The Astonishing Healthcare Podcast

Judi Health
  • 5.0 (16)
  • Medicine
  • Updated Weekly

If you’ve ever wondered what pharmacy benefit managers (PBMs) do, why the pharmaceutical supply chain is so complicated or the pace of change in healthcare seems so slow, how vendor purchasing decisions are made, or why our nation’s electronic claim administration infrastructure must be updated, Astonishing Healthcare by Judi Health (Capital Rx) is the podcast for you. Covering everything from niche and broad pharmacy and health benefit topics to regulatory change, disruptive technologies, and macro issues like the trend for drug prices or the total cost of care, we’ve got the information and insights you need. For show notes and additional resources from Judi Health, visit https://www.judi.health.

  1. 3d ago

    AH118 - Chemo, Cars, & Where Health Plan Savings May be Hiding, with Brian Cotter

    Most of the conversations out in the market about drug spend and inflated costs for employers focus on the pharmacy benefit and PBM relationship. But what about the medical side, where specialty drugs also live, and prices can be every bit as confounding? In this episode of Astonishing Healthcare, we welcomed Brian Cotter, founder of Bright Spot Insights, to the studio to help unpack the wild price variations that are hiding in plain sight. Brian shares a striking example: oxaliplatin (Eloxatin), a chemotherapy drug whose average sales price fell more than 99% after going generic, dropping from $2,053 to about $9.40 per dose. Yet there are hospitals listing a single treatment for anywhere from $8,000 to $10,000 - and even upwards of $30,000! He explains why this happens, how plan sponsors can spot it in their own claims data, and the practical steps to act on what they find. Along the way, he makes a compelling case for treating every data set as suspect until validated, and for why plan sponsors should question the assumptions that quietly drive costs. Episode Highlights Price variation is real, and it's astonishing: A drug can easily cost 100x more depending on the provider. Assumptions about biosimilars vs. reference drugs, and whether it's cheaper to process a specialty medication through the pharmacy vs. medical benefit, should be checked regularly.Plan sponsors MUST get their data and use it: Leverage the RFP process to set the terms, then assume it's incorrect until validated; benchmark drugs to Medicare when claims are thin; and pull in price transparency files to see what the market pays.Direct contracts with clear reimbursement terms can help: Use creative member engagement, such as arranging transportation to lower-cost, high-quality providers or infusion centers, to convert savings opportunities into actual savings.Data validation and AI - trust in your data is the foundation for everything: Almost every data set will be different, so data must be scrubbed and validated before using it. AI helps with heavy data engineering, but human review still matters, especially when a tool gets a little too "creative." Related Content How employers can take back control of unnecessary pharmacy spendingAH114 - How Employers Can Use Clinical Programs to Reduce Cost and Complexity, with Nash Albadarin, PharmDHow to obtain Rx data and what to do with itAH030 - Plan Sponsors Need a Source of Truth; Get Your Data Now & Find It, with Jeff HoganJudi Health™ Achieves FedRAMP® Ready Status, Enabling Multi-Market Growth Across Federal Healthcare Organizations Connect with Brian on LinkedIn or explore free tools at www.brightspotinsights.com. Head to the Insights section at Judi Health for show notes and related content, and be sure to subscribe so you don't miss the next episode!

  2. Sep 18

    AH117 - Star Ratings Changes in 2027 Plans Can't Ignore, with Angela Kalantarova and Jay Tran

