AH026 - The Power of APIs in Healthcare, with Alfonso Martinez

Transcript

Lightly edited for clarity.

[00:27] Justin Venneri: Hello and thank you for joining us for this episode of the Astonishing Healthcare podcast. I'm Justin Venneri, your host and Director of Communications at Capital Rx, and today I've got the pleasure of having one of our directors on the product team, Alfonso Martinez, in the studio for what I think will be one of the more interesting, informative, and hopefully entertaining discussions about technology, specifically APIs or application programming interfaces and pharmacy benefit administration that you'll ever hear. So, Alfonso, thanks for joining me today.

[00:54] Alfonso Martinez: Hey Justin, thank you for having me.

[00:57] Justin Venneri: So, you helped us out on the marketing team with some content a while back. It was a blog that I'll link in the show notes about modern tech and APIs (Capital Rx’s JUDI® - The Beauty of an Open Platform), and I think we've got some updated examples. But maybe let's start off at a high level quickly. And forgive me, but I want to take a minute to just share a little bit about your background and path to Capital Rx and maybe a little bit more about your role here beyond your title.

[01:18] Alfonso Martinez: Sure thing. So, I've been in the healthcare space for over a decade now, and I've had the privilege of working with technology companies and the provider, or the healthcare delivery side, and the consumer, or the patient side. And now, over the last three and a half years, I've been in the payer, or the benefit, side, specifically the pharmacy benefits. And my role here at Capital Rx is Director of Product as part of the product management team. And what we do is we take the needs from our clients or from the market, and we partner with our engineering team to develop technology that supports those needs. That's product management, sort of in a nutshell.

[02:03] Justin Venneri: Got it. And like I said, we'll start super high level. What exactly are APIs?

[02:08] Alfonso Martinez: An API, or as you mentioned, an application programming interface, is a tool that allows different software applications to communicate with each other, essentially.  

So, think of it as a waiter in a restaurant. When you go to a restaurant, you tell the waiter what you want. The waiter goes to the kitchen to relay your order. The chefs then prepare your meal and give it to the waiter who brings it back to you.  

Similarly, in the digital world, when one application needs to access data or functionality from another application, it sends a payload request via the API. The API then communicates with the other application to get the necessary information or to perform the required action, and then it brings back that result to that initial application, or that first application.

[03:05] Justin Venneri: Okay, that makes sense. And then what are APIs used for?

[03:09] Alfonso Martinez: APIs can be used for many different things. Anything from accessing and sharing data real time, to integrating applications or functionality across applications, to automating tasks, enhancing a user experience, processing payments, authenticating and authorizing users into other applications. Or, generally, they could be used for extending a platform's capabilities with other platforms capabilities.

[03:38] Justin Venneri: Got it. And part of the reason for the discussion today, and in general, is the move to more modern systems in the healthcare industry. Is it fair to say that most Medicare, Medicaid and commercial health plans today rely on closed systems?

[03:54] Alfonso Martinez: Oh yes. Yeah, this is sadly the case and the current state of our industry.

[04:00] Justin Venneri: And now I'm not going to go over the top here -- we're not going to go over the top here -- with JUDI stuff our enterprise health platform, I promise. But I do want to talk about why having a modern tech stack is important. So we're going to try and talk about this in just as helpful, educational, not salesy way as is possible. We've got well over 150 APIs available for everything from what to what? And why is that important?

[04:23] Alfonso Martinez: One thing to note is that it's relatively easy to develop and manage new API endpoints, which are very helpful for plan sponsors or any user of a platform like JUDI, because they have ever-changing reporting requirements. They have the need to access and interact with member data and claims data, and they have the need to integrate the systems that they use with systems that adjudicate claims and do many other things. They need to integrate those vendors easily, and those vendors themselves change fairly often.  

So, if you're running a health plan, you don't want to be sort of boxed in, you want the flexibility.  

