AH039 - Transition Benefits and the Relationship Between Communications and Product Management

Transcript

Lightly edited for clarity; this episode complements Medicare Transition Benefits & How JUDI’s Modern Design Enables Faster Results and Reliable Compliance (9/2024).

[00:27] Justin Venneri: Hello and thank you for joining us for this episode of the Astonishing Healthcare podcast. This is Justin Venneri, your host and Director of Communications at Capital Rx. And today we're going to be covering a topic, Medicare transition benefits, that is pretty unique and pretty specific, but I think it provides a good window into what goes on here at Capital Rx to make sure that we can provide a good benefits experience to members. With me in the studio, I have Samantha Custer, who is our Director of Customer Experience, and Product Manager Jake Mulkey, who work together to make this happen. Sam and Jake, thanks for joining me today.

[01:02] Jake Mulkey: Thanks for having us.

[01:03] Justin Venneri: Sam, I'll start with you. Why don't you give us a quick background. What was your path to Capital Rx like? And tell us a little bit about your role.

[01:10] Samantha Custer: Yeah, thank you. So, I have been with Capital Rx for four years now, and just before this I spent twelve years with Elixir, or as others may know as Envision Rx, in many roles. So, I really grew my career working my way around PBM roles, just trying to understand the total depth of everything I did so that I could, in my next role, do more or understand more.

My role here at Capital Rx is I oversee the team who manages all member facing communications and any coordinating communications to our prescriber or network constituent groups. My thought is basically if it involves a member, it comes through our queue, and we make sure that the experience and everything that ties to that experience is flawless.

[01:56] Justin Venneri: Okay, Sam, thanks for that. And Jake, how about you?

[01:59] Jake Mulkey: Yeah, so my name is Jake Mulkey. I'm a Product Manager here at Capital Rx. I've been here about two and a half years. I got my start actually in Columbus here about six years ago, working for CoverMyMeds in the access and adherence space, working with members, making sure that they had access to medications and really wanted to move more into the tech side. So, check out Capital Rx. And I've been here, I'd say, for two and a half years, starting on our data exchange team, working with claims eligibility accumulations exchanges, and then now working more closely with our core adjudication product and the actual adjudication of pharmacy claims.

[02:32] Justin Venneri: Okay. As I mentioned in the opening this is sort of a niche topic. What exactly are transition benefits? Who made up their requirements? What purpose do they serve?

[02:41] Samantha Custer: So, Medicare transition benefits are essentially a temporary provision that helps enrollees or members to have continued access to their medications when they're not covered by their Medicare Part D prescription drug plan or their Medicare Advantage plan.  

So, say an enrollee who switches plans, or they're new to Medicare entirely and they need to fill a medication, but it's not on formulary. Transition benefits will provide them a temporary supply of their medication to give them additional time to talk to their doctor about alternatives or what next steps they may have to take. CMS, which is the Centers for Medicare and Medicaid Services, are the entity that established transition benefits way back in 2006. So, this is at the same time when the Medicare Part D prescription drug plan first launched, and their intent was to help people smoothly transition into plans without abruptly losing access to medication. So it was an effort to try and make the member experience better.

[03:41] Justin Venneri: That makes sense. What are some of the consequences of not, quote unquote, doing this? Right?

[03:46] Samantha Custer: Yeah. Oh, gosh. There are a lot of risks. So, if transition benefits are not managed properly, I mean, the first risk is to the enrollees or to your membership. If an enrollee can't access their medication, it could lead to gaps in care and ultimately have those negative outcomes, which could be health complications, hospital visits, and such. So that, to me, is probably the largest risk, in my opinion.  

But then also tying back to an enrollee or to a member, if their transition benefit isn't working as they expect, it could lead to them expressing their dissatisfaction by filing complaints and grievances against the plan sponsor, which is bad for them. It could impact their reputation. And then there's serious compliance risks. Being that this is managed and required by CMS, they perform audits and if the plan doesn't have their transition benefit program in place as it's required, it could lead to regulatory action with fines and sanctions against the plan. So that in itself is also super risky.

[04:48] Justin Venneri: And I remember talking with Jay Tran, PharmD, on our team back for episode five about Medicare Star Ratings. Is this one of the areas where it could have a negative impact because of the customer experience in those surveys?

[04:58] Samantha Custer: Absolutely. So, if members are filing grievances and CMS is issuing sanctions, that absolutely can impact the Stars rating.

Related Content

• AH005 - Star Ratings, MTM, & CMS Translation Requirements with Jay Tran, PharmD
• Pharmacy Benefits 101: Medicare Star Ratings‍
• How Our Favorite New JUDI® Features Aid Pharmacy Benefit Administration
• How Our Favorite New JUDI® Features Aid Government Programs

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[05:07] Justin Venneri: Got it. And Jake, the technology that helps here within JUDI, I presume, can you just talk us through how this might work in a legacy system versus a modern system like JUDI, and how that makes a difference?

[05:21] Jake Mulkey: Yeah, I think the main thing here is to remember that with legacy benefits and legacy pharmacy benefit managers, they're often using multiple different software technologies, end to end, in these processes.  