    On this episode of Astonishing Healthcare, we welcome two pharmacists from Judi Health back to the show: Jay Tran, PharmD, VP of Clinical and Client Operations, and Angela Kalantarova, PharmD, Senior Clinical Program Manager. Together, they walk through what health plans and plan sponsors should expect for Medicare Star Ratings in 2027, including the measure changes that matter most. The conversation covers Medication Therapy Management (MTM) returning as a Stars measure with lower cost thresholds and new core disease states, from Alzheimer's to arthritis, which roughly doubled the number of eligible members year over year for Judi Rx™. We also cover the SUPD denominator exception and the removal of the Medicare Plan Finder measure, and then Jay and Angela also look ahead to the proposed IOP-LD opioid measure and share real-world results from Judi Rx's Level 2 adherence pilot. Finally, they explain how intervention strategies differ across Medicare and commercial populations, and why consistent, data-driven execution moves the needle. Highlights MTM is back for 2027: After two years on display, medication therapy management (MTM) returns as a Stars measure. Eligibility expansion (new disease states, a lower cost threshold, and drug count criteria) is expected to drive a three- to four-fold increase in eligible members industry-wide.Star measure updates to track: A new denominator exception recognizes PCSK9 inhibitors and bempedoic acid within the SUPD measure, while the Medicare Plan Finder measure exits the Star Rating, removing one reporting burden for clients.A proposed opioid measure (IOPLD) could become a Star Rating measure by 2028, pending CMS's final decision.A pilot of the Judi Rx Medicare Stars Service Level 2 program delivered a 4.3 percent average adherence improvement across three measures - broader results are highly encouraging that plans can achieve 3+ Stars.Simple interventions, like refill reminders and extended day supply fills, can meaningfully move adherence measures without requiring complex program overhauls. Related Content AH096 - A Quick Government Programs Update: The IRA & MPPP, Managing D-SNPs, and More, with Jason BarrettoHow Our Favorite New Judi® Features Aid Government ProgramsAH114 - How Employers Can Use Clinical Programs to Reduce Cost and Complexity, with Nash Albadarin, PharmDHealth Benefits 101: The Importance of Clinical ProgramsJudi Health™ Achieves FedRAMP® Ready Status, Enabling Multi-Market Growth Across Federal Healthcare Organizations Please visit Judi Health - Insights for more information about this episode and content from the Judi Health team!

  3. Sep 4

    AH116 - The Claims "Spin Cycle" & Battle Between PI & RCM, with Lynn Garbee

    On Episode 116 of Astonishing Healthcare, Lynn Garbee, SVP of Managed Services at Judi Health, joins Justin Venneri in the studio for a lively discussion about the costly battle between payment integrity (PI) and revenue cycle management (RCM) in the U.S. healthcare system. She explains the "claims spin cycle," a pattern of denials and resubmissions that generates an estimated $300–$400 billion in administrative waste annually, and why the denial-driven savings everyone seems to be after aren't really a sustainable strategy. Lynn also walks through concrete steps that plan sponsors can take right now to be more aware of their plans' expenditures and address waste, including auditing for hidden PI and contingency fees, and managing high-cost claimants in an era of GLP-1s and gene therapies. Discussion Highlights: Healthcare costs are outpacing the entire economy. Spending has climbed from 8% to 18% of GDP over Lynn's career, forcing everyday people to make hard decisions between healthcare, food, and housing - this is the crisis that drives her.The PI vs. RCM battle creates a lose-lose cycle for payers and providers.PI is necessary - we need to ensure that what is coded is what really happened between a patient and provider - but what began as a way to confirm codes has drifted toward more of a "savings obsession."The numbers expose how little the system actually gains - most of the effort just adds administrative cost. Roughly 15% of claims are denied, and about half of those are eventually overturned; on the prior authorization side, ~94% of authorizations get approved, and ~81% of the small share denied are later reversed.Contract constraints may be blocking access to more innovative, cost-effective arrangements. Related Content AH113 - From Legacy Mainframe to Judi Cloud™: Modernizing Claims Adjudication, with Andy KageleiryExplaining the Healthcare Claims Adjudication Process for Modern TPAsPrior Authorization Guide: Pharmacy, Medical, Dental, and Vision PAsPharmacy Benefits 101: The Importance of the Network Please visit Judi Health - Insights for more information about this episode and content from the Judi Health team!