[05:04] Justin Venneri: Okay, can you provide just some examples or use cases that may resonate with our listeners?

[05:10] Alfonso Martinez: Yes, 100%. So, bringing this home a little to the world of pharmacy benefits and the world of healthcare benefits, you can think of using APIs for many different use cases.  

So, imagine a world where you can empower your team, your staff, to take action at the right time. Imagine a world where maybe a team of nurses could engage with members right after the member has picked up a drug at the pharmacy. You can do this through API-based integrations. And specifically, we support real-time claims integrations. And we support API integrations that you can tackle along with our real time claims integration that can allow you to make that type of workflow a reality.  

Or imagine that you want members to know how much they would pay for a drug before they pick up this drug. This is functionality that Capital Rx exposes through our member portal, but you can expose this directly through any member experience that you already support. You can do that through drug pricing API endpoints.  

Or imagine you want to automate some workflows. Like, for example, you could take action when a specific reject code is triggered -- when a member looks to pick up a drug, that drug is rejected for one of many reasons. You could programmatically create workflows that trigger an action based on that particular piece of information that's triggered at the pharmacy. You receive it immediately. And then you can do things. You can trigger things like send a timely notification to the pharmacist or to a prescriber, for example. Or have your team make an outbound call to the member. You can do all that with the power of APIs.  

You can also think about not only reacting to information that happens that you can retrieve from systems like JUDI, but you can also edit information. For example, you could enable your team to programmatically create authorizations or overrides to allow for members to access the right medications at the right time. You can also imagine a world where you enhance any member experiences that you might have invested in. You can allow for those member experiences to pull data and put that data directly in the hands of those members. And again, we do have functionality available at Capital Rx that allows for members to access this data directly. But some of our clients, some of our plan sponsors, have invested deeply in specific experiences that they simply want to complement. And maybe they don't want to direct the member to the member portal that I love, but maybe the plan sponsor is not interested in directing that member to the member portal, but rather is interested in showing pharmacy claims data, or showing some of the functionality that JUDI has directly.

[08:11] Justin Venneri: Like on reporting, or like on an app, or like to anybody, basically?

[08:16] Alfonso Martinez: Right. So, on an app, for example, would be the examples that's coming to mind now. Like if you have developed a really cool app for members in a specific niche and you're just interested in pulling some pharmacy information in it, APIs can allow you to do that. And open systems like JUDI make it really easy for you to do that.  

Thinking here about other use cases that come to mind that I know our plan sponsors put in place, you can think of things like supporting your own programs, like setting up your own discount card, for example, if you happen to have temp workers. Or maybe you have your own tools internally that you've either developed internally or that you have adopted from vendors, and that you're not interested in transitioning out of your organization using Capital Rx and a platform like JUDI allow you to integrate those tools very easily.  

Or, just very recently, we've enabled, through the form of APIs payment processing, we've partnered with an industry leading payment processor that is known -- in this particular example -- for their beautifully written and well supported APIs. And because of the ease of access to their APIs and the open nature of JUDI, we were able to partner with them very quickly and develop a solution for the new Medicare Prescription Payment Plan (M3P). And we've brought that solution to market very quickly, and we're very excited about it. And this is a fantastic sort of example of how an API first organization can move very quickly to support the drastically changing needs for plan sponsors, in this case for the Medicare Part D plan sponsors.  

So, I think, in short, APIs allow you to create your own path, your own experience, and allow you to open up your imagination to workflows that historically have been very challenging to support.

[10:23] Justin Venneri: Those are some great examples, Alfonso. So, I've got a slight pivot for you, though. We hear a lot about getting to a value-based world, the potential for providing value-based care and the benefits of that. And I think one thing that comes up almost every time I ask someone about it, or the topic arises, is the need to integrate data, to break down silos, to pull data and vendors together, to be able to do that and deliver that level of care. Is that something APIs can help with?

