AH082 - Pharmacy Benefit Implementations: Have No Fear, Alignment & Process are Here

Transcript

Lightly edited for clarity.‍

[00:27] Justin Venneri: Hello and thank you for tuning in to this episode of Astonishing Healthcare. This is Justin Venneri, Senior Director of Communications at Capital Rx, and two of the best, most experienced, implementation focused professionals here on our team are in the studio with me today. I'm excited to have Kristen Morgan and Tracey Rollins with me. Tracey is Senior Director of Implementations and Kristen is Director of Implementations for Health Plans. Thank you both for taking the time today.

[00:51] Tracey Rollins: Thanks so much for having us. Excited to be here.

[00:54] Kristen Morgan: Yes, thank you so much for inviting us.

[00:56] Justin Venneri: Tracey, let's start off with you. Tell us a little bit about your background. What led you to Capital Rx?

[01:00] Tracey Rollins: I joined Capital Rx in August of 2020. My background previous to coming here was CVS Caremark in both account management and implementation, and then prior to that was with Express Scripts for some time. I have been in the industry for over 20 years, although I don't like to say that because it ages me, but really I came here because I wanted to be part of a company that had real impact on the industry.

[01:21] Justin Venneri: That makes sense. And Kristen, same to you please.

[01:23] Kristen Morgan: Thanks, Justin. I joined Capital Rx in January of 2020, so I am approaching six years this upcoming January, and that is simply wild to think about considering that there were 40 people here when I started. I came from a background at Express Scripts and OptumRx working in benefits configuration, account management, service delivery, and then implementation, supporting a coalition clients. I've been in the industry for 15 years, and I honestly came to Capital Rx just looking for a fresh perspective, and I found so much more.

[01:55] Justin Venneri: Glad to hear that, and we're glad to have you here. So you both have overseen implementations of all sizes, full service PBM, and then pharmacy benefit administration, which is more modular for health plans and TPAs as well. What should employers or health plans know about your role and the team and the implementation process?

[02:14] Tracey Rollins: Yeah. So, when clients make the decision to move to us, it is important that they have an understanding of what to expect during the implementation process. That is very critical for a smooth transition and effective ongoing management of pharmacy benefits.  

So our typical runway for most clients is about 90 days to allow time for discovery and planning, benefit design, setup, testing and validation, member communications, and really all the post go-live activities. So we really provide clients with a project plan with clear timelines, milestones, assigned roles, and clients are assigned an implementation manager who oversees and supports the entire implementation.

[02:47] Kristen Morgan: Yeah, from a health plan perspective, they operate a little bit different from the PBM side. For health plans we operate in work streams, and that's based upon what is being delegated to Capital Rx. Minimally, we typically operate with around four to five work streams, but that's based upon the client resource structure too. So whatever works for the client. We work from a very extensive project plan, and this ensures that we're all aligned on all requirements and timelines which are truly critical to the success of the implementation.

[03:14] Justin Venneri: That makes sense. And I assume you guys are super busy right now or will be very shortly leading up to the major go live dates, like January 1^st, and then I guess some of the off-cycle ones might be mid-year, whether it's 7/1 or one of the other quarters. So I definitely really appreciate you taking the time to chat with us. Have things changed recently? Are there more off cycle starts?

[03:35] Tracey Rollins: I would say not as many off cycle starts, but more so clients are making decisions earlier than normal. So the typical or standard, as I mentioned, runway is 90 days for implementations, where health plans may experience a year-long implementation period. But we're now seeing that on the employer side group as well, as clients are making decisions earlier in the year in hopes of being more strategic in the process of onboarding.  

So we're seeing more benefit and network customizations, more custom open enrollment sites, more third-party vendor integrations, custom communications, and on-site kickoffs, just to name a few of the notable differences we've seen this year.

[04:07] Justin Venneri: Interesting. Okay.

[04:08] Kristen Morgan: I think to add to that, there is a heightened sense of urgency and accuracy surrounding regulatory matters as we onboard client. Each year as an organization, we are becoming more and more mindful of the ever-changing regulatory landscape and how it impacts our implementations and what accommodations need to be made to remain in compliance.

[04:26] Justin Venneri: Let's get into it here and see if you can help alleviate people's fears about switching their PBM or PBA. This is one of the main things that we hear out there in terms of pushback during the sales process. Hope Nakazato has talked about it, Bridget Mulvenna has talked about it, Josh Golden talks about it all the time: overcoming fears and concerns. We don't want people to worry about member disruption, transitioning data, et cetera, et cetera.  

So I have a couple questions. First, in your opinion, is that a reasonable or generally warranted fear? And then what do you think it's based on?

[04:57] Kristen Morgan: It's absolutely warranted and it's reasonable. Change is very hard and scary for clients and their members. Members just want to know if they're going to be able to continue getting their medications and how the change is going to impact them. Can I still get my same medications? Is it going to cost me more? Can I keep going to Joe's Pharmacy? But our processes during implementation account for this. We are going to spend a lot of time discussing during the implementation different strategies that ensure a successful go-live.

