The Astonishing Healthcare Podcast

Hosted by Judi Health

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125

Latest episode

Sep 2026

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EN-US

About the show

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.

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60 recent

October 2, 202624 min

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 spending AH114 - How Employers Can Use Clinical Programs to Reduce Cost and Complexity, with Nash Albadarin, PharmD How to obtain Rx data and what to do with it AH030 - Plan Sponsors Need a Source of Truth; Get Your Data Now & Find It, with Jeff Hogan Judi 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!

September 18, 202623 min

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 Barretto How Our Favorite New Judi® Features Aid Government Programs AH114 - How Employers Can Use Clinical Programs to Reduce Cost and Complexity, with Nash Albadarin, PharmD Health Benefits 101: The Importance of Clinical Programs Judi 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!

September 4, 202622 min

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 Kageleiry Explaining the Healthcare Claims Adjudication Process for Modern TPAs Prior Authorization Guide: Pharmacy, Medical, Dental, and Vision PAs Pharmacy 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!

August 21, 202627 min

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. Highlights FedRAMP® 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 Administration AH112 - From Transparent PBM to Unified Health Technology, with AJ Loiacono and Kristin Begley What 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 Access The OpenAI Team's Black Hat Presentation Please visit Judi Health - Insights for more information about this episode and content from the Judi Health team!

August 7, 202620 min

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, PharmD Health Benefits 101: The Importance of Clinical Programs Replay - Improving Metabolic Health in a GLP-1 World Poster: The Impact of Text Messaging and Pharmacist Outreach Interventions on Medication Adherence Rates in a Commercial PBM Population How PBMs are tackling behavioral health (Managed HC Executive) For more information about this episode and content from Judi Health, visit www.judi.health/insights.

July 24, 202623 min

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 Takeaways ‍ A 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 TPAs 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 Care AH111 - Building a Single Source of Truth for Medical and Pharmacy Benefits, with Kevin Sundquist & Liya Lomsadze Judi Health Partners with CLEAR as a Preferred Identity Verification Partner to Power Secure, Interoperable Health Benefits Access Replay: 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 .

July 17, 202626 min

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 Takeaways The 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 Care AH100 - The End of the Age of Confusion, It's Time for Acceptance, with AJ Loiacono AH067 - Aligned Health Benefits and the Freedom to Unbundle, with Kristin Begley, PharmD What 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 .

July 10, 202629 min

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 authorizatio n 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 Sundquist Top 10 New Judi® Updates Improving Health Benefits Administration AH094 - 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 .

June 26, 2026Episode 11029 min

AH110 - Inside the 2026 U.S. Medicine Use Trends Report with Michael Kleinrock

What happens when two consecutive years of double-digit drug spending growth collide with a wave of pricing legislation, executive orders, and policy turbulence? On the latest episode of Astonishing Healthcare, host Justin Venneri welcomes Michael Kleinrock , Director of Research Development at the IQVIA Institute for Human Data Science, back to the show to find out and unpack the findings from IQVIA's 2026 Medicine Use Trends Report . The headline number is hard to ignore: net drug spending in the U.S. reached $606 billion in 2025, a 10.6% increase year over year, following a 14.4% jump the year before. But the story behind that figure is far more interesting. Michael and Justin dig into what's driving growth (hint: it's not just GLP-1s), why the roughly $670 billion gross-to-net gap matters so much, and why list price still shapes what patients pay even though "nobody pays it." They also explore the uneven reality of the biosimilars market, the trade-offs created by the IRA's Medicare out-of-pocket cap, prescription abandonment, and where spending is headed through 2030. Please note: IQVIA Institute will be hosting a webinar on July 15th, 2026, featuring a star panel, including past Astonishing Healthcare guest John O'Brien, CEO, National Pharmaceutical Council , Murray Aitken , Executive Director at The IQVIA Institute for Human Data Science, Stacie Dusetzina, Professor, Health Policy & Ingram Professor of Cancer Research, Vanderbilt University Medical Center, and others, to discuss this year's report. Related Content AH071 - A Look at What's Really Driving Drug Spend, and How it Impacts Us, with IQVIA's Michael Kleinrock Beyond the Rebate: How Executives Can Better Manage Pharmacy Spend AH105 - The Perfect Storm Driving the Future of Drug Pricing, With Josh Golden For more information about this episode and its transcript, please visit Judi Health Insights .

June 12, 202625 min

AH109 - Unlocking PGx: Evidence, Use Cases, and Implementation

On episode 109 of Astonishing Healthcare , host Justin Venneri explores pharmacogenomics (PGx) with a trio of experts: Caitlin Munro, PharmD (Clinical Partnerships Lead, Judi Health); Haleh Campbell, PharmD (Clinical Programs Administration Manager, Judi Health); and Houda Hachad, PharmD (Vice President of Clinical Operations, Aranscia). Together, they break down what PGx is, why now is the right moment for broader adoption, and how genetics can shape the way each of us processes and responds to medications. The conversation moves from the basics to the practical: where the evidence is strongest, which patients stand to benefit most, and what it takes to apply PGx in a way that's clinically responsible and genuinely useful for patients and providers. They also dig into findings from a study the Judi Health team recently presented at the Pharmacy Quality Alliance (PQA) annual meeting and explain why pharmacist support and clinical decision support, not just a lab report, make all the difference. Key Takeaways PGx adds a piece to the puzzle; it's not a silver bullet. Pharmacogenomics looks at how inherited genetic differences affect the way a person processes or responds to medications. It narrows uncertainty and supports clinical judgment, but it doesn't replace it. Several forces are converging to make this the right moment. Testing costs have dropped, evidence-based guidelines from expert consortia are now widely adopted, and hundreds of FDA labels include pharmacogenomic information. The strongest use cases involve complexity and risk. Patients on multiple medications, those starting new therapies, and people who've had treatment failures or unexpected side effects often benefit most, especially across common drug classes like antidepressants, cardiovascular medications, and pain therapies. Human support drives engagement and trust. Rx Helix data showed that testing adoption was significantly higher among members who received clinician-led, pre-test telephone outreach. The future is proactive. With unified claims processing that combines pharmacy and medical data, leaders see a path toward PGx-enabled medication management, identifying patients before therapy begins to optimize treatment earlier in their journey. Related Content Health Benefits 101: The Importance of Clinical Programs AH073 - How Low Cost Alternative Programs Can & Should Work, with Jackie Lolos, PharmD, and Haleh Campbell, PharmD Replay – The Bridge to Better Healthcare: Uniting Medical and Pharmacy Services on One Platform to Achieve Value-Based Care AH060 - A New Approach to Colorectal Cancer (CRC) Screening, with Geneoscopy For more information about this episode and its transcript, please visit Judi Health Insights .