Government Programs: The True Meaning of Customization 

June 27, 2023

Justin Venneri

We continue Capital Rx’s Government Programs: Behind the Scenes with Jason Barretto series with Part 3, which focuses on customizations – the typical timeline and process – and pharmacy partner alignment and competitive dynamics.

Jason is our Vice President of Government Programs here, and he’s helped shape how Capital Rx ensures that clients are aware of and involved in each step of the process. I asked him about delivering final products that meet expectations and the intent that’s driving the customization, JUDI®’s flexibility and user-friendliness, as well as how long changes can and should take.

Related Government Programs Content

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

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

      JUDI® is a Tech-Enabler – A Case Study

Additionally, Jason notes that health plans no longer need to fear that their requests and hard work will come back to bite them in the form of competitive offerings from others in their region, potentially impacting their opportunities for growth. The following Q&A highlighting Jason’s answers to the questions is lightly edited for length and clarity.

Let’s dive into “customization” and how to avoid surprises and ensure that a final product meets the expectations of the health plan. Can you give an example of a situation where customization was necessary to meet specific needs?

The best example is the New York Medicaid Fee-For-Service carve out point of sale Reject 831, but we’ll have to cover that separately. What’s important here is to understand that a little bit of everything is required to ensure that there are no surprises and that final products meet expectations (and intent).  

It starts with communication. An open dialogue between the health plan and PBM is necessary because the health plan must be aware of what’s happening. Having an open, easy-to-use platform like JUDI® helps because real-time collaboration is important. We allow health plans to test the solution, especially when it comes to a new process adjustment or enhancement.  

Clients can see the functionality in JUDI and can make sure it works for them. If it’s a process change, we’ll walk them through it and ensure everyone is on the same page about how the process will work on a go-forward basis.

Can you walk me through the timeline or typical process to make a pharmacy program customization for a client?

What we’ll do is intake a change request, or whatever it is, that we need to find a solution for. We’ll look at our delegated responsibilities and whether it impacts us or the client. Through that defined process, we’ll determine whether systems/processes account for the change relatively quickly.

It’s kind of amazing. We’ve future-proofed some of our solutions. As changes have been requested or made – either regulatory or client requests - we have the capability to make the adjustments in a non-technical manner. It’s a “configuration adjustment,” and those are typically able to be made the same day or the next day. Or it might not require any changes because we already meet the intent completely. If it requires a new solution – IT or a process – we figure that out, communicate that, and ensure alignment.  

How often can we, with JUDI, meet the need immediately or within a couple of days?

I would say that about ⅔ of the items require less than a day’s worth of work. This is because the business model and JUDI are set up the right way. The Inflation Reduction Act is a good example. We had already implemented the guidance finalized at the end of 2022 for 2023. We didn’t need a grace period, as afforded to health plans by the federal government. We had future-proofed it through our processes and systems by building them as the requirements were being developed.  

Going back to the configuration and advantage we have with JUDI, we can make adjustments in a day. That’s why it’s important to build JUDI as a configuration-capable tool. We spend less time in the development world and more time bringing value to the customer.

PBM Partner Alignment & Competitive Dynamics

When we’re customizing and delivering solutions for clients, how important are alignment and competitive dynamics? When you were on the health plan side, how often did you feel like you were potentially helping your competition by asking a PBM partner to make a change or do something innovative for you?

Unfortunately, it was every time. Everyone says there are firewalls up at the integrated models, but as you start to think of ways to be innovative and try to execute those ideas, you quickly realize that the PBM partner that’s there to support you may be using you as a free consultative mechanism to build out capabilities that further enhance their revenue streams. They end up selling a product that you, the health plan, essentially co-designed. It happened almost every single time.  

We would end up with a new thing, and then another health plan would be doing it through the same PBM. That’s a very frustrating situation because you’re trying to gain a competitive advantage. It’s also frustrating when the PBM partner may have health plan assets in the same markets, and you see them mimicking your toolset, features, and capabilities.

Did that impact your willingness to be innovative or creative?

It made me pause. I wondered if I should use them, bring the request to a third party, or try to develop it in-house. And therein likes another challenge. A lot of the agreements will have exclusivity rights within them that may limit a health plan’s ability to do something with someone else.  

As an aside, but it does relate to alignment, our template contract is 40 pages. The last one I saw before joining Capital Rx was over 1,000 pages. It was a challenge to evaluate and maintain an agreement of that size.  

When you’re talking to health plan executives now, what resonates most about not owning competing assets?

I think health plans generally understand how Capital Rx’s model is currently different. But regarding dispensing assets, clinical programs, and other strategies, we’re trying to enable them.

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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