Related Content on Value-Based Care

• AH007 - There’s No Value-Based Care Without Considering Pharmacy, with Sunil Budhrani, MD
• AH009 - Modern Technology in Healthcare: Enhancing Efficiency & Security, with Ryan Kelly

[10:50] Alfonso Martinez: Certainly APIs, I think, are instrumental in enabling that or making that a reality, and you can think of it as going in both ways. So, to sort of build and expand on some of the examples that I just walked through, using APIs, a health plan can use their own tool or tools and integrate those with our system or any other sort of API-based system and enable the workflows that they need using the data from the systems that they need to be referencing all real-time.  

For example, you can think of maybe some digital health solutions and some virtual care providers that help members manage their chronic conditions. They can integrate with systems like JUDI, using API, so that they can pull data real-time to engage with those patients the right way at the right time.  

And I do want to say though, that when it comes to data integrations and data sharing for larger use cases like value-based care, we can integrate and exchange data in a number of ways, APIs being one of them. And the way I think of these integrations is as them being leveraging different integration methodologies for different use cases. So, for example, in the world of value based care, there's a lot of analytics needed. The data that you need shared for purposes of large scale analytics doesn't necessarily need to be shared in the form of API transactions. You can integrate data from a variety of sources and in a variety of ways, not only using API, but also via larger data exchanges and integrations of data warehouses.

[12:42] Justin Venneri: So, it really just comes down to having an open, flexible platform? Is there a potential for JUDI to be a quote, unquote hub for plan sponsors, given everything we're discussing here?

[12:53] Alfonso Martinez: Well, in a way, JUDI already is a hub for plan sponsors. It already is a hub for pharmacy benefits. And you can imagine, as JUDI’s functionality continues to increase, continues to develop, JUDI becomes more and more central to the management of benefits for plan sponsors. And we're accelerating very quickly in terms of developing improved workflows that deliver the infrastructure that our industry needs to be able to operate at the efficiency that we should be operating.

[13:28] Justin Venneri: Okay, great. All right. And well, here we are at the last question that I ask everybody. What's the most astonishing thing you've seen APIs do? Perhaps given the context of our discussion, or the most astonishing thing you can share? Tell us a good story, maybe something you've seen somebody try. You can take it from here.

[13:45] Alfonso Martinez: So, I think that the most astonishing thing I've seen at Capital Rx, at least in my years here, has been seeing our CTO, Ryan Kelly, work in an annoyingly impressive way. This individual, for those who haven't met him, will answer complex questions about pharmacy benefits. On one company forum we use slack. So, imagine a slack channel with many, many members and many users, answers very complex questions, and at the same time answers very technical questions about our code base on another forum, and at the same time responds to team-related comments of Joe coast nature on other forms, all in a span of three minutes. It is annoying but it is impressive.

[14:31] Justin Venneri: It’s almost like there's two or three of him at once. It has to be seen.

[14:35] Alfonso Martinez: It has to be. I'm convinced.

[14:38] Justin Venneri: I've seen it. I've seen it.

[14:39] Alfonso Martinez: It is incredible. Well, on a more serious note, the most astonishing thing I've seen related to APIs while my time here at Capital Rx has been our ability to generate API keys for actual use -- for both test as well as production, or use in the production or real environment, in the matter of minutes. Big props to our development team that implemented this functionality. But in a matter of three minutes, I can partner with a vendor. I can generate the API public and private key that that vendor needs to access JUDI. I can set up the appropriate permissions that that API key needs to have, and I can share those in a secure fashion with that vendor, or that third party, or that client, and they can immediately start to support their workflows.

[15:37] Justin Venneri: Sometimes you go a little over my head, but I think overall, Alfonso, it was great to have you on the show today and you explained things in an astonishingly straightforward way. So, I appreciate that, and I hope to have you back on again. Thanks for taking the time.

[15:49] Alfonso Martinez: Awesome, thank you.

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