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In this episode, we are joined by Chris Hamilton, Partner and Employee Benefits Practice Leader at Hotchkiss Insurance, an independent insurance agency based in Texas. With nearly two decades of experience in corporate finance and employee benefits, Chris helps employers navigate the complexities of the healthcare system, reduce costs, and gain greater control over their health plans by moving beyond traditional insurance models. In addition to his work at Hotchkiss Insurance, Chris is the founder of Benefits Insider, an educational platform dedicated to helping employers understand how healthcare financing really works. Through practical case studies, industry analysis, and real-world examples, he empowers business leaders to make more informed decisions about employee benefits and healthcare spending. Recognized as the 2025 BenefitsPro Advisor of the Year, Chris has become a leading voice on healthcare transparency, employer-sponsored health plans, and cost-containment strategies. He regularly contributes to podcasts, conferences, and educational content designed to simplify one of the most misunderstood areas of business. This conversation explores: How Chris got started in the healthcare and employee benefits industry The unintended consequences of the Affordable Care Act on employers and healthcare The incentives that drive insurance companies, pharmacy benefit managers (PBMs), and other healthcare stakeholders Alternative approaches to controlling healthcare costs Why are healthcare costs continuing to rise, and what can employers do to take back control of their benefits strategy? Tune in to hear Chris's practical insights into the healthcare system and how businesses can create more efficient, cost-effective plans for their employees. Connect with Chris: Personal Website Hotchkiss Insurance LinkedIn Youtube Tiktok
Let's talk PBM's. What even is a P-B-M? Pharmacy benefit managers have been around since the 1960's, although back then, they were basically claims processors. Things changed in the 80's and 90's following the first iteration of ERISA when employers saw PBMs as potential cost containment strategies. The industry continued to explode until 2007 when CVS acquired Caremark, and now the market is really consolidated into just three major players. Why does this matter? Well, PBMs control just about everything drug-related in the US these days, and that includes the cost. Given that we have not seen the promised drop in drug prices, Americans and employers are still bearing the burden of this bloated and broken system. To unpack how this works and what folks are doing about it, we invited back Shawn Gremminger, the President and CEO of the National Alliance of Healthcare Purchaser Coalitions. His organization works with regional coalitions of employers to help them advance health policy, leverage their collective power, and drive market change.
THIS SPONSORED PODCAST EPISODE IS BROUGHT TO YOU BY CVS HEALTH.In this sponsored episode, James Margiotta, Chief Growth Officer at CVS Caremark, joins Health Affairs Publishing's Jessica Bylander to unpack the role of pharmacy benefit managers (PBMs), their impact on prescription drug costs, and the value PBMs bring to the health care system.James has nearly 35 years of experience driving innovation, operational excellence, and enterprise value across the healthcare system. In his current role, James leads the team responsible for partnering with clients to identify their unique needs and bringing forward strategic solutions to meet their objectives.Throughout his career at CVS Health, James has scaled businesses across CVS Caremark, CVS Accountable Care, Minute Clinic, Aetna, and CVS Pharmacy — each with its own challenges, cultures, and market dynamics.James and Jessica's conversation explores how PBMs help employers, health plans, governments, and unions manage rising prescription drug costs while balancing affordability, transparency, and member experience. James explains CVS Caremark's approach to controlling costs, dives into the growing demands for price transparency, and how artificial intelligence may transform pharmacy benefits and member navigation services.
THIS SPONSORED PODCAST EPISODE IS BROUGHT TO YOU BY CVS HEALTH.In this sponsored episode, James Margiotta, Chief Growth Officer at CVS Caremark, joins Health Affairs Publishing's Jessica Bylander to unpack the role of pharmacy benefit managers (PBMs), their impact on prescription drug costs, and the value PBMs bring to the health care system.James has nearly 35 years of experience driving innovation, operational excellence, and enterprise value across the healthcare system. In his current role, James leads the team responsible for partnering with clients to identify their unique needs and bringing forward strategic solutions to meet their objectives.Throughout his career at CVS Health, James has scaled businesses across CVS Caremark, CVS Accountable Care, Minute Clinic, Aetna, and CVS Pharmacy — each with its own challenges, cultures, and market dynamics.James and Jessica's conversation explores how PBMs help employers, health plans, governments, and unions manage rising prescription drug costs while balancing affordability, transparency, and member experience. James explains CVS Caremark's approach to controlling costs, dives into the growing demands for price transparency, and how artificial intelligence may transform pharmacy benefits and member navigation services.