  4. Aug 21

    AH115 - Achieving FedRAMP® Ready Status & Why Security is a Team Sport, with Shane Garoutte

    In this episode of Astonishing Healthcare, host Justin Venneri sits down with Shane Garoutte, Chief Information Security Officer at Judi Health, for a conversation about cybersecurity and what it takes to protect member data in a landscape where the adversaries don't play by any rules. Shane offers a practical look at why cloud security standards matter so much in healthcare, especially as large-scale breaches continue to affect organizations handling protected health information. He explains why FedRAMP® Ready status is different, how continuous monitoring changes business behavior, and why security must be treated as a company-wide responsibility and "team sport" rather than a narrow compliance exercise. Shane also offers listeners some timely, actionable cybersecurity tips for remote work and travel, including why multi-factor authentication, physical device awareness, and healthy skepticism around texts and login alerts help reduce risk. HighlightsFedRAMP® Ready status is a differentiated achievement. The real investment is not just technical compliance, but changing day-to-day business behavior through continuous security practices across the entire organization. ‍Healthcare security depends on practical habits, not just frameworks – everyone plays a part. Shane shares advice on physical device awareness, multi-factor authentication, passkeys, and healthy skepticism, offering listeners simple steps to reduce risk at work and at home. ‍A strong cybersecurity culture is built on trust and teamwork. Security teams should be seen as partners, not punishers; fear can push employees to hide mistakes instead of reporting them early. ‍Security maturity is a business differentiator. Shane connects FedRAMP Ready status to Judi Health's cloud-first architecture, scalability, and technology-first approach to benefits administration, showing why employers, plan sponsors, and health plans should care. ‍Agentic AI is changing the threat landscape, and fast. The most astonishing story highlights why cybersecurity defenses must be at least as dynamic, adaptive, and creative as AI-powered systems and threat actors move beyond traditional attack patterns. Related Content & Reference Materials Top 10 New Judi® Updates Improving Health Benefits AdministrationAH112 - From Transparent PBM to Unified Health Technology, with AJ Loiacono and Kristin BegleyWhat is a Core Administrative Processing System (CAPS) in Healthcare Payer Operations?Judi Health Partners with CLEAR as a Preferred Identity Verification Partner to Power Secure, Interoperable Health Benefits AccessThe OpenAI Team's Black Hat Presentation Please visit Judi Health - Insights for more information about this episode and content from the Judi Health team!

  5. Aug 7

    AH114 - How Employers Can Use Clinical Programs to Reduce Cost and Complexity, with Nash Albadarin, PharmD

    We welcomed Nash Albadarin, PharmD, Associate Director of Clinical Programs at Judi Health™, back to the studio to talk about the evolution of clinical programs and clinical consulting for Episode 114 of Astonishing Healthcare! What happens when a proactive clinical consulting strategy is employed? What questions should employers ask to evaluate clinical programs? What sorts of results are we seeing with high-touch programs for low-cost alternatives or risk mitigation? Nash discusses his new role at Judi Health and answers these questions, and many more. A pharmacist by training with over 10 years of experience in the PBM industry, Nash describes what a consultative, data-driven approach to clinical programs looks like in practice, and he backs it up with data and real-world examples that show hundreds of thousands of dollars in savings and meaningful reductions in opioid exposure for employers. He also describes a new site-of-care optimization program that's turning heads. Highlights Proactive clinical strategies drive meaningful results and help build trust. For years, PBMs waited for clients to flag a spending problem before responding. Judi Health™ is flipping that model, scrutinizing claims data so the team can bring vetted solutions to the table or contact plan members before red flags appear.The results are concrete and substantial. Recent biosimilar conversions drove $130,000 in annualized member savings and $850,000 in annualized plan savings, while Rx Ally cut short-acting opioid day supply by 14.3 days for enrolled members.Shifting care from medical to pharmacy - and the site-of-care - yields surprising savings. A newer clinical program, CareShift Health, optimizes site-of-care and shifts select medical drugs to the pharmacy benefit, resulting in a lower net cost.Unified data unlocks hidden savings. Medical and pharmacy spend have traditionally lived in separate silos. When you compare them side by side, the excess billing and administration costs tied to provider-administered drugs become clear, and clients are often "blown away" by what they find. Related Content AH043 - Pharmacy Benefits 101: DMP & MTM, Explained, with Nash Albadarin, PharmDHealth Benefits 101: The Importance of Clinical ProgramsReplay - Improving Metabolic Health in a GLP-1 WorldPoster: The Impact of Text Messaging and Pharmacist Outreach Interventions on Medication Adherence Rates in a Commercial PBM PopulationHow PBMs are tackling behavioral health (Managed HC Executive) For more information about this episode and content from Judi Health, visit www.judi.health/insights.

