The Astonishing Healthcare Podcast

On this episode of Astonishing Healthcare, Lloyd Fiorini, General Counsel & Chief Compliance Officer at Judi Health, returns to the studio for a discussion about the barrage of regulatory changes shaping the pharmacy benefit manager (PBM) landscape in early 2026. Within just two weeks, the Department of Labor announced new proposed rules, the Consolidated Appropriations Act of 2026 became law, and the FTC's announced a settlement with Express Scripts. Then, to top it all off, TrumpRx went live.Lloyd offers clear, helpful explanations of the key takeaways from each of these concurrent reforms aimed at improving transparency and how PBMs operate and interact with the other stakeholders in the supply chain, from independent pharmacies to patients and plan sponsors (employers). Whether you're responsible for a self-funded plan or overseeing a Medicare Part D plan, this episode provides the detail and insights about where the puck is going that you need. As Lloyd said, "I think we've made a great step forward, but the work isn't done."It's also worth giving a shoutout to previous guest Jim Winkler, as "Change is Imminent" is in the title of AH090!Episode HighlightsThe Department of Labor’s historic proposed rules on PBM disclosures fills a gap left by the CAA of 2021The Consolidated Appropriations Act of 2026 redefines the financial alignment of pharmacy benefits beyond just Medicare Part Patient/plan member protection seems to be what the FTC’s recent settlement was all aboutTrumpRx signals a broader shift toward transparent, cost-plus pricing models, but it's just for cash-paying customers, at least for nowDelinking and efforts to block vertical integration are hotly contestedRelated ContentAH095 - What's in Store for the New Year? A Special Round-Robin Episode of Astonishing HealthcareHow to obtain Rx data and what to do with itAH096 - A Quick Government Programs Update: The IRA & MPPP, Managing D-SNPs, and More, with Jason BarrettoSigns it is time to change your PBM vendor, and how to overcome common hesitationsReference LinksUS Department of Labor proposes historic pharmacy benefit manager fee disclosure rule (January 29)PBM Reforms Signed Into Law, Reshaping Medicare Part D Drug Pricing Transparency (February 3)FTC Secures Landmark Settlement with Express Scripts to Lower Drug Costs for American Patients (February 4)TrumpRx Launches (February 6)For more information about Judi Health and this episode, please visit Judi Health - Insights.

On this episode of Astonishing Healthcare, Judi Health's Mike Tate (VP, National Business Development) and Mark Pearce (Director, TPA Operations) join us in the studio to discuss the role of Third-Party Administrators (TPAs) in the self-funded employer market. As Mike explains, TPAs act as the "enforcers" of an employer's plan document, responsible for pulling everything together and ensuring claims accuracy, network access, and financial stewardship. Mark dives into the distinction between carrier-owned (ASO) and independent TPAs, explaining how independent models offer greater flexibility in plan design. And of course, they highlight a significant industry challenge: legacy technology. Many administrators rely on antiquated systems that limit customization and data visibility. In contrast, modern platforms empower plan sponsors to integrate point solutions effectively, customize networks for high-value care (e.g., through centers of excellence), and drive better member engagement. If you've ever asked yourself, "What does a TPA really do?" or "Should I look at different TPAs?" this episode will be worth your time to listen to.Ultimately, successful healthcare administration relies on managing "hundreds of little things" correctly for each benefit (Rx, medical, vision, and dental) - from provider payments to member support. That's how you create positive financial and clinical outcomes. Related ContentAH080 - Health Benefits 101: The Importance of "Smart" Care Navigation, with Andy KageleiryReplay: The Future of Health Benefit Design: How Judi® Powers Seamless Care and Better OutcomesAH067 - Aligned Health Benefits and the Freedom to Unbundle, with Kristin Begley, PharmDJudi Health™ Earns Best Healthcare InsurTech Solution in the 9th Annual MedTech Breakthrough Awards ProgramFor more information about Judi Health and this episode, please visit Judi Health - Insights.