So you may have one system, legacy adjudication software, actually doing the claims processing unrelated to any of the reporting and data storage or data extraction tools that are necessary in order to fuel those letters that then go out in print proofs and get written off by Sam's team as a stamp of approval and then sent actually to those vendors. And so the beauty of JUDI really here is that rather than having to use maybe three or four different softwares -- you know, one for claims adjudication, one for the data connection and data exchange of that information with the print vendor, and one for the actual reporting software -- all of those are within JUDI and come from a very distinct piece of technology that we purposely built out in JUDI to make as seamless as possible with one another. And so, the flow there, really, we can very easily flag claims during adjudication that do qualify for transition benefits, have that stamp kind of be a very quick, easy, intelligible filter to use when we're running reports for transition letters, and then our actual reporting tool hooks up to external vendors seamlessly within our data exchange module. And so, it really is an end-to-end experience that, instead of having to leverage multiple different technologies and multiple different teams across the organization, you're talking with the team that owns that entire end to end workflow, right? That's the beauty of it's not something that you need a huge operational lift in order to the dots and to actually get transition benefits being compliant with CMS regulation.

[07:15] Justin Venneri: Very cool. Okay. It sounds like there's a lot of real-time activity here or real-time transactions. Is that just what it sounds like in this context?

[07:23] Jake Mulkey: Yeah, I mean, that's really true. That's fair. When we think about transition benefits, those claims are flagged in real time as they're being adjudicated. And the beauty of JUDI is when you're building adjudication processes, we’re able to build that into the actual adjudication of the claim. And so there's no post processing or post flagging of these claims. They are flagged on the way in as a transition claim that is, that has filled under transition benefit and made it extremely easy for us to then see that in real time and account for that when we're doing any sort of data reporting or extraction to our print vendor.

[08:01] Samantha Custer: And it's really important, too, that the timeliness of it is pointed out, because with transition benefits, there's notifications that are tied to it, that we have to send written notification and transmit notification to their prescribers within three business days. So, there isn't really the bandwidth to have anything happen past point of sale. It all has to happen very concurrent and very quickly.

[08:24] Justin Venneri: That makes sense. We often talk about how many vendors JUDI connects with, you know, 600+ that we push or pull data from. Do we have to connect with someone? You mentioned a print vendor here and then, and at the point of sale, that's obviously the pharmacy. So how does that process work within JUDI? Jake, do you want to take that first for sure?

[08:44] Jake Mulkey: So, you're absolutely right. JUDI is designed with those connections in mind, whether that be the actual pharmacy adjudication and the pharmacy software that then passes through the switch to adjudicate the claim, or if that's on the way out the door. Working with Sam's team to establish connectivity to any necessary print vendors, to see kind of the back end of that process through and like, say, our actual module within JUDI, our data exchange module is able to very seamlessly and without too much technical expertise, set up those connections and test those connections to ensure that we're able to exchange data, share data, ingest data as needed -- you know, our cadence is daily for those reports -- and really clearly see what is sent.  

We also will get response information back via API from those vendors, too. So, it's really clear, you know, on the way out the door, what have we sent, and have we gotten confirmation on mailing and what actual documents the member has in hand? So again, we can ensure that we're being compliant with some of those time windows that are mandated by CMS.

[09:49] Justin Venneri: Makes sense. And then I guess that all goes into the reporting.

[09:52] Jake Mulkey: Yep, exactly. The actual report that's pulled out of JUDI is just directly sent via an SFTP connection and sent over to our print vendor. Sam's team looks at the proofs, make sure everything falls in, and we do a certain level of QA on a daily basis as we're getting these programs up to speed and getting new clients onboarded. But after that time, it really is something that, you know, you can set it up, maybe do QA for a few days to make sure everything is looking good, proofs are coming out clean. But from that point on, it is really an automated process, and so there's very little interruption or any sort of manual work that has to be done around this transition process. After a client has been set up and after their claims have been flagged in real time at point of sale.

[10:34] Justin Venneri: And Sam, how easy is it once this is set up to make changes or to flex the messages or outreach?

[10:41] Samantha Custer: So, the messaging that goes to the member and the prescriber populations, it's all modeled. So, there's very little changes that actually occur from a plan sponsor perspective. But if CMS issues changes to any one part of the process, being that JUDI's modular and very flexible with how we can do things and with the systems that we have in place with our print partner, changes can be adhered to quickly and easily, and then we can quickly test them out and trust that once everything has been put in place and confirmed through a QA process, we can trust that we can put it back to automation very quickly so that we don't have to think about it and it just works in the background.

[11:18] Justin Venneri: A question for you on this. I always wonder how applicable things like this are for other groups. So I have two questions, and I'll start with you, Sam. You know, this is obviously a CMS requirement. It's designed for Part D. But I feel like on the commercial side, there's opportunities to help with transitions as well, whether it's continuation of therapy or other things. Is that similar and run on similar rails?