  6. Jul 24

    AH113 - From Legacy Mainframe to Judi Cloud™: Modernizing Claims Adjudication, with Andy Kageleiry

    On this episode of Astonishing Healthcare, Andy Kageleiry (SVP, Enterprise at Judi Health) returns to the studio for a discussion about the state of the technology powering most health plans' and third-party administrators' (TPAs') operations, and how modern enterprise health tech like Judi® eliminates administrative waste, supports flexible plan designs, and unifies medical, pharmacy, vision, and dental claims on one platform. He describes several surprising, common pain points that plan administrators regularly face, including manual claim review, limited data access, an inability to scale or pivot when needed, and point solution fatigue. Andy also introduces the Judi Cloud™ solution, which lets health plans and TPAs license the Judi platform directly. Key Takeaways‍A single claim can be incredibly time-consuming to process, but it doesn't have to be. Eligibility, network status, coverage rules, benefit design, and coordination of benefits all have to resolve correctly in real time. Legacy platforms built on decades-old mainframes can't keep pace, leaving operations teams to close the gap by hand.‍Infrastructure point solutions don't fix root cause problems. Every added vendor means another integration, another relationship, and more overhead. That administrative drag contributes to an estimated $1 trillion in annual healthcare waste, slower provider payments, and members who can't reconcile their EOB with their bill.‍A modern, unified CAPS turns the equation around. Judi Cloud lets health plans and TPAs license the Judi platform, enabling them to process medical, pharmacy, vision, and dental claims on one system, cutting manual work, supporting flexible plan designs, and giving clients full, self-serve access to their own data. Related Content Explaining the Healthcare Claims Adjudication Process for Modern TPAsJudi Health™ Announces Capital Rx is Now Judi Rx™, Launches Judi Care™ and Judi Cloud™ to Power the Next Era of Health Benefits Administration and Patient CareAH111 - Building a Single Source of Truth for Medical and Pharmacy Benefits, with Kevin Sundquist & Liya LomsadzeJudi Health Partners with CLEAR as a Preferred Identity Verification Partner to Power Secure, Interoperable Health Benefits AccessReplay: The Future of Health Benefit Design: How Judi® Powers Seamless Care and Better Outcomes For more information about this episode, please visit Judi Health Insights.

  7. Jul 17

    AH112 - From Transparent PBM to Unified Health Technology, with AJ Loiacono and Kristin Begley, PharmD

    What does it take to move from fixing one broken corner of healthcare to reimagining the whole thing? On this episode of Astonishing Healthcare, host Justin Venneri sits down with two of his favorite guests together for the first time: Judi Health's CEO, AJ Loiacono, and Chief Commercial Officer, Kristin Begley, PharmD. The catalyst for this special episode is the company's rebrand, the evolution from Capital Rx, the transparent PBM that built Judi®, into Judi Health, a unified health technology company. AJ and Kristin explain why the "Rx" designation remains a core piece of the company's identity but no longer fully reflects the organization's evolving mission. They also describe the difference between "little T" transparency and the real thing, why incentive alignment matters so much, and what it took to build the first platform to process medical, pharmacy, dental, and vision claims on one system. They also express gratitude to the team and share bold predictions for where health benefits go next. Key TakeawaysThe rebrand reflects an expanded mission, not a new one. Capital Rx launched as a transparent PBM, with "Rx" signaling its focus on pharmacy. Over eight years, the company broadened its administrative capabilities, including medical claims processing, and much more - all powered by Judi. Thus, the primary brand: Judi Health, with services harmonized as Judi Rx (pharmacy), Judi Care (medical administration, TPA, navigation), and Judi Cloud (platform licensing for health plans and TPAs).There's a real difference between "little T" transparency and true transparency. AJ argues that true transparency means an auditable workflow: full disclosure of all compensation, proof that every customer receives the same pricing and benefit, and no hidden earnings. He calls out the "little H" holding company trick and explains why alignment yields better outcomes for plans and their members.‍Nobody had built unified claims processing before. AJ recalls initial skepticism around unified claims. His response: "If Netflix had kept mailing DVDs, we wouldn't be talking about Netflix." To date, no other organization has built a unified claims processing platform. Judi is the exception.Unified claims processing will become the standard. Once employers realize they have options, markets shift quickly. AJ, who predicted the rise of transparent PBMs, makes a new call: unified claims will be the industry norm. Related Content Judi Health™ Announces Capital Rx is Now Judi Rx™, Launches Judi Care™ and Judi Cloud™ to Power the Next Era of Health Benefits Administration and Patient CareAH100 - The End of the Age of Confusion, It's Time for Acceptance, with AJ LoiaconoAH067 - Aligned Health Benefits and the Freedom to Unbundle, with Kristin Begley, PharmDWhat is a Core Administrative Processing System (CAPS) in Healthcare Payer Operations?AH111 - Building a Single Source of Truth for Medical and Pharmacy Benefits, with Kevin Sundquist & Liya Lomsadze For more information about this episode, please visit Judi Health Insights.