In this episode of the PBM Reform Podcast, host Greg Reybold, Vice President and General Counsel at APCI, welcomes Josh Golden, Senior Vice President of Strategy at Judi Health and a nationally recognized voice in Pharmacy Benefit Manager reform. With more than 20 years of healthcare consulting experience, Golden brings deep expertise in vendor procurement, contract negotiation, plan design, and benefit strategy for large employers, government entities, and unions. Together, Reybold and Golden examine the financial models behind today's PBM industry and why true transparency remains so difficult for employers, plan sponsors, patients, and pharmacies. The conversation explores how current PBM arrangements often benefit the PBMs more than the employers paying for coverage or the patients relying on their prescription benefits. Golden explains why auditing PBM contracts, rebate structures, spread pricing, administrative fees, pharmacy networks, and formulary decisions is essential to understanding the real economics of prescription drug benefits. This episode also addresses a growing concern in healthcare: PBM steering behavior. Are patients being quietly pushed toward specific formularies, specific pharmacies, and restricted networks that operate like closed networks without being clearly disclosed? Reybold and Golden discuss how this behavior can limit patient choice, disadvantage independent pharmacies, and distort the stated goal of lowering drug costs. The discussion also tackles the role of federal reform efforts, including whether the Appropriations Act represents meaningful PBM accountability or whether it risks becoming another layer in the broader shell game surrounding PBM reform. Finally, the episode asks one of the most important questions in pharmacy policy today: should PBMs own pharmacies? If vertical integration is promoted as a way to lower drug costs, where is the proof — and who actually benefits? Transparency, Auditing, and the PBM Shell Game | PBM Reform
In this episode of the PBM Reform Podcast, host Greg Reybold, Vice President and General Counsel at APCI, welcomes Josh Golden, Senior Vice President of Strategy at Judi Health and a nationally recognized voice in Pharmacy Benefit Manager reform. With more than 20 years of healthcare consulting experience, Golden brings deep expertise in vendor procurement, contract negotiation, plan design, and benefit strategy for large employers, government entities, and unions. Together, Reybold and Golden examine the financial models behind today's PBM industry and why true transparency remains so difficult for employers, plan sponsors, patients, and pharmacies. The conversation explores how current PBM arrangements often benefit the PBMs more than the employers paying for coverage or the patients relying on their prescription benefits. Golden explains why auditing PBM contracts, rebate structures, spread pricing, administrative fees, pharmacy networks, and formulary decisions is essential to understanding the real economics of prescription drug benefits. This episode also addresses a growing concern in healthcare: PBM steering behavior. Are patients being quietly pushed toward specific formularies, specific pharmacies, and restricted networks that operate like closed networks without being clearly disclosed? Reybold and Golden discuss how this behavior can limit patient choice, disadvantage independent pharmacies, and distort the stated goal of lowering drug costs. The discussion also tackles the role of federal reform efforts, including whether the Appropriations Act represents meaningful PBM accountability or whether it risks becoming another layer in the broader shell game surrounding PBM reform. Finally, the episode asks one of the most important questions in pharmacy policy today: should PBMs own pharmacies? If vertical integration is promoted as a way to lower drug costs, where is the proof — and who actually benefits? Transparency, Auditing, and the PBM Shell Game | PBM Reform Josh Golden is the Senior Vice President of Strategy at Judi Health (a prominent healthcare technology and benefit management firm closely associated with Capital Rx) and a nationally recognized thought leader in Pharmacy Benefit Manager (PBM) reform. With over 20 years of healthcare consulting experience, Golden specializes in vendor procurement, contract negotiation, and plan design consultation for large employers, government entities, and unions.
This time on Healthcare Now we've got a friendly face returning (by phone)! Dr Betsy Dovec is the brain behind The Surgical Institute Of Central Florida, she joins Larry and Doctor Mark from out on the scene in Winter Garden to talk with them about the world behind health care now! What's the latest about those weight-loss drugs? What do you need to know to keep yourself safe if you use them? More big lawsuits about billing, learn the math in play at some of the PBMs and insurance companies! Rural care challenges and the ACA are just a couple of the subjects at hand! And what about burgers? See omnystudio.com/listener for privacy information.
This time on Healthcare Now we've got a friendly face returning (by phone)! Dr Betsy Dovec is the brain behind The Surgical Institute Of Central Florida, she joins Larry and Doctor Mark from out on the scene in Winter Garden to talk with them about the world behind health care now! What's the latest about those weight-loss drugs? What do you need to know to keep yourself safe if you use them? More big lawsuits about billing, learn the math in play at some of the PBMs and insurance companies! Rural care challenges and the ACA are just a couple of the subjects at hand! And what about burgers? See omnystudio.com/listener for privacy information.
Mike and Madison discuss TrumpRx's expansion to include more than 600 generic drugs, Optum Rx's latest pharmacy transparency announcement and what potential Federal Trade Commission action against PBMs could mean for plan sponsors. Register for upcoming Employers Health webinars or watch on demand at https://www.employershealthco.com/resource-center/events/ Sign up for our monthly newsletter at https://www.employershealthco.com/#subscribe_cta Find additional helpful benefits strategies and resources at https://www.employershealthco.com/resource-center/articles/
So much for common ground… Buckle up because this week Jillian Michaels sits across from Sam Seder, host of The Majority Report, for a bare-knuckle debate on government waste, Iran, Israel, Russia, Ukraine, DOGE, USAID and more. Nothing was off-limits. If you wanted a polite, coordinated conversation, go somewhere else. This is a full-throated ideological fight. In this episode, they tear into: The Global Health & Foreign Aid Crisis: The dismantling of USAID is front and center — is America's withdrawal from international NGO funding a necessary correction or a catastrophic failure? The debate gets heated fast, with the "last-mile" operational collapse in Uganda and the human cost of overnight co-investment mandates laid bare. The Mamdani-Khomeini Comparison: The Iranian diaspora isn't staying quiet — and this is where things get truly combustible. Jillian comes in swinging, amplifying the voices of exiles who lived through the revolution and are drawing chilling parallels between Mamdani's ideological framework and the Ayatollah's early intellectual positioning and Sam gets outraged. The Iran Conflict & The Fog of War: A fierce legal and ethical battle erupts over the recent strikes in Iran. The tragic Minab school bombing, the possibility of flawed targeting intelligence, and the complex question of civilian protections when military assets are embedded in non-military infrastructure all get put under the microscope. Russia, Ukraine & the NATO Fault Line: With the war grinding into a new phase, they go head to head on whether Western alliance commitments are a stabilizing force or a provocation that made this conflict inevitable DOGE, PBMs, and Domestic Warfare: The heat turns inward to tackle domestic deregulation, the rising influence of the Department of Government Efficiency, and whether the new delinking and transparency rules under the TrumpRx framework are liberating healthcare or creating new corporate loopholes for PBMs to exploit. Two distinct worldviews. Absolute zero consensus. Who held their ground, and who got exposed? Stream the full, unfiltered debate now and drop your thoughts in the comments below. OneSkin: Get 15% off OneSkin with the code KEEPINGITREAL at https://www.oneskin.co/KEEPINGITREAL #oneskinpod Skims: Shop Everyday Cotton, and all of my favorite bras and underwear at http://www.skims.com/jillian #skimspartner Beam: Visit https://shopbeam.com/REAL and use code REAL to get our exclusive discount of up to 40% off. Learn more about your ad choices. Visit megaphone.fm/adchoices
The city of Des Moines is expecting a budget shortfall after Governor Kim Reynolds signed a property tax bill into law. Democratic candidate for governor Rob Sand says he would address PBMs. And who are the Republicans running to represent Iowa's Second Congressional District?
On today's episode of The Gist Healthcare Podcast: health systems join a new federal initiative aimed at streamlining prior authorizations, lawmakers revive legislation that would ban PBMs from owning retail pharmacies, and a judge clears the way for CVS Health to sell its long-term care pharmacy business. Hosted on Acast. See acast.com/privacy for more information.
Independent pharmacies in Rhode Island are making a call for pharmacy benefit manager reform, pointing to "predatory practices" such as price gouging and limiting access to medications. Local pharmacy owner have now launched a campaign seeking immediate relief from the Rhode Island General Assembly to protect independent pharmacies and customers from what they describe as harmful conduct by PBMs. Nicholas Shanos of Suburban Pharmacy joins Gene to discuss these issues.See omnystudio.com/listener for privacy information.
In 2008, Katy Talento walked away from Capitol Hill and into a Catholic convent. Within a year, she walked out. Within another decade, she sat inside the White House shaping health policy. Somewhere in between, she got labeled “infertile” after a single cycle of testing and spent years believing it.That label stuck. The pain that came before it never got investigated. Doctors offered birth control and moved on. No one asked why her body was struggling. No one followed the thread.Talento built her career inside the very systems she now critiques. She worked on federal health policy, global disease programs, and later advised the Trump administration on healthcare reform. She helped advance price transparency rules in a system where hospitals can still list 457 different prices for the same service.Then she left.Now she builds employer health plans that bypass insurers, PBMs, and traditional networks. Her approach replaces insurance contracts with direct payment, nurse navigators, and cost sharing models that promise simplicity but raise hard questions about risk and protection.This conversation sits in that tension.Talento describes a healthcare system shaped by layered incentives, where insurers, hospitals, and intermediaries profit from complexity. She argues that employers hold the leverage to disrupt it. The host pushes on what happens when patients fall outside those structures, when contracts disappear, and when community based models fail.The episode moves through infertility, misdiagnosis, insurance design, and the mechanics of employer sponsored care. It tracks how policy decisions made in Washington ripple into exam rooms, billing departments, and family lives.It also confronts a harder truth.Even insiders who understand the system can still get caught in it.RELATED LINKSAllBetter HealthKaty TalentoThem Before UsAn Arm and a LegRelentless Health ValueFEEDBACKLike this episode? Rate and review Out of Patients on your favorite podcast platform. For guest suggestions or sponsorship email podcasts@matthewzachary.comSee Privacy Policy at https://art19.com/privacy and California Privacy Notice at https://art19.com/privacy#do-not-sell-my-info.
**In this episode, I explain why rapid growth