AH037 - The Story of a Claim: Redefining the Benefit Experience, with Kevin Sundquist

Transcript

Lightly edited for clarity, sources linked at the end.

[00:27] Justin Venneri: Hello and thank you for listening to this episode of the Astonishing Healthcare podcast. I'm Justin Venneri, your host and Director of Communications at Capital Rx. And joining me in the studio today is our Vice President of Product, Kevin Sundquist. Some of you may recognize his name or the title of this episode if you watched our webinar about the story of a claim that Kevin moderated earlier this year and that got really great feedback. I'll link that in the show notes. So, we figured we'd go over things again and ask a couple of incremental questions. Kevin, thanks for joining me today.

[00:56] Kevin Sundquist: Hey, excited to be here.

[00:58] Justin Venneri: So, for those that may not have seen it, that may not know you, give us a little bit about your background, please. What was your path to Capital Rx like and how'd you end up in product development here?

[01:07] Kevin Sundquist: Yeah, I started out doing statistics. My goal in life was actually to become an actuary. That was kind of a dream of mine. And as I went through my coursework in undergrad, I actually became really excited about clinical trials. So, I eventually went to grad school and did perspective research and kind of did a work study, you know -- really focused on the analysis and evaluation of drug efficacy. Then when I got my first job out of college, I actually worked at Optum doing prospective research using pharmacy medical claims, EHR, information. Really just trying to understand the marketplace and the effectiveness of drugs that are actually being prescribed and like, you know, post approval. How are they working? How much should they cost? You know, and what's the ROI on? If a member is taking a drug, how much are we reducing the overall costs for that patient?  

So, in 2019, I got offered to come to Capital Rx and do analyses for our clients. Right, so where's your trend? What types of drugs are members taking? Who are the top utilizers? And as we built out JUDI, I found myself consistently building products to help myself answer questions right, like taking data out of JUDI, running test claims, building conversion code using R and Python. And one day, our Head of Product at the time said, well, why don't you just build products in JUDI for us?  

Eventually, I joined the product team as a senior product manager and worked on various different parts of JUDI, as we've either built them out or maintained them. From plan management, where you select co-pays, network accumulations, to the actual network, like when people talk about the price of a drug, literally within JUDI, I help build our products that priced at NADAC, or at a unit price, or at a specialty list cost.

So, you know, working on that and then actually building out our first iteration of our formulary management tool really got me thinking about how can we holistically attack and modernize the story of a claim, right, once it comes into our system? So, within JUDI, I've worked on almost every module. So, once I took over the department, how do we take that holistic story and make sure that we're building our products towards either, you know, making part of that more efficient or more transparent for our clients and even our own staff? Because everything we build is for our employees as well as our customers.

[03:32] Justin Venneri: Yeah, I think that's an interesting point, because a lot of the functionality is things we needed to actually manage or administer the benefit more easily, efficiently for the clients. Right?

[03:43] Kevin Sundquist: Yeah, absolutely. I mean, some of the best ideas come not from the product managers, right? Sometimes they come from our coworkers. It comes from social events, it comes from meetings, it comes from new client requests, right? So, one of the really powerful parts about product at Capital Rx is that we have a constant feedback loop of coworkers, clients, consultants that are giving us ideas to make our products better, not only operationally, but to make our offering more attractive to potential clients, because when they win, we win. It's kind of like this constant day of, we are trying to reduce costs. We make $5 on a drug that costs $1,000. It's really about trying to make sure that we are not incentivized to make money on increasing costs of medications. We're incentivized to make that process as efficient and transparent as possible.

[04:32] Justin Venneri: Makes sense. So that process, all the modules in JUDI that make this happen, I get a prescription from the doctor, I've got to go get an inhaler, or I got to go get amoxicillin for my kid. They're my dependent. They're on the plan. Talk me through what happens when that prescription goes to the pharmacy. I'm trying to go pick it up. What starts off the journey or the story of a claim, really?

[04:53] Kevin Sundquist: When you go to the doctor and they prescribe you medication, they send it typically through prescription technology these days that send it right to the pharmacy. And you go, and the pharmacist actually gets that medication. And typically, before you even get there. I mean, back in the day, they give you a piece of paper, right? And you go, and they'd run it through the insurance. But nowadays it's all electronically transferred. And they say, okay, this is who it's for. This is for this drug at this pharmacy with this information, right? So, we then, as the plan administrator or the PBM will take that information, say, okay, this is this member. So Jane Doe is part of this employer that has this benefit, and then that benefit has, okay, this network. So, the pharmacy is part of a network, right? So that decides how a drug is priced. And then once it goes through this pharmacy for this member, it goes, what drug is it? Right. So, okay, is this amoxicillin? Is this Humira, is this Dilara? Like, what drug is this, actually? And then based on that, we decide co-pays or if it's included in the benefit.  

