AJ Loiacono & Holly Maloney (Part 3): Capital Rx’s Expansion into Medicare

Capital Rx

Capital Rx

We're incredibly proud that JUDI®, our cloud-native, custom-built enterprise pharmacy platform, rang in the New Year processing Medicare claims. It was truly a special moment in time for Capital Rx. In Part 3 of A.J. Loiacono's end-of-year discussion with General Catalyst's Holly Maloney, AJ describes why it's so important for the evolution of pharmacy benefits administration in the U.S. that JUDI can now handle the one-third of the market that is government-sponsored.

Transcript

Edited lightly for length and clarity.

Holly Maloney - General Catalyst

AJ, I know we've chatted a lot about government programming. Can you give [everyone] a little bit more context as to how you think about the government side of your business and how that may impact the company going forward?

AJ Loiacono - Capital Rx

Yeah, it's probably our largest endeavor to date. And it's an enormous project that touches everyone from operations to underwriting to engineering and reporting teams. But the whole point of it is when we started in this business; we recognized that we would begin with the commercial side of the business; not to say that it's easy, but it's easier than certainly Medicare. And so when we entered the business, we obviously wanted to gain experience and build out our systems, but we always had this long-term outlook that, over five years, we would build a platform that could process Medicare claims. Medicaid claims are a little bit easier, but you could process Medicare claims.

 

And why is this so important? As you know, all the systems that are out there today literally were built before Medicare expansion. I mean, let that set in for a second. They were written 20-30 years ago. They're very static systems that don't scale well. They barely contemplate the requirements for Medicare today and forget about the future. So, we always recognized there would be a point in time when we would want to and feel that we would need to address the one-third of the market that is government-sponsored. And so we had a long-term outlook, and for us over this last year and a half, from a build-out and capabilities perspective, we focused on our JUDI® platform, which is our proprietary platform that adjudicates claims and system workflows.

We had to invest an enormous amount of time to make JUDI ready for government [programs]. But what JUDI has/had a huge advantage with was a clean sheet of paper: what are the workflows involved with Medicare? What can we do better? How do we make it more accurate and a better customer/patient experience? I feel that for us, it's so critical to help seniors, in particular in the Medicare program, and give them a better service model. Help them reduce costs. Be willing to finally offer the country a claim administrator that doesn't want to make money on drugs and - just for a flat administrative fee - wants to provide the best service… the best outcomes with the most accurate workflows. And I think this is what's been missing in a lot of our government programs and why we're so excited to enter the market in 2023.

If you'd like to watch the two prior videos in this interview series:

Part 1: Navigating 2022 - A Recap of Top Challenges Faced

Part 2: Outlook for 2023 - What to Watch For


Get in touch if you'd like to learn more about Capital Rx's full-service pharmacy benefit solutions and Medicare capabilities.

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