Capital Rx’s Government Programs: Behind the Scenes with Jason Barretto

June 20, 2023

Justin Venneri

Capital Rx’s JUDI®, our proprietary claims processing platform serving commercial, Medicare, and Medicaid lines of business, was built from the ground up to streamline all the necessary functions to administer a pharmacy benefit efficiently. It is the only platform of its kind built following the enactment of Medicare Part D, and JUDI can handle Medicare and Medicaid claims processing requirements without the usual worries about bending outdated systems to meet regulatory standards.

JUDI helps with plan design changes, setup, and system deployment incredibly efficiently.
JUDI Drives Operational Efficiency to New Levels

Behind the scenes, an army of developers and subject matter experts with extensive government programs experience work tirelessly to ensure that health plans and other stakeholders who want control over their pharmacy benefit programs have the support they need to be successful.

I sat down with Jason Barretto, Capital Rx’s Vice President of Government Programs, for a 4-part discussion about how his experience working with pharmacy benefit managers (PBMs) while at health plans helps address clients’ pain points and influences the development and deployment of new features and functionality in JUDI. The following Q&A is lightly edited for length and clarity.

Leveraging Experience and an Aligned Pharmacy Benefit Model to Build Trust with Health Plans

Jason, prior to Capital Rx, what was your role on the health plan side, and how did that experience shape your understanding of the industry and lead you to join our mission?

I’ve had various roles over the past 15+ years at health plans within the “pharmacy departments,” managing PBMs with responsibilities ranging from management of data analysis, reporting, and requests for proposals (RFPs) early on to managing operations and business processes and establishing policies, standards, and guidelines and controls, for plans covering over 5 million lives (more recently). I had to work with PBMs the way they wanted, and many of the same issues that existed when I started in the industry still exist today.

We had a very robust monitoring and oversight process of delegated functions to ensure that contract terms were abided by. The industry is dominated by a handful of players, and what got me to join Capital Rx was: as I tried to innovate and collaborate with PBM partners, I noticed that the onus was always on us - on the health plan - to figure out how to stand out in the market. On too many occasions, I realized or felt like I was doing the work my PBM partner should have been doing, and then they could go out and sell the innovation – i.e., they could monetize it.

Part of that was how we structured our agreements and managed them. But, for example, we had to be compliant. Compliance is critical for a health plan, and as you identify certain gaps, you’ll work through them with the PBM. I quickly realized, and it wasn’t nefarious, that there were a lot of bad processes and systems out there - everything was antiquated.

I started to look for alternatives to see if there were any new PBMs or if someone was trying to do something different, and that was when I came across Capital Rx.

What stood out to you about the Capital Rx pharmacy benefits model?

Two things stood out:

  1. The tech platform, JUDI, is new and built from the ground up to handle everything for commercial, Medicare, and Medicaid claims processing and plan management (it’s not sitting on an older platform).
  1. The mission and goal of being a transparent PBM – i.e., Capital Rx will not obtain revenue outside the work they do on behalf of the client.

Number 2 was one of my biggest issues with the PBMs I managed. It was so hard to uncover every line item and figure out how they obtained revenue. I had to ask very specific questions and know very specific things to ask the right questions to get the response, whether it was to share the information with a regulator or just understand what the PBM partner of mine was making on my business and if it was reasonable.

That’s part of the challenge for a health plan as you’re peeling back the onion. You’re trying to figure out where and how your partner is making money, if it’s reasonable, or if it should be passed back to you (the client) or incorporated in the overall package of the agreement(s). There’s a lot of ambiguity there, and it’s due to how the [vertically integrated] organizations are set up with intertwined relationships between dispensing assets or if they are providing clinical services or doing rebate management and aggregation, for example. It’s just hard to understand who is involved and how making money impacts the relationship (and how it impacts the bottom line as a health plan).

Capital Rx is upfront and explicit about revenue streams, and that gives the health plan peace of mind about what they are paying for. Everyone should know what they are paying for. That’s how it should always be, as the client of a PBM or in day-to-day life.

How do a) clarity on revenue and b) your experience on the health plan side come together to inform your approach to developing pharmacy benefit solutions for health plans?

I keep that all top of mind in everything I do. Whether it’s how I approach a function or deliverable that requires some sort of solution, client support, or a reporting issue, I leverage my health plan experience to shape how we do things.  

Are we going to do something IT-enabled that requires minimal effort at no cost? Or is it something that’s partly IT-enabled and high-level effort and very involved, and we can do it at a reasonable cost? We’re putting that cost front and center to ensure that clients understand what they are paying (and why they are paying for it). It’s not buried anywhere or offset by some other arbitrary revenue stream. 

Related Content

What Really Makes a Pharmacy Benefit Administration (PBA) Solution Different?

Partnership & Collaboration: Why PBMs and Health Plans Should Sync on Regulatory Change Management, with Jason Barretto

Government Programs: The True Meaning of Customization

What role do you see Capital Rx playing in the future of healthcare? 

The two things that brought me here are where the industry is going, in my opinion. We’re having a huge impact. JUDI and the IT enablement are huge, and we invest a far greater portion of our revenue in R&D compared to our competitors.

If you have a good platform with good processes surrounding it, you’re going to be more efficient and have less overhead. That’s huge for clients and our ability to explain exactly where their dollars are going. It’ll take time, but I think these things will become the industry norm. State legislators are doing a lot to protect themselves, given how much they spend on health care, but it might take federal legislation. Regardless, I think it will happen over time.

Contact us if you’d like to learn more about Capital Rx and what JUDI can do for your pharmacy benefit program and beneficiaries.

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