So one thing you'll notice is that as we talk about benefit design, it's really important for plans and consultants to understand is that even though we're talking about network as part of a claim story and formulary as part of a claim story and co-pays. And like, all of that in JUDI is decided at the benefit level. So, when you're building and crafting your benefits for your members, remember that their story is affected by your choices. If you choose to exclude something, that means someone might go to the pharmacy not knowing that the drug that their doctor prescribed them is excluded, for better or for worse. And just understanding that these decisions impact how that claim ends up being filled with always the understanding that there are circumstances that can override that. One claim could pay for a member one way, but depending on if they've gone through a prior authorization process, if they've gotten an override or anything along those lines, it can change.  

And that's one of the hallmarks of JUDI, in our platform, is that we've made it as efficient as possible and simple as possible to effectuate what we want that claim to be. So when Kristin Begley, our Chief Commercial Officer, talks about “N of One benefits”, that's really what she's talking about, is you can design a generalized benefit, but with the efficiency and the ease of use of JUDI.  

We can really customize it per member so that the story of a claim doesn't have to be the same for everybody, even though there are some hallmarks that it goes through. And then obviously, there's the ever-growing history for that member. We talk about accumulations. One claim that cost $10 is not going to affect your accumulations as much as, let's say you fill a $1,000 drug every month. So then mid-year, your story of that claim, how much it costs, might exactly change. So, you know, thinking about these different things when building your benefits, when explaining to your members what your goals are really is important.

[07:53] Justin Venneri: And these things happen like in milliseconds, right? The information's being exchanged in a way that allows the member to know, or the pharmacist or the pharmacy tech at the counter to say, hey, like here's your co-pay, here's how much this drug is going to cost you out of pocket right now. And the patient's like, cool. That makes sense to me because I know what my benefit is. I pay for it, and I walk out. What are some of the things that can happen to a member where maybe there's a reason for a rejection or something else?

[08:21] Kevin Sundquist: No, I think there's a lot of things that can really, like -- there are over 2,000 different NCPDP rejects for a reason, right? There are many different things that could happen. And whether they're nefarious or by a mistake or plan design, a member goes in, they fill their medication, and then the pharmacy tries to refill the medication, right? And they refill it a little bit too soon. We have rejections for that. And that's not any fault of the members. Sometimes it's just a matter of a day or two days. So not every rejection is meant to be harmful. There are rejections like opioid safety edits or other types of things that really can affect the claim.  

Now, you know, when we talk about network, what pharmacies are you allowed to pay? Now, different providers of these benefits have different network collections. So, if you switch from one vendor to another, your pharmacy may no longer be in network or you'll have a different price. And there's just all these different parts about a claim that could change depending on the benefit or any sort of changes. If you move from a traditional plan one year to a PPO plan, there's just all these different things that could change. And, you know, not all of that -- they're meant to either conserve costs.  

So, if you have a specific network and your plan has changed to that, that's meant because they got a lower price somewhere else. And we're trying to save money for you, even though it may inconvenience you at one time. We have to think about if you get a medication every month and let's say it's over the mail. Yes, one time change your mail vendor is frustrating, but if you think about the macro change in price over the years that you may fill that script, we're doing it for a purpose, to save you and your plan, typically quite a lot of money.

[10:03] Justin Venneri: Got it. You mentioned prior authorization. What happens when prior authorization is required? And we have a great podcast episode on this with Sara Izadi, our Chief Clinical Officer, and Lori Shaw, our Director of Prior Authorization, and Callie on your team, who was talking about some of the things you're doing in the background to improve that process. How do we try to minimize delays and denials there?

Related Content

• Replay – The Future of Pharmacy Claims Processing: A Deep Dive into a Modern Adjudication System
• Pharmacy Benefits 101: Prior Authorizations
• How Our Favorite New JUDI Features Aid Pharmacy Benefit Administration

[10:27] Kevin Sundquist: Yeah, no, Callie could host her own podcast, along with, obviously, the wonderful Sara and Lorece. I've learned a lot about prior authorization as like, how do we reduce barriers to care? And that's really what we try and do here at Capital Rx and that any responsible fiduciary should be doing.

If a member needs a medication, it's okay to check to make sure that that's valid, but we shouldn't be doing it overly. We should be trying to minimize the effect to the member. And one of the things that we do when we built our own prior authorization tool is try to mimic that experience and solve for all of the different things that could happen. Now, let's say back to the network example. A member goes and they try and fill Humira, a classically paid medication. They get a 75 reject, which is required prior authorization. And let's say they get a 4W reject, which means that they're not filling it at the exclusive specialty provider. Now, if we didn't do that and we said, hey, you tried to fill this medication, we're going to give you a prioritization override. And then they go and they try and fill it after being told they can, and then they have to switch the pharmacy. Why don't we do both of those at once? Why don't we make sure that the member has as least inconvenience as possible? So, let's not only facilitate the approval of that medication, let's also facilitate the transfer of that drug to the appropriate mail provider. Or, you know, drive them out of the retail setting where they may be getting a much more expensive cost, right?  