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[05:25] Justin Venneri: And that's on the health plan side, right, Kristin? Or is there, Tracey? Is it the same on the PBM side?

[05:30] Tracey Rollins: Yeah, I think that's the same on the PBM side. Really, for most of our clients, I would say member disruption is one of their main concerns. We do spend a lot of time during implementations and early conversations to dive into, you know, member communications, what we can do to mitigate member disruption. And so at the end of the day, our process is thorough and does exactly that: leaves no stone unturned.  

One thing we offer our clients that sets us apart from many other PBMs is continuation of therapy, which allows members time - it's typically 90 days - but really to continue their current therapy with no interruptions. So this allows members time to speak with their physicians if needed, to get a new prescription. Maybe they need to get a prior authorization and provide the detailed communications during that time with next steps needed.

[06:11] Justin Venneri: We worked on a blog over a year ago, and Tracey you were part of that. We were talking about successful implementations. And so this is effectively like an update to that, which we'll link in the show notes, of course. But let's focus on PBM or commercial implementations here for a minute and go a little deeper. How do you establish trust quickly once you know we've got to get to work on the implementation for a new client?

[06:33] Kristen Morgan: Every single person working on implementations on our team has PBM/PBA background, and the experience is crucial in our success. Implementation milestones are clear and we have focused SMEs supporting most of the critical conversations. And we truly have experts in getting through those details, like data exchange, member communications, clinical conversations, just to name a few.

[06:56] Justin Venneri: SMEs is subject matter experts, right?

[06:58] Kristen Morgan: Yes. Sometimes the message is hard, but it's our job as your trusted implementation lead to answer questions honestly, raise risk as we see it, and come to the table with thoughtful solutions and feedback.

[07:09] Tracey Rollins: Yeah. And to add on to that, establishing trust really does start from day one. From our perspective, we focus on three things. Transparency, responsiveness, and expertise. We set clear expectations up front, what the client can expect from us, what we are going to need from them during implementation, and how that process will flow.  

We do strive to stay highly responsive, answering questions quickly, proactively addressing concerns, and really providing regular updates so the client always knows where things stand. And we do demonstrate a deep understanding of both the PBM industry and the implementation process, which reassures the client that they are in capable hands. When clients feel heard, informed and confident in our capabilities, that trust just builds naturally.

[07:47] Justin Venneri: Okay, and then what do you or does your team do to set the plan up for the best chance of a successful implementation? What are the top couple of things? It sounds like starting early is a big one. Good communication is important. What are some things that you say can make or break an implementation? Tracey, you want to go first.

[08:04] Tracey Rollins: For PBM, and really this goes for all of our implementations, our implementation managers focus on building a really strong foundation from the start by establishing early alignment, delivering tailored project plans, ensuring proactive communication and issue resolution.  

We do place emphasis on client readiness through training, testing, and ongoing support, so they understand what to expect for their go-live. One critical piece to PBM implementations that has the ability to hinder an implementation is establishing connectivity with the client's vendors. So think medical for accumulations and eligibility, for example. This requires these vendors to come to the table prepared to be able to implement and connect with this client. So with that, we start these conversations very early on in the implementation with the vendors to ensure no issues for the clients going live with us.

[08:49] Justin Venneri: So they just have to provide you – us, essentially - with a list. And then by connectivity, I'm assuming that's through the technology platform, the APIs and such, we make sure we can push and pull data from the parties they need.

[08:59] Tracey Rollins: Correct. That's part of it. And just really establishing feeds for eligibility and accumulation files to come over.

[09:05] Justin Venneri: Got it. Kristen, how about on the health plan side?

[09:07] Kristen Morgan: Yeah. Health plan implementations are some of the most complex implementations, and rightfully so. These are clients who know what they're looking for. They're familiar with requirements and regulations and expect their PBA to be up to par.  

Clear and upfront understanding on client delegated elections allows for identification of those requirements, which then translates into the build out of their custom project plan, which is how we are successful for go-live. Getting those delegations right early on ensures that our project plan and timelines align with the scope of work that needs to be completed in those appropriate timelines.

[09:39] Justin Venneri: Okay. And Judi®, our enterprise health platform. What role does you know, quote unquote “modern technology” play in this process? How important is having that to you guys in your role? And we say it all the time, things are easier with Judi, we're more efficient because of Judi. Are there any simple examples you can share?

[09:56] Kristen Morgan: Oh absolutely. We love working with Judi. In collaboration with our benefits teams, development product teams, we can achieve what sometimes feels like the impossible with Judi.  

We've seen clients implement complex position gold carding, GLP-1 cost containment strategies to limit days supplier channel. Another neat feature of Judi that clients like is the ability to stamp claims with a name to easily identify them. Maybe they want visibility to certain diabetic drugs processing to support a custom wellness program they designed. With Judi, we can stamp those claims and have instant clear visibility to the program through reporting.

[10:30] Justin Venneri: Well that's really neat. Learned something new today.

[10:32] Tracey Rollins: We like to say if a client can dream it, we can build it.

