sense. And it seems like a lot of your involvement with a member population really depends on what clinical programs or what the overall pharmacy benefit program looks like that the client may have selected or designed, and they're using us for. Obviously, if they don't have pharmacogenomics as part of it, then you're not supporting them in that way. But it seems like you guys touch a lot of areas here. How much of your role, or your team's role, involves technology? Or maybe I'll ask it this way. How does technology like JUDI®, our enterprise health platform, help your team achieve the success you've described thus far in the discussion?

Amy Stockton, PharmD: Yeah, sure. JUDI is integral. I think it's something we say on a regular basis. I think we're all blown away by the things that JUDI can do. Most of us came from other PBMs who are using old technology. And so, JUDI is really revolutionary for us. It's kind of a one-stop shop. We can get everything we need from JUDI: the client information, the member information. There's a lot of customization that's available. And the search features that it has really help us to be able to find the information we need really quickly.  

From an adjudication standpoint, we have amazing functionality with overrides and tags. I won't go into that because I know there's a lot of information behind that. But we do have to be aware of those when we're looking at claims and why they aren't processing -- or maybe why they are. It's very user friendly, which makes it easy to train new hires on the system.  

I think one thing that the pharmacists say a lot is, because the system is cloud-based, we have very few disruptions or downtime. And I know from my previous experience we used to have disruptions to our work fairly frequently when the system went down. So, we really enjoy that piece of it and it allows us to work really well with other stakeholders. I think what's cool about being a front-line team is if we see an opportunity or a place where we can improve the workflows, we can work together with other teams, like the dev teams, as everything is done in-house. So, we often have the ability to kind of help solution for technological or operational challenges, which I think is a unique place to be in this role as well.

[16:32] Justin Venneri: That's nice. And it sounds like it ensures that the workflows make sense, which you said earlier is important. Obviously, the access information and the ability to make those outbound calls. And forgive me if I'm stealing from a future question we have here, but would you say that the ability to interact with the other stakeholders, including outside pharmacists or the provider, is that something that you see kind of evolving over time, especially as the clinical programs evolve and become more specialized and you have to be more involved in the continuum of care?

Amy Stockton, PharmD: Yes, you're on the right track, definitely. So, I think the team will continue to grow eventually. We will not support the PA team as much as we do now with the coverage determinations. So as new clinical programs are being developed, and as we see needs arise for those, I think eventually we will have teams of clinical care pharmacists who are more specialized or delegated to specific clinical programs. I think one of our challenges now is we all have to be experts on all the programs. So, we're juggling quite a bit. So, I see us going in that direction to make sure that we are truly an expert on the programs we're delegated to.  

Something we always keep in mind is we want to make sure that we're using our team of pharmacists for clinical purposes, not administrative purposes. So that's always in the back of our mind as we continue to grow. Like you said. Yes, I think there are definitely more opportunities for direct patient and provider contact to support patients and members and help them make informed decisions about their health care and hopefully improve their lives by assisting with their medication needs. It's really exciting. Tying into your last question about JUDI is constantly evolving to address the additional programs. So, it’s really exciting to see how we can integrate them into JUDI and how JUDI can meet differing needs for each program.

[18:33] Justin Venneri: Excellent. And so here we are at the last question I ask everyone. Based on your experience in industry and everything we've talked about today, what is the most astonishing thing you've seen -- that you can share, of course -- and why. Tell us a good story.

Amy Stockton, PharmD: From a Capital Rx standpoint? I just think everybody's individual investment into our mission and the teamwork. There's just an unwillingness to fail. And when you combine that with the technology we have and all the brilliant people we have here, I think that's a unique and special situation to be in. It's really a joy to come to work every day and work with all the people who make this place so special.  

On a more personal level, I would say when I graduated from pharmacy school, I never expected to work from home, so I really enjoy that. But I would say we are a mostly remote team. My team is completely remote. All our interactions are over Zoom. Of course, we use Slack to type back and forth, but when we do get to meet each other – I think the funniest thing is realizing how tall or short somebody is. Because you see somebody on a Zoom screen, and you have this vision in your mind of how tall they are. And then in real life, sometimes it's not what you thought. So, we've giggled about that quite a bit.

[19:57] Justin Venneri: Oh, that's funny. It's true. Okay, well, Amy, thank you so much for spending the time with us today to talk about your team and the role of clinical care pharmacists here at Capital Rx and more broadly, and we look forward to staying in touch with you and seeing how things develop with these new clinical programs.

Amy Stockton, PharmD: Sounds good. Thank you so much for having me, Justin. Appreciate your time.

Outro: Thank you for listening to Astonishing Healthcare by Capital Rx. Head over to www.cap-rx.com/insights and visit the podcast section for show notes and other relevant content. If you liked this episode, be sure to subscribe so you don't miss the next one. And definitely share the link to this show with your network if you enjoyed it. Have a great rest of your day.

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.

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