So, we integrate things like costs. We integrate things like step therapy, quantity limits, right? So, if they go to the pharmacy and they're also not approved for that quantity, they're not starting the process all over. We try and do as few reviews as possible for the same member, for the same medication. We want to do a one and done approach, I mean, from all that we do here, right. We don't want you having to call us twice, whether it's about a PA or whether it's about a claim. We want to be able to answer all of those questions in one interaction, not only for the efficiency of our company, but for you. We don't want to waste your time.

[12:32] Justin Venneri: When you talk about benefit design and making selections and setting up the criteria or the requirements or on prior authorization or the formulary, what helps set things up the quote unquote right way, in your opinion, so that the path from prescription pad to paying at the pharmacy counter is smoothest.

[12:53] Kevin Sundquist: I think there's a few things even upstream, right? I mean, if we could get rid of fax machines, that would be fantastic, right?

[12:59] Justin Venneri: No such luck.

[13:00] Kevin Sundquist: Yeah, that's a really exciting space in AI. Like, who's this fax for? Trying to answer that type of question, which we've integrated within our tools today. I think 60% of our faxes are automatically identified using AI, which is like a very exciting milestone for our team. And then trying to set up criteria to even push the pedal to the metal there. To try and auto approve cases so that when you're creating criteria, what do we know about these members? So the plan sends us an eligibility file and they have information about that member that we might not be privy to. If they tell us that or provide that information, not only can we set up criteria so that we can check information or send the doctor via EPA a specific questionnaire set, we could also leverage that information to auto PA.  

The case -- I mean, previously when we talked about barriers to care -- auto PA basically makes it seem like there are very few of these cases can get approved and moved along. And also auto denials. If a medication is going to be denied, we should let the member know as soon as possible. I don't love to talk about denying medication, but would you rather know if you're going to get denied medication quicker so you can call your plan or you can try and understand and work out a care plan with your doctor? I think that when we try and make these cases and the criteria around them, we need to make sure that we're doing it in a way that can be hopefully as automated as possible.  

I mean, one thing that's really interesting is taking note information from the HR system and trying to find if we know a member’s AIC level or their weight or their BMI, so that we can, you know, weight loss, obviously, or that one's coming from. So, I think that there are lots of things that we can do when thinking and being thoughtful about our criteria and our requirements. And back to the benefit design. Let's let these drugs go through PA. Let's not just exclude them from a benefit. Maybe we have them go through a review and make sure that they're appropriate instead of just like excluding them off the bat.

[15:01] Justin Venneri: So you mentioned your work on drug prices and NADAC. What are some unique things about the NADAC network compared to other options?

[15:08] Kevin Sundquist: I think that at the end of the day, I'm all for lower prices and so is Capital Rx. And I think competition breeds there. If you're looking at a list, it's like shopping at Macy's today, right? You go into Macy's and your blanket costs $200, but it's on a 50% discount. And if you get that blanket for $200, you don't understand how the pricing works. And today, there is no transparency about that. You don't even know what something's on discount, what you're paying.  

So, I am open for any pricing source. Whether you want to use WAC, whether you want to use NADAC. I just would like drugs to cost less in America. I want less people to be worried about if they're going to be able to pay for medication and be more worried about getting better. We need to be and strive for a healthier population that's focused on the value that our medication and our, you know, treatments are providing. Not specifically how much a plan is spending or, you know, trying to control trends. The trend should be, how healthy our populations. So, you know, whether you want to work with Mark Cuban or, you know, any other pricing source out there, I'm all for it, but I want there to be competition. I want to be very clear that I have five pricing sources and I want to get the lowest. I don't ever want the highest. I just want to make sure that the members are being advantaged by deflation, especially in generics. So that's my take on pricing.

[16:28] Justin Venneri: Cool. And then you alluded to this a couple of times already. I'll just call it clarity. Clarity around prices and competition around prices. Communication. Clear communication around what's happening. How does modern technology and the way the system and information are processed and presented to different stakeholders, whether it be our rep or the pharmacist at the pharmacy, how does that help with the whole process of letting the member know, aiding them and getting their medication, etc.?

[16:56] Kevin Sundquist: Yeah, absolutely. I mean, I think an untapped area or a place that we try and leverage messaging as much as possible is not only internally, so that when someone calls in or someone's researching a claim, they understand, but also referencing like point of sale messaging, RPOs messaging for a refill too soon is, hey, you filled it on this date. The next available date is x, y, or z. So leveraging our technology, because we can customize all of that, we can add messages to the pharmacist, we can add messages just for internal, we can add what we call a program stamp to claims and then being able to take the information and contextualize it. This person filled this claim at this point in their accumulations. At this point in the year, if someone calls in on January 5 and they're like, my drug costs this dollar amount last month, you're not discovering like, oh, what happened? Where did the accumulate? Oh, it's a new year, right? Your plan accumulations reset every year.  

So, back to my earlier point, we want to solve a member's question as soon as possible. And not only does that make it more efficient for them, it makes it more efficient for us. So, whether it's using our reasons for adjudication -- reasons for rejection, I mean -- I said earlier in the call, there are thousands of reject codes, right? There are hundreds of different NCPDP input fields, whether it's submission, clarification code, and other coverage code, a DAW code, right? So, all these different things effectuate how a claim pays. And using that information, instead of something having to go and find it, is really at the heart of what we're trying to build within our systems. So that we can really give a clear answer to the member, and even tell them what they need to change. Like, hey, your prescriber is submitting this as a DAW 2. Your plan doesn't cover that. So you need to go back and have them switch the medication. If they really think you need to fill the brand, they need to switch the DAW code -- “Dispensed As Written” is DAW, where the doctor is saying that they need the brand as opposed to the generic.  

So I think that our goal here is really, again, to make sure that we are servicing our members to the best of our ability while also maintaining our duty to uphold the spirit of what benefit has been built. Back to the whole point of, you know, at least my goal in doing our original, you know, webinar is just informing people that the decisions they make down to networks, inclusion, exclusions, PA, like, all of this effectuates how a member's experience is at the point of sale and the story of the claim, or the potentially thousands of claims, depending on the size of the employer.

[19:35] Justin Venneri: All right, I ask everyone this. I'm going to ask it of you in a little bit different way, just because we could totally geek out on this. Or you probably have some crazy stories based on all the data you've seen, what is relating to our discussion here, and the story of a claim or the journey of a claim. What's the most interesting or astonishing thing you've seen and what are you most excited about in terms of what's next? When we think about combining claims, whether it's medical and pharmacy and other, I'm going to ask you to bust out your crystal ball. What do you think the most exciting thing about the future is?

[20:07] Kevin Sundquist: I think I'll start with one of the most amazing things that I've seen working at Capital Rx and in the industry, I have just seen this idea of a couple of guys in a WeWork turning into a large company that's actually playing on the main stage. I'm hearing the same sound bites from people across the country that I feel like AJ and Ryan have been talking about for years. And it's really just been something that has been so awesome to be a part of and be building the technology and be on the forefront with my colleagues on really bringing about this change and showing that it can be done. There's hope for that, right. And really putting our money where our mouth is and continuing to double down.  

In this vision, you kind of said, what do I see in my crystal ball? I mean, I see a unified health plan on a modern system that allows someone to actually tell the story, the journey, the epic, the saga, of a clinic, because it goes back to that person at the doctor's office who does the right thing. I said at the beginning, it really starts with someone making the public health positive choice to go to the doctor or go to their physical. I want to know more of that information and drive these efficiencies. And that is where we're going. We are going all the way to at the top, which is where does that physician and member interaction start? That lead to a prescription, that lead to fills, that lead to, hopefully that member getting better over time.  

I mean, back in my days at Optum, I was all excited about this idea of taking the information from these claims and being able to enact change. Well, now when we move into unified claims processing and we can make actionable insights on that and help plans to -- and employers -- get to healthier populations.

[21:59] Justin Venneri: I think everybody's really excited to see if the ROI is there. Like if you have all the data with your background, you'd be sitting there like a kid in a candy store going, oh wow, like, okay, now I can see what happened here. There was adherence, the member got better, they didn't go back to the doctor, there weren't more claims. Right? That's kind of what we want to get to.

[22:20] Kevin Sundquist: Yeah. And I mean, I'm not going to sit here and say that other people aren't doing that, but I mean, I think the one thing that's different about what we're trying to do here, not to get on the selling point of this, but for us, ROI is tied to administering a benefit. So, if we move into a space where we're incentivized to make sure you go to the doctor, we're making sure that members are getting better, we're driving to properly priced medications. It's more like trying to use this to continue to add to our tool belt of things that we can deliver on. And obviously, I mean, we believe in that and are, you know, consistently doubling down on our efforts to not only just do that, but built the technology to do it right. I think that's what really differentiates us. And what I find exciting, obviously being on the delivery of that technology side, is that we're not stopping at any one point. We are continuing to move on and make big bets.

[23:12] Justin Venneri: Well, that's awesome Kevin, thanks so much for spending time with me today. I definitely look forward to having you back on the show and seeing kind of where we're at at a future point in time.

[23:22] Kevin Sundquist: Yeah, it was awesome. Thanks for having me.

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