  8. Jul 10

    AH111 - Building a Single Source of Truth for Medical and Pharmacy Benefits, with Kevin Sundquist & Liya Lomsadze

    What actually happens after you hand your insurance card to the front desk at a doctor's office? On the pharmacy side, a claim clears in milliseconds. On the medical side, the same visit can trigger a weeks- or months-long odyssey of coding, clearinghouses, carve-outs, and paper claims before anyone knows what's owed. On this episode of Astonishing Healthcare, host Justin Venneri revisits the "story of a claim," this time following the far more complicated journey of a medical claim. Joining him are two guests who've been working to improve medical claims processing for years: Kevin Sundquist (VP, Product) and Liya Lomsadze (Senior Director, Product). Together, they trace why medical claims lag, why the system got carved into so many disconnected pieces, and how unifying medical and pharmacy benefits on a single platform - Judi® - changes the experience for plan sponsors, members, and providers. Highlights While pharmacy claims are adjudicated in real time, medical claims often can't even be created on the spot. The clinical record and billing system are frequently separate, and each handoff adds lag and introduces new chances for error – a single mislabeled insurance record can delay a simple lab claim by six months.In the medical world, it's common to split a single claim's journey across multiple vendors: in-network pricing to one entity, out-of-network pricing to another, prior authorization to a third, and benefit application to yet another. Plan sponsors, brokers, and consultants need one system and the flexibility to carve out any piece to a preferred partner if they’d like.Rigid legacy systems force unnecessary compromises and workarounds. Manual tracking of visits to a chiropractor or physical therapist and hacking deductibles for plan members are all too common.Judi’s capabilities are expanding. Payments, care navigation and management, case management, and much more are brought into a more connected experience for members, sponsors, and providers. Related Content AH037 - The Story of a Claim: Redefining the Benefit Experience, with Kevin SundquistTop 10 New Judi® Updates Improving Health Benefits AdministrationAH094 - How Unified Claims Processing Evolved from Pharmacy: Improving Member Care & Operating Efficiency For more information about this episode and its transcript, please visit Judi Health Insights.

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Ratings & Reviews

5
out of 5
16 Ratings

About

If you’ve ever wondered what pharmacy benefit managers (PBMs) do, why the pharmaceutical supply chain is so complicated or the pace of change in healthcare seems so slow, how vendor purchasing decisions are made, or why our nation’s electronic claim administration infrastructure must be updated, Astonishing Healthcare by Judi Health (Capital Rx) is the podcast for you. Covering everything from niche and broad pharmacy and health benefit topics to regulatory change, disruptive technologies, and macro issues like the trend for drug prices or the total cost of care, we’ve got the information and insights you need. For show notes and additional resources from Judi Health, visit https://www.judi.health.

Information

  • Creator
    Judi Health
  • Years Active
    2024 - 2026
  • Episodes
    126
  • Rating
    Clean

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