The simple truth that most pharmacy claims processing platforms are more than 20 years old tends to surprise people in the pharmacy benefits world. “You’re exaggerating, right?” No, unfortunately. A lack of investment in infrastructure beyond core prescription claim processing functionality has led to tables upon tables and lists upon lists in the legacy systems that most health plans rely on in the U.S., which means stakeholders expend more time and resources than is truly needed to manage their pharmacy benefit programs.
It also means that access to data and other information may be limited or restricted.
Modern, Open PBM Software Exists
I asked Ryan Kelly, Co-Founder and Chief Technology Officer here at Capital Rx, about the importance of building an open platform. JUDI® is our purpose-built, cloud-native enterprise health platform that provides several advantages over legacy systems, not the least of which is offering payers, including health plans, health systems, employers, municipalities, and others, the flexibility to leverage JUDI in some beneficial time and cost saving ways, if they so choose.
Ryan explained that APIs – application programming interfaces – enable a level of connection and interoperability required to support efficient full-service pharmacy benefit administration. However, “In most systems, APIs don’t exist or aren’t available. So, we can improve the client’s or member’s experience, especially if they’d like the flexibility to manage specific aspects of a pharmacy program themselves or provide their members with a unique experience,” he added.
How APIs Improve Pharmacy Benefit Administration
For most Medicare, Medicaid, and commercial health plans relying on “closed” systems, it may be hard to imagine having the kind of flexibility and options for customization that exist with JUDI. So, I asked one of our resident API experts, Alfonso Martinez, Director, Product Management, what JUDI being an open platform means for plan sponsors or health plan executives, and he provided a few specific examples of how “openness” helps.
New API Endpoints
JUDI was built on a clean slate and is modular, meaning clients can pick and choose what services they’d like. Well over 130 APIs are available for everything from adjudication to prior authorization and identity and access management, among others. And it’s relatively easy to develop and manage new API endpoints, which should prove helpful to plan sponsors given new reporting requirements, the need to access and interact with member and claims data, and the opportunity to integrate with other vendors.
It's an oversimplification, but there are APIs, some functionality, and a database, and the APIs, which are REST APIs for all our tech-savvy readers, are a way for a browser, user interface, or other applications to interact with the database and access functionality.
That may sound confusing or be too vague, so here are some examples:
The Value of an API-based Architecture
An API-based architecture allows other organizations to programmatically engage with JUDI as a platform in whatever way they want. Alfonso says, “In JUDI, you can read or pull data, update data, or create new records.”
Access to Pharmacy Claims Data
If a plan sponsor wants to enhance the user experience and pull data into an app, APIs provide this flexibility.
Read our case study to see how the development teams at Capital Rx and Anthem/Elevance collaborated to give Indianapolis Public School members a single view of their medical and pharmacy benefits and claims in the Sydney patient portal.
Power Pharmacy Benefit-related Workflows
Plan sponsors and health plans are able to power workflows based on when claims are processed in JUDI. With our real-time claims integration and robust API endpoints, automating workflows like taking action when a specific reject code is triggered for a member or a drug, sending a timely notification to the pharmacist, or making an outbound call to a member can be made a reality.
Another example is the ability to programmatically create a prior authorization (PA) or override right from the user interface or clients' applications (e.g., to allow a member to have access to a medication prescribed by a particular physician).
The efficient exchange of information and data is essential as we move toward value- and outcomes-based care models in the U.S., and the ability to integrate with any vendor that a payer works with, so long as they can integrate with API endpoints, will be expected.
- If a health plan wants to use its own PA tool and integrate it with JUDI’s claims adjudication system, it’s no problem, thanks to APIs.
- If there’s a digital health or virtual care provider, like Virta Health or Vida Health, that can help members manage chronic conditions in different ways, and a plan sponsor wants to surface pharmacy data to members or share data efficiently with the vendor, they can do so in real time.
- If you have invested in creating a great member or prescriber digital experience, for example, and you want to complement it with data that lives in JUDI, the APIs allow you to do that.
It’s time to move to an open enterprise health platform.
There’s no longer a need to rely on legacy technology solutions and deal with all their limitations. Plan sponsors and health plans must have the flexibility to put together and manage their pharmacy programs in the most efficient ways possible, manage and update data, and power workflows seamlessly through one interface.
JUDI’s APIs represent a significant leap forward for claims processing platforms you need to see today.
To learn more about JUDI and Capital Rx’s PBM and PBA solutions, CLICK HERE to get in touch!