[11:40] Samantha Custer: Yes. So, transition benefits and continuation of therapy, they're very similar in their intent. They're operationalized a little bit differently just because continuation of therapy is more completed in a bulk setting and not done at point of sale. But we do actually have plans who leverage our transition benefit setup that we use for Medicare on the commercial side, which just proves that having a system that can handle these types of capabilities pays off because we were able to agree to those kinds of setup and work to deliver similar lettering and experience on a commercial benefit plan as we do Medicare.

[12:16] Justin Venneri: And Jake along those lines, thinking about other things that collaboration and modern technology can do. We've heard from several of our colleagues, whether Will Tafoya talking about the relationship between customer care and the product team, or our clinical side with Lorece and Sara with Callie describing how the clinical team works with the product team for prior authorizations. Can you just share your experience in just working back and forth with Sam from a product perspective and then just overall, any tips or things that you've learned over the years for a good relationship between product and another business unit?

[12:52] Jake Mulkey: Yeah, for sure. So, I think the one thing that is great and that I always love about working with Sam, right, is she super knowledgeable and always is very up to date with requirements and making sure that, like, kind of all the t's are crossed and the I's are dotted. And I think that really makes for a synergistic relationship with product and with the product management practice that we have at Capital Rx.  

We are a very fast-growing organization and being able to work with knowledgeable folks on the operations side who understand the products oftentimes just as well as the product managers do, really, really benefits the whole process end to end. And that really gives product managers the time and the ability to work cross collaboratively with other product teams, with other operational stakeholders to make sure that not only are we meeting the need, in this case for Sam and the print team, but also that we're meeting the need from an adjudication perspective and that we've worked with clinical to ensure, you know, right now we're in the process of working with the IRA changes for Part B transition for 2025. And so it gives us more brain space to not only have that solid foundation of knowing that the folks we're working with know their stuff and have that strong base of knowledge, but that we can leverage each other as we're continuing to get updates from CMS on or any new law or regulation that would come in that might influence how we work with other teams or collaborate with other teams here at Capital Rx.  

And so that's always my approach, right? If I'm working in product management and I hope to be for, you know, a while, I always want to see that not only are the folks I'm working with knowledgeable and passionate about the things that they're doing day in and day out, but that we're able to come together and really work for that minimum viable product to make sure that we're meeting the need not only of plan sponsors, but that we're doing so in a compliant way and in a timely way to really give everyone the sense that we're doing everything that we possibly can under the sun to impact member benefits and the ease that members have when their pharmacy benefit is administered by someone who's leveraging JUDI as that platform. So really, really excited. And it's awesome to be working on this product team and be working with people like Sam.

[15:06] Justin Venneri: Sam, anything you'd add from the quote unquote operation side of things when working with Product?

[15:10] Samantha Custer: You know, I completely agree with everything Jake said. So working with operational partners or product partners who understand the intent because they take the time to listen and truly understand the scope of work and are detail oriented, it's just so helpful because then it feels like what you're doing is you're always meeting in the middle and you're developing things that other people rely so greatly on us for. So having the expertise and the tool that will essentially drive all of this is imperative. And working with Jake and his team is. We always get that and more.

[15:45] Justin Venneri: Awesome. So, last question. Thank you both for taking the time to chat with me today. What's the most astonishing thing or surprising thing that you've seen that you can share relating to member comms or product? Sam, do you want to go first?

[15:58] Samantha Custer: Sure. Man. I'm not sure if I've seen anything -- I don't know if it's just this space I'm in, astonishing or surprising yet with communications. Or maybe I'm surprised a little every day and nothing really is shook me.

[16:10] Justin Venneri: Haha, that's interesting.

[16:11] Samantha Custer: I do think that the way that technology and AI are emerging rapidly, I suspect that there's going to be some things that are coming along the way that will drive new capabilities for how companies interact with their members and their care teams. And I think that's what's going to really wow me.

[16:28] Justin Venneri: All right, we'll keep an eye on AI. Jake, how about you?

[16:31] Jake Mulkey: No, I think for me, just the sheer magnitude of power that JUDI provides users. I think communications and the transition benefits use case is an example of that. You know, I'm also really close with adjudication and our benefits team and working with benefits build out and being able to see the growth we've had and how they're able to maintain the huge growth because of the ease of implementation of testing benefits, administering, setting up those benefits. I really give props to that team, but I think it also shows just how strong JUDI is and that we're able to continually grow exponentially because of the ease of use of JUDI, member comms and transition being an example of that.  

But really every team sees that and sees the impact that JUDI has. And I couldn't be more excited to see what we're going to be doing in the next year, two years, five years here, because I think it's just such an exciting time to be in this space.

[17:29] Justin Venneri: All right, well, thank you both for joining me in the studio today, and I look forward to staying in touch. And I'm sure there are going to be new regulations and new things that we have to accommodate from a communications perspective and a product perspective. So, there will definitely be more to talk about.

[17:43] Jake Mulkey: Always is.

[17:43] Samantha Custer: Thank you. Thanks for having us.

[17:44] Jake Mulkey: Thanks for having us.

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