For the 100th episode of Astonishing Healthcare, we welcomed AJ Loiacono, our co-founder and CEO, back to the show for a lively discussion about the evolution of our industry and business. What started as a transparent pharmacy benefits manager (PBM) in the "age of indifference" is now a more comprehensive health benefits manager (HBM), and we've entered the "era of acceptance." It's been an incredible 8+ years of growth, fueled by innovation and an unwavering commitment to our clients and delivering on our mission: to build the infrastructure our country needs to deliver the healthcare we deserve. But we had to endure an "age of confusion" to get here!AJ explains why traditional healthcare giants are facing a "BlackBerry moment" - trying to emulate a conflict-free challenger when "it’s already too late." The balance of power is shifting away from the traditional PBMs, as the industry now demands full transparency - buyers of health benefits today are smarter than ever before. We also discuss how and why the U.S. wastes [at least] a trillion dollars annually by trying to deliver care using inefficient, fragmented systems; we built the infrastructure to stop it. This episode isn't just a retrospective; it’s a blueprint of sorts, and we've got the cultural DNA required to bring about sustainable change (vs. just daydreaming about it). Related ContentReplay - Unifying Medical and Pharmacy Benefits: The Blueprint for Better Employee Health and WellnessJudi Health’s Capital Rx Surpasses Five Million Contracted PBM Lives as America’s Largest Employers, Unions, and Leading Health Systems Evolve Their Health Benefits StrategiesAH095 - What's in Store for the New Year? A Special Round-Robin Episode of Astonishing HealthcareHealth Benefits 101: Service Excellence & Scaling an Award-Winning Call Center ModelFor more information about Judi Health and this episode, please visit Judi Health - Insights.

For Episode 99 of Astonishing Healthcare, we welcome Hannan Allen, SVP of Consultant Relations to the company and show! The discussion builds on Episodes 90 and 93, with Jim Winkler of Business Group on Health and Susana Villegas Spillman, respectively, by explaining why "pharmacy benefit consultants have a really tough job right now" and tackling some timely questions, including how has the role of the benefits broker or consultant evolved? What's making the job so complex lately? And, are plan sponsors' primary needs changing? We cover these questions and many more - including who will win Super Bowl LX. - with Hannan, so if you're working in the pharmacy and health benefits space, you won't want to miss this one. Tune in to hear about:Biosimilars - the big opportunity and challenges PBMs have createdThe push for transparency, and what it means for consultantsHow to weigh price/cost, and why drug mix is so importantPrioritizing member care and programs that benefit membersThe opportunity cost of sticking with the status quo (is astonishing)Related ContentHow employers can take back control of unnecessary pharmacy spendingJudi Health Policy Pulse: 2025 Regulatory Roundup, the Push for PBM ReformReplay: PBM Procurement Decoded: Insights from a Pharmacist and an ActuaryHealth Benefits 101: Service Excellence & Scaling an Award-Winning Call Center ModelFor more information about Judi Health and this episode, please visit Judi Health - Insights.

This episode of Astonishing Healthcare features three members of The Judi Group's leadership team: Jeff Hogan (Co-Founder & Managing Director), Chris Deacon (Director, Growth & Strategy), and Julie Selesnick (Director, Legal & Compliance). The Judi Group is a new venture - a premier advisory firm in healthcare on a mission to help companies evaluate the totality of their health vendors and contracts, deliver insights that lead to more responsible action, and ultimately improve the overall cost picture and health outcomes for their health plans and plan members, respectively. But why now? What steps can employer plan sponsors take to improve their contracting and access data? How do you set up a sustainable fiduciary process? For the answers to these and many more questions, like our guests' personal reasons for embarking on this journey, you'll have to listen in!HighlightsWe've reached a boiling point - everyone is tired of how the US healthcare system operates,, the misaligned incentives throughout the supply chain, and the unnecessary complexity of it all.There's a growing willingness among employers to challenge the status quo, embrace transparency, and create customized benefit plans that better serve their unique populations.Jeff is driven - in part - by his experience as a public servant, Julie tends to fight for the underdog, and Chris is inspired by the opportunity to make a tangible difference in healthcare.The RFP process must be redesigned for each employer, with their unique needs in mind.Access to claim-level data is critical if employers are to fulfill their fiduciary duties, make informed decisions, and ensure prudent use of employees' healthcare dollars.Related ContentAH041 - ERISA Litigation Outlook and Meeting CAA Requirements: What Can Plan Fiduciaries Do?Health Benefits 101: The Importance of a Transparent PBM ModelReplay - Unifying Medical and Pharmacy Benefits: The Blueprint for Better Employee Health and WellnessJudi Health Policy Pulse: 2025 Regulatory Roundup, the Push for PBM ReformTo learn more about the Judi Group, the team, and its mission and services, please visit www.judi.group.For more information about Judi Health and this episode, please visit Judi Health - Insights.DisclaimerThis podcast is for informational and entertainment purposes only. The views expressed are those of our guests, do not constitute professional advice, and may not represent Judi Health's/Capital Rx's position on any matters discussed. We make no representations or warranties regarding the accuracy or completeness of the content; information is subject to change and may not be updated.

For Episode 97 of Astonishing Healthcare, we sat down with three team members who interned with Judi Health (Capital Rx) and recently joined our mission as full-time employees! Jakob Deel, Lisa Yu, and Bryan SebaRaj discuss their respective paths to Judi Health, from why they chose healthcare and how they found their internships to why they decided to join a newer, disruptive health tech company over larger "hyperscalers." So, this episode has something for every undergrad and graduate student. That said, Episode 97 isn't just about landing an internship or transitioning from an intern to full-time employee. The trio also discusses the engineering, development, and operations/policy work they are doing to help advance our industry. Our goal is really to raise awareness of the different paths the next generation of healthcare disruptors can take, how to prepare if you're on that path, and highlight the reward at the end of this first step in what will undoubtedly be long and successful careers!To learn more about life at Judi Health, check out our Careers Page, and keep an eye out for our 2026 summer internship program openings, which will be posted there soon.For more information about Judi Health and this episode, please visit Judi Health - Insights.

For Episode 96 of Astonishing Healthcare, Jason Barretto, our SVP of Government Programs, returns to the show for a discussion about what's happening on the health plan side of the business. As a company, we spend a lot of time talking about and showing how modern technology streamlines benefit administration workflows and overall operating efficiency, solves longstanding problems, and helps clients stay nimble to meet the intent of new regulations. Well, Jason's experience managing PBM relationships at health plans helps him - and our team - add real value when working with our clients. And, thankfully, he loves to talk about it!During this episode, we discuss:Intensifying demand for transparency (beyond just price transparency)The Inflation Reduction Act (IRA) and the implementation of Maximum Fair Prices (MFP)Slow adoption of the Medicare Prescription Payment Plan (MPPP) and how CMS is removing barriersA streamlined approach to managing Dual Special Needs Programs (D-SNPs), something Jason "wanted to solve" when he started hereA really interesting observation about the popularity of GLP-1sCMS changing its audit approach and the importance of audit readiness in 2026Related ContentHow Our Favorite New Judi® Features Aid Government ProgramsJudi Health Policy Pulse: 2025 Regulatory Roundup, the Push for PBM ReformJudi® is a Tech-Enabler – A Case StudyAH058 - Building Judi®, the Healthcare Infrastructure of the Future, with Liya LomsadzePartnership & Collaboration: Why PBMs and Health Plans Should Sync on Regulatory Change ManagementFor more information about Judi Health and this episode, please visit Judi Health - Insights.

Episode 95 of Astonishing Healthcare features six previous guests on the show who share astonishing observations from 2025 and some bold predictions for the New Year! Industry veteran Jeffrey Hogan, our General Counsel and Chief Compliance Officer, Lloyd Fiorini, ERISA law expert Nick Welle, two of our clinical leaders – Sarra Izadi, PharmD, Chief Clinical Officer, and Bonnie Hui-Callahan, PharmD, CDCES, Sr. Director, Clinical Programs, and our Chief Technology Officer and Co-Founder, Ryan Kelly, joined us for this round-robin discussion that’s packed with insightful reflections and optimism about the future. We won’t ruin it in the show notes, but based on what we saw in 2025: Everyone has finally had enough of the costs and opacity of the U.S. healthcare system – a $70k family premium is truly astonishing It’s surprising that, despite the lawsuits, warnings, and reform efforts, the proverbial hammer didn’t drop on anyone for not being a good health plan fiduciary The speed and impact of AI have broadly been more positive than expected The rise of cardio-diabesity How GLP-1s helped shift the balance of power in the pharmaceutical supply chain And in 2026, we may see: Employers fight back – they take agency over their plans, and for first movers that started with transitioning to aligned PBMs, it’s “game on” for the rest of their health plans The cash price – or acquisition cost – of drugs in the U.S. becomes the baseline – i.e., we finally see a real change in how drugs are priced ICHRAs and other alternative models become more popular Employers look to new clinical programs and models that demonstrate a return on their spending AI become more important for clinical workflows (not decision-making, at least not yet) Pharmaceutical manufacturers find themselves with increasing bargaining power vs. traditional PBMs A new Stanley Cup champion, and a Super Bowl ring for… Related Content Judi Health Policy Pulse: 2025 Regulatory Roundup, the Push for PBM Reform Replay - Unifying Medical and Pharmacy Benefits: The Blueprint for Better Employee Health and Wellness AH094 - How Unified Claims Processing Evolved from Pharmacy: Improving Member Care & Operating Efficiency Health Benefits 101: The Importance of Clinical Programs How to obtain Rx data and what to do with it For more information about Capital Rx and this episode, please visit Judi Health - Insights.

We got the ball rolling in 2025 with this episode, and it ended up at the very top of the activity list, so we'll close out the year with it as well! Thank you, Dr. Eric Bricker for joining us in the studio for Episode 48 of the Astonishing Healthcare podcast. Known for his entertaining and educational videos covering all sorts of hot topics in and around healthcare and employer/employee benefits, Dr. Bricker and host Justin Venneri discussed the issues of high-cost drugs and access to claims data - two topics he covered on AHealthcareZ - Healthcare Finance Explained - that should [still] be top of mind for plan sponsors as pharmacy costs continue to rise.Dr. Bricker shared several ways employers, depending on their size and risk tolerance, may be able to navigate the challenge of rising pharmaceutical costs for orphan and other expensive drugs - including GLP-1s. He also explains how the RFP process can be used to secure the plan's claim data, which is necessary to meet fiduciary obligations. While every plan is unique, most plan sponsors face similar challenges that the traditional PBM model isn't flexible or aligned enough to solve.Lastly, Dr. Bricker expressed astonishment by the complacency out there, but he was right! The setup was perfect for an acceleration in the pace of change in 2025, and we see the momentum carrying over into 2026 - so, tune in to hear why, if you didn't catch Episode 48 the first time around.AHealthcareZ Reference VideosHigh Cost Orphan Disease Drugs ExplainedDo Employers Own Their Claims Data? It's Complicated.Related ContentAH030 - Plan Sponsors Need a Source of Truth; Get Your Data Now & Find It, with Jeff HoganHow to obtain Rx data and what to do with itAH093 - Health Benefits that Work for Everyone: Aligning Incentives & Focusing on Members’ Needs, with Susana Villegas SpillmanWhy Savings Don't Materialize: The Truth About Pharmacy Benefit Procurement eBook (Free)For more information about Capital Rx and this episode, please visit Judi Health - Insights.

In this Best of '25! episode of the Astonishing Healthcare podcast, Lisa Ellerhorst (Sr. Director, Customer Care Operations) and Sonia Pettis (Manager, Customer Care Operations) discuss our approach to member care! Lisa and Sonia have been with Judi Health (Capital Rx) since 2020 and have helped Will Tafoya develop our unique contact center model from the ground up. Building on Episode 34 - Customer Care in Healthcare: Setting a Higher Bar, and the questions plan sponsors and benefits consultants often ask during the RFP process (Episode 84), this episode covers:Several of the most frequent reasons plan members call and how those questions are handled, including switching a prescription from retail to mail and vice versa, prior authorizations for GLP-1s, and more.How to navigate transitions and focus on quality care (over speed).What it takes to maintain a high level of customer satisfaction (99%) while handling a 50% spike in call volume year-over-year.The communication strategy used to educate members and help them navigate new offerings effectively.The role of AI and how agentic AI can support member care and free up our skilled, PTCB-certified reps to handle more complex issues.Future-proofing the service model and preparing for the 2026 welcome season.Related ContentPharmacy Benefits 101: Building an Award-Winning Call Center from ScratchAH017 - Pharmacy Benefits 101: Prior AuthorizationHow employers can take back control of unnecessary pharmacy spendingCapital Rx’s Customer Care Team Wins 5 Stevie® Awards for Customer ServiceWatch: Are Your Prior Authorizations Actually Working?For more information about Capital Rx and this episode, please visit Judi Health - Insights.

Episode 94 of Astonishing Healthcare features two members of our product team, Liya Lomsadze (Sr. Director) and Jake Mulkey (Director), who explain how building a next-generation pharmacy claim adjudication system (Judi®), known for its split-second accuracy and streamlined workflows, served as the perfect foundation for building a unified platform that now includes medical claims, and will integrate vision and dental, too. Liya and Jake explain the contrast between pharmacy’s real-time nature and medical’s weeks-or-months-long lag, and how this gap impacts the experience for members and providers of care. The discussion covers the challenges behind supporting complex plan designs, opportunities around automating prior authorizations with real clinical data, and benefits of reducing manual interventions that slow down or interfere with care coordination. Liya and Jake also share stories about launch day, lessons learned from pharmacy claim adjudication, and their vision for a real-time future with integrated benefits. This episode is a must listen for anyone interested in how enterprise health technology can improve health benefit administration and focus resources on what's most important: plan members' experience and improving health outcomes.Related ContentReplay – The Bridge to Better Healthcare: Uniting Medical and Pharmacy Services on One Platform to Achieve Value-Based CareAH080 - Health Benefits 101: The Importance of "Smart" Care Navigation, with Andy KageleiryMedicare Transition Benefits & How Judi®’s Modern Design Enables Faster Results and Reliable ComplianceHealth Benefits 101: The Importance of Clinical ProgramsThis Startup Hit A $3.25 Billion Valuation Building Software To Fix Drug Pricing (Forbes)For more information about Capital Rx and this episode, please visit Judi Health - Insights.

Episode 93 of Astonishing Healthcare features Susana Villegas Spillman, who brings over 20 years of health benefits plan management experience to the studio for a discussion about what works, what’s broken, and what employer plan sponsors deal with day in and day out. This “unfiltered perspective” from the plan sponsor’s seat is welcome and timely. If you’re one of the increasingly large percentage of benefits directors, CHROs, CFOs, et al. out there looking to transition from a traditional benefits experience to a new, transparent, aligned, unified model, this episode is for you!Susana explains how a fragmented system fails members, and while we’ve evolved from the default “call the number on the back of the card” - which directs you to the emergency room - point solutions create more silos, and data is too scattered and stale to drive meaningful change. This forces employers to take control, which leads to her “most astonishing thing,” which is a critical reminder for every benefits leader: “Know what’s in your contracts.”Episode 93 covers:The importance of centering the strategy around long-term goals and member experience (with ruthless accountability).The upside of unbundling services from carriers and using independent navigation partners to guide members to high-quality care; why culture fit and flexibility matter when evaluating vendors.Why qualitative measures of success offer a better gauge of program effectiveness vs. empty promises of ROI.The evolving role of benefits consultants, and how to evaluate consultant relationships.The outdated RFP processes and how to run a better RFP.GLP-1 coverage for weight loss.Related ContentHealth Benefits 101: The Importance of a Transparent PBM ModelWhy this benefit leader switched to a more modern, transparent PBMReplay - Unifying Medical and Pharmacy Benefits: The Blueprint for Better Employee Health and WellnessAH078 - More About Judi Health™ & the Unified Benefits Experience, with Dr. Sunil Budhrani and Mike TateCheck out our Health Benefits 101 ContentFor more information about Capital Rx and this episode, please visit Judi Health - Insights.

The level of interest in Episode 84 of Astonishing Healthcare made this one an easy choice to lift it to "best of" status. We'll be back with fresh new episodes in early December, and then we'll close out the year with two more Best of '25s. For those of you who didn't check this one out, Josh Golden, SVP of Strategy, and RFP Content Manager, Nic Bolitho, joined host Justin Venneri in the studio for a discussion about trends they're seeing in the market and how to run a better request for proposal (RFP) process to select a pharmacy benefit management (PBM) partner. Long story short, the "old way" of running a PBM RFP is broken, but, as Josh describes, there are some "tectonic shifts" happening as plan sponsors demand to see more options (i.e., transparent PBMs) and benefits brokers and consultants upgrade the questions and scoring used to force accountability and drive meaningful results for plans and plan members.HighlightsUnit-cost-based spreadsheet comparisons and marketing fluff are "out;" evaluating drug mix and how the PBM manages the plan (the 'M' in PBM) or makes money off of the plan are "in."Plan sponsors and benefits consultants must demand flexibility - the PBM contract should not be a "house of cards." For example, agreements should provide the freedom to add new vendors or carve out services without collapsing your financial arrangement.Legacy tech platforms are a barrier to innovation; ask potential partners if their technology can handle customizations and integrations with agility to avoid being told, "We just can't do that."Precise questions about member experience are a must; RFPs should move beyond open-ended questions that invite marketing fluff. Use specific, binary questions to obtain an accurate measure of the member experience and the effectiveness of clinical programs (e.g., NPS, turnaround times for prior authorizations, etc.).Related ContentReplay: PBM Procurement Decoded: Insights from a Pharmacist and an Actuary Why Savings Don't Materialize: The Truth About Pharmacy Benefit Procurement eBook AH034 - Customer Care in Healthcare: Setting a Higher Bar, with Will TafoyaAH035 - Pharmacy Benefits 101: Clinical Programs, with Bonnie Hui-Callahan, PharmD5 ways to improve PBM procurement (EBN) For more information about Capital Rx and this episode, please visit Judi Health - Insights.

In this episode of Astonishing Healthcare, Judi Health's Sam Custer, who leads the member communications team, shares tips and insights on how to communicate effectively with plan members - around open enrollment and throughout the year. Sam last joined us for Episode 39, which highlighted how the communications and product teams collaborated to ensure we provide clear, compliant communication materials to Medicare members to meet CMS requirements, and this time, we dive into how to educate plan members at open enrollment and throughout the year. After all, as Marsha Perry, our head of benefits and compensation, explained during Episode 72 - The Benefits You Probably Didn't Know You Have, benefits-related education is more than just a once-a-year thing (during open enrollment).Sam describes how we approach understanding each client's unique needs and the importance of consistent messaging across all channels. We dive into ways to keep members informed throughout the year, the benefits of in-person/on-site events, and much more. If you're a "benefits nerd" like us (and Marsha 😀), this episode is for you.The Articles that Prompted the EpisodeEmployers prepare for disruptive and transformative health plan changes, WTW survey findsBenefit managers share their 7 open enrollment best practicesRelated ContentAH050 - PBM Pain Points and Overcoming the Fear of Change, with Hope Nakazato, PharmD12 New Judi® Features Innovating Pharmacy Benefit AdministrationAH082 - Pharmacy Benefit Implementations: Have No Fear, Alignment & Process are HereFor more content and information about this episode, including the show notes and transcript, please visit Judi Health - Insights.

On Episode 91 of Astonishing Healthcare, we dove into the Workplace Intelligence Forecast for 2026 - The 10 Trends Businesses Need to Focus On! Here at Judi Health, we obviously live in the health benefits world and generally focus on content revolving around the pharmaceutical supply chain (i.e., PBM), health tech, and the administration of employee benefits, more broadly... but there is A LOT more going on our there that impacts America's workforce. Our guest, Dan Schawbel, Managing Partner of Workplace Intelligence (links below), has been tracking and publishing research on workplace trends for well over 15 years, and he unpacks the forces shaping the future of work, today. Aside from rising healthcare costs, how are employers - and their benefits leaders - thinking about remote work vs. returning to the office (and the impact on working mothers), the use of AI and a widening skills gaps, and the shift from white-collar to blue-collar jobs? Dan paints a picture of a market where employer leverage has returned amidst hiring freezes and layoffs. This newer dynamic intensifies the pressure on benefits teams, who are on the front lines, grappling with the complexities of GLP-1 drug coverage, and the critical need for mental health support, for example. Other highlights of the discussion include:AI is widening the skills gap, and many companies are failing to provide adequate training, leaving employees feeling unprepared; this is fundamentally reshaping learning and development needs for 2026.The era of the "Great Resignation" is over - employers now have leverage, driving return-to-office mandates and changing the power dynamic.Amidst rising costs, a comprehensive and affordable healthcare plan has become a powerful tool for employers - sometimes valued even more than a salary increase.Unsustainable healthcare cost increases are reaching a boiling point. Dan predicts 2026 will be the year the system either breaks or fundamentally changes, driven by extreme cost pressures on both employers and employees.The gap between what the C-suite thinks about AI and what the workforce says is extraordinarily wide: "We found that 96% of the C-suite expect AI to boost worker productivity... But when we asked employees, 77% of them say that AI has increased their workload. So it's done the exact opposite."Additional Resources/LinksConnect with Dan Schawbel on LinkedInWorkplace Intelligence Weekly (Free Newsletter - LinkedIn)Join Dan Schawbel and Claude Silver, Chief Heart Officer at VaynerX and author of Be Yourself At Work, for an exclusive webinar to look at the Workplace Trends 2026 Forecast: Click Here to RegisterRelated ContentAH072 - The Benefits You Probably Didn't Know You Have, with Marsha PerryReplay - Strategic Well-Being: Rethinking Health Benefits to Empower Employees and Drive ImpactAH086 - Balancing Technology and a Human Touch in Member Service, with Lisa Ellerhorst and Sonia PettisHealth Benefits 101: The Importance of a Transparent PBM ModelFor more content and information about this episode, including the show notes and transcript, please visit Judi Health - Insights.

For Episode 90 of Astonishing Healthcare, Jim Winkler, Chief Strategy Officer at Business Group on Health, joins us in the studio for a lively discussion about the results of their 2026 Employer Health Care Strategy Survey! This annual study is packed with qualitative and quantitative information and highlights the top trends in employer-sponsored health care. Jim brings decades of experience to the table and puts helpful context around the headline data and employers' expectation for a ~9% year-over-year health care cost increase. He also shares his perspective on the evolution of the role benefits brokers and consultants play, how employers can navigate the rapidly evolving market and inflationary storm, vendor accountability, and how to position difficult decisions around making big changes. Discussion HighlightsCosts are expected to rise 9% in 2026, marking the worst multi-year surge in over a decade; it’s another year of healthcare costs rising by more than benefits teams forecasted.Pharmacy's share of the total cost has jumped to 24%, driven by expensive GLP-1 and cancer drugs, and some other new cost drivers include mental health and autoimmune conditions.Proactive employers have been reviewing their data and are optimizing their programs, cutting underused solutions, investing where there’s a tangible return, and tightening controls on high-cost treatments.Employers are aggressively scrutinizing partners and exploring alternative PBM and health plan models, as they should be (vendor accountability has become increasingly important over the years) - change is imminent (i.e., expect an acceleration of RFP activity).Additional Resources2025 Employer Well-being Strategy Survey: Executive SummaryBusiness Group on Health - Resources (Surveys, Data, etc.)Related ContentHow employers can take back control of unnecessary pharmacy spendingReplay - Strategic Well-Being: Rethinking Health Benefits to Empower Employees and Drive ImpactSigns it is time to change your PBM vendor, and how to overcome common hesitationsHealth Benefits 101: The Importance of a Transparent PBM ModelFor more content and information about this episode, including the show notes and transcript, please visit Judi Health - Insights.

On Episode 89 of Astonishing Healthcare, we are talking about some "visual treats," as the title suggests! Our guest, Andrew Tsang, has been posting some very cool things on LinkedIn of late, including Sankey and other dynamic charts highlighting where the money flows in healthcare (from the premium dollars to the care plan members receive), and which stakeholders win or lose in different scenarios via a 5-Way Seesaw he developed using AI! If you're a [healthcare] data nerd, this episode is definitely for you, and you'll want to check out:How many layers are between your employer's healthcare dollars and care? on LinkedIn (you can see where every $100 an employer spends goes!)What would happen if power actually shifted in healthcare? on LinkedIn (5-Way Seesaw)Andrew discussed how and why:A significant portion of the healthcare premium is consumed by administrative layers and middlemen before ever funding patient care.Employers can combat wasteful spending by demanding full access to their claims data, then identifying and eliminating things that extract value from their plans (or don't work for their populations).Integrated care models (like Kaiser Permanente) and direct primary care help eliminate friction by aligning provider and payer incentives, allowing doctors to focus on practicing medicine (vs. revenue cycle management).New technologies like AI-powered prior authorizations may reduce administrative costs for payers but risk creating new burdens for providers and patients, if we're not careful.Hospitals face a fundamental conflict: core, life-saving services like ICU and emergency care are often unprofitable and must be cross-subsidized by higher-margin procedures.Related ContentHow 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 HoganCapital Rx Unveils Healthcare’s First Unified Pharmacy and Medical Claims Processing PlatformPharmacy Benefits 101: Prior AuthorizationsAH048 - High-Cost Orphan Drugs, Securing Claims Data, and More, with Dr. Eric BrickerFor more content and information about this episode, including the show notes and transcript, please visit Judi Health - Insights.

On Episode 88 of Astonishing Healthcare, we're celebrating Women Pharmacist Day (#WPD2025) and sharing stories from four of our amazing team members: Allison Gallant, PharmD (Sr. Strategic Account Executive), Cindy Strassner, RPh (Customer Success Pharmacist), Lorece Shaw, PharmD (Sr. Director of Prior Authorization and Clinical Care), and Hope Nakazato, PharmD (VP of National Business Development). These women aren't just talking about improving healthcare or celebrating one day - they're actively promoting and implementing change, mentoring the next generation of pharmacists, and building systems to improve clinical workflows and member care.Lorece, Allison, Hope, and Cindy highlight their career journeys, insights on leadership, and the importance of mentorship to their personal and professional development throughout the discussion. They offer unfiltered advice on career growth, overcoming obstacles, staying resilient and expressing confidence in yourself, and how to work together to fix what's broken in pharmacy and health benefits. Whether you're interested in "non-traditional" career paths for pharmacists, curious about how pharmacists work in managed care, or just need some motivation to go for the next big opportunity and a reminder that you've got to be prepared and show up with confidence, per Allison and Lorece, respectively, this episode is for you!Related ContentSigns it is time to change your PBM vendor, and how to overcome common hesitations (by Hope Nakazato, PharmD, MBA)AH018 - What's the Right Path? Post-grad Options for PharmacistsPharmacy Benefits 101: Prior AuthorizationsHealth Benefits 101: The Importance of Clinical ProgramsAH040 - Celebrating Women Pharmacist Day 2024For more content and information about this episode, including the show notes and transcript, please visit Judi Health - Insights.

In this episode of Astonishing Healthcare, return guest Libbi Green, PharmD (Manager, Formulary Operations) joins Justin Venneri for a discussion about the 2025 flu season, including the latest vaccine-related updates that employer plan sponsors and plan members need to know. We discuss the effectiveness of last year's flu vaccines, factors influencing the rates, vaccination timing, and how there can be differences in state vs. federal guidelines, among other topics!HighlightsLarger employers may need to tailor flu programs across different states due to varying regulations.Federal agencies - ACIP and the CDC - are recommending the annual flu vaccine but are emphasizing single dose formulations that are free of preservatives.For people who regularly get or would like to get the flu vaccine, the timing is good now, before the end of October. For other vaccines - COVID, etc. - it's important to discuss timing and need with providers to reach a "shared decision."For plan sponsors, working with a PBM partner "to ensure patients have the access that they need and that you're meeting all regulatory compliance" is crucial.Judi®'s flexibility helps allow plan sponsors to react quickly and ensure vaccine-related claims are appropriately processed for their populations.Related ContentWhat employers need to know about federal vaccine policy changes (Mercer)AH072 - The Benefits You Probably Didn't Know You Have, with Marsha PerryAH071 - A Look at What's Really Driving Drug Spend, and How it Impacts Us, with IQVIA's Michael Kleinrock12 New Judi® Features Innovating Pharmacy Benefit AdministrationReference MaterialsInterim Estimates of 2024–2025 Seasonal Influenza Vaccine Effectiveness — Four Vaccine Effectiveness Networks, United States, October 2024–February 2025RSV monoclonal antibody nirsevimab 83% effective in babies, data revealBEYFORTUS® reduced hospital and doctor visits for RSV disease in babies by 87%, according to largest US real-world studyFor more content and information about this episode, including the show notes and transcript, please visit Judi Health - Insights.

Episode 86 of the Astonishing Healthcare podcast focuses on several pharmacy and health plan member service-related topics with Lisa Ellerhorst (Sr. Director, Customer Care Operations) and Sonia Pettis (Manager, Customer Care Operations)! Lisa and Sonia have been with Judi Health (Capital Rx) since 2020 and have helped Will Tafoya develop our unique contact center model from the ground up. Building on Episode 34 - Customer Care in Healthcare: Setting a Higher Bar, and the questions plan sponsors can ask during the RFP process (Episode 84), we discuss:Several of the most frequent reasons plan members call and how those questions are handled, including switching a prescription from retail to mail and vice versa, prior authorizations for GLP-1s, and more. How to navigate transitions and focus on quality care (over speed).What it takes to maintain a high level of customer satisfaction (99%) while handling a 50% spike in call volume year-over-year.The communication strategy used to educate members and help them navigate new offerings effectively.The role of AI and how agentic AI can support member care and free up our skilled, PTCB-certified reps to handle more complex issues.Future-proofing the service model and preparing for the 2026 welcome season.Related ContentPharmacy Benefits 101: Building an Award-Winning Call Center from ScratchWatch: Are Your Prior Authorizations Actually Working?AH017 - Pharmacy Benefits 101: Prior AuthorizationHow employers can take back control of unnecessary pharmacy spendingCapital Rx’s Customer Care Team Wins 5 Stevie® Awards for Customer ServiceFor more information about Capital Rx and this episode, please visit Judi Health - Insights.