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Next-Gen PBM Capital Rx Becomes a Tech Co: Inside New PBA Biz, $106M Series C & Big Plans

by JESSICA DAMASSA

What’s the bigger news coming out of Capital Rx: that the next-gen PBM just closed a $106 million dollar Series C? Or, that the health tech startup’s business model has expanded significantly over the past 18 months, from PBM-only to PBM-plus-PBA, meaning that instead of just servicing the pharmacy benefits management needs of employer groups directly, that now they’re also adding to their business by selling THEIR TECH to other carriers and health systems so they can use it to administrate their benefits plans??

Capital Rx’s CEO AJ Loiacono takes those questions in stride, lets us in on which “side” of the business fueled their 200% year-over-year growth in 2021, and gives us the details on that tech that his business developed and why its standout compared to the inefficient infrastructure that currently exists to administrate and process pharmacy claims.

The big deal here is that AJ and team are tackling one of the biggest friction points in the cost of pharmacy benefits: the cost to administer a plan. They reduce that cost, and the “net cost” of every drug is reduced. AJ says its in this way that Capital Rx operates at one-seventh the cost of his competitors, the “Big Three PBMs” (CVS’s Caremark, Express Scripts, and UnitedHealth’s OptumRx) and saves its customers an average 27% on their prescription drug spend.

Now that Capital Rx has their slick enterprise software, will the business continue to operate a dual PBM-plus-PBA model, or will they double-down on the PBA side? AJ lets us know what’s next and (spoiler alert) it sounds like things might go in a surprising direction. If Capital Rx’s software is so effective at doing all the things it takes to manage pharmacy claims — underwriting sequences, implementation management and onboarding, communication, patient portals, network management, reimbursement networks, eligibility checks, etc. – what stops Capital Rx from processing other kinds of healthcare claims? Is a step into the medical claims processing side of the healthcare world on the roadmap? Tune in and find out!

For Your Radar — Huge Implications for Healthcare in Pending Privacy Legislation

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Deven McGraw
Vince Kuraitis

By VINCE KURAITIS and DEVEN McGRAW

Two years ago we wouldn’t have believed it — the U.S. Congress is considering broad privacy and data protection legislation in 2019. There is some bipartisan support and a strong possibility that legislation will be passed. Two recent articles in The Washington Post and AP News will help you get up to speed.

Federal privacy legislation would have a huge impact on all healthcare stakeholders, including patients.  Here’s an overview of the ground we’ll cover in this post:

  • Why Now?
  • Six Key Issues for Healthcare
  • What’s Next?

We are aware of at least 5 proposed Congressional bills and 16 Privacy Frameworks/Principles. These are listed in the Appendix below; please feel free to update these lists in your comments.  In this post we’ll focus on providing background and describing issues. In a future post we will compare and contrast specific legislative proposals.

Continue reading…

Silencing Noisy Health Care?

By MATTHEW HOLT

As you’ve probably heard (enough!) from me and Indu Subaiya over recent months on video, at Health 2.0 or here on THCB, we are finally arriving at the point where health care tech is “flipping the stack” — where we realize that we can’t practice the old way, and instead need to move the care of the chronically ill to an always on, always monitoring, always measuring, always messaging tech platform.

But we need to figure out a way to both create that platform and the services for the people who need help–without overwhelming them. Too often we are putting too much technology into patients’ and clinicians’ lives and creating too much noise. While I’ve been aping Bob Wachter calling for an air traffic control function in health care, one of the most interesting new companies in health tech/services, Livongo, has been working on a  related idea. They’ve been promoting it by looking to #SilenceNoisyHealthCare on Twitter and Linkedin recently

Tuesday 30th at 1 ET – 10 PT I’m hosting a webinar with Livongo’s CEO Glen Tullman &  & Chief Medical Officer Jennifer Schneider, M.D. Jessica DaMassa tweeted that Glen and I are in a cage match, and it is an Oxford v Cambridge affair (although Jennifer brings some Stanford & Hopkins class to the proceedings).

But what’s really going on is that Livongo is adopting a new philosophy that they think will silence the noise and fix the patient experience. What do they mean by that? Join me on the webinar to learn more.