[10:35] Justin Venneri: Gotcha. And then maybe an inside baseball question here, and a follow on -  sorry, I ask a lot of two on one questions - which teams does implementation work most closely with internally and on the client side? And how does that help ensure successful implementation and handoff once the plan goes live.

[10:50] Tracey Rollins: For PBMs on the client side we work most closely with the client's HR or benefits team, the client's medical and eligibility vendors, and the client's broker or consultant. Internally we do work very closely with many teams, so to be honest, most teams in the organization touch implementation in some way or another.  

We do work most closely with the benefits team, member communications, data exchange teams for historical files for eligibility and accumulations as I mentioned earlier. But really, collaboration across all parties, both internal and with the client is critical to really ensure accurate sets, setup, data integrity and a smooth go live for the clients and transition for their members.

[11:27] Kristen Morgan: Yeah, for PBA we still have to work with the same functional areas internally, but the level of effort just may be different. Additionally, there are some areas which we don't typically have to engage extensively during a PBM implementation - areas like regulatory, customer care, government programs, prior authorization teams, for example, and they turn into full on work stream conversations with health plans.  

What's really important since we operate in work streams for PBA is to ensure that we have clear owners on the client side to support decision making for all requirements so we can keep moving through those project plan milestones.

[11:59] Justin Venneri: Got it. And I have to ask this one because it comes up a lot and I'd love to hear your answers. With all of our recent growth and larger clients that we're bringing on board does this change anything for you, respectively on the PBM or PBA side? Like, ask another way. If a prospect was sitting with you and expressed a concern about a smooth implementation because we're so busy, what would you say? Kristen, you want to take that first?

[12:21] Kristen Morgan: I'd say no. This has actually made us better. With being busy comes experience, and we have a lot of that here at Capital Rx. When I started in 2020, we had small 100 life groups, and then we had 10,000 life groups, and 50,000 life groups, and now we have 600,000 life groups and beyond. And these clients are bigger with more customizations, which has been great because we've been able to put together what feels like an infinite job aid library to support all these customizations that we're seeing.  

So we're rarely now doing anything for the first time. We're using a tried-and-true, established process, and our clients would also agree. Their feedback is that they typically really enjoy the implementation process.

[13:02] Justin Venneri: Tracey, how about on the PBM side?

[13:04] Tracey Rollins: Yes, to add to that, we've also built in efficiencies on our team so the implementation project manager can spend more time focused on the clients and their intended strategies. For example, we have implementation coordinators managing a lot of the internal submissions on tasks for completion and tracking those through to execution.  

And new to this year now, we've established what we're calling a Data Exchange Implementation Project Manager to support all the data exchange activities during implementation. So those subject matter expert roles really work closely with our implementation managers but allow them to step away from more of the admin duties and focus on specifically more client functions.

[13:39] Justin Venneri: Got it. And last one for now, and I ask everybody that comes on the show, thank you so much for taking the time today. What is the most astonishing thing that you've seen over the years relating to implementations, that you can share, of course, has to be compliant – you know, gotta put your compliance hat on. I know you've seen a lot.  

So if it's something funny, something serious, a learning moment, whatever, tell us a good quick story. Tracey?

[13:59] Tracey Rollins: Well, what I really love to see is how smoothly some of our highly complex implementations come together. Those clients that have multiple eligibility feeds, custom formulary setups, tight turnaround timelines. What really stands out to me is the level of collaboration and commitment across both our internal teams and the clients.  

Everyone is aligned, proactive, fully engaged, and really seeing that level of coordination where hundreds of moving pieces come together seamlessly at go live remind me really how powerful teamwork can be. So really so much is possible when everyone's pulling in the same direction.

[14:29] Justin Venneri: Yeah. I think we had over 90 implementations this past year, and I know it's growing again, so it is amazing to see how efficiently everything does come together. And it's kind of like one of those moments where, okay, 1/1 just happened and it all worked, right?

[14:43] Tracey Rollins: Absolutely.

[14:44] Justin Venneri: Kristen, close us out here. Same question to you. What's the most astonishing, coolest, and most interesting thing you've seen over the years?

[14:50] Kristen Morgan: Yeah, I think what I want to leave the group with is there will not be a more passionate team supporting the client onboarding than what these clients will experience at Capital Rx. We are straight nutty about satisfaction and we spend the first half of the year after our big 1/1 season combing through all the lessons learned from the prior year and then creating new processes, updating job aids, project plans, and whatever else is needed to ensure that we are even more buttoned-up for future implementations.  

We only get one shot to make a first impression on members, so we better get it right during the implementation. We absolutely love our clients. We want them happy and to hand them off to the account teams, excited and confident with their decision to move to Capital Rx.

[15:30] Justin Venneri: And not to get too salesy, but that's a nice thing, right, because the account teams are involved in the process. So everybody's on the same page going into the handoff, right?

[15:38] Kristen Morgan: Absolutely.

[15:38] Justin Venneri: Awesome. Kristen and Tracey, thank you so much for taking the time today. Really enjoyed hearing your perspectives on implementation and look forward to staying in touch and hopefully having you back on.

[15:47] Tracey Rollins: Thanks for having us.

[15:49] Kristen Morgan: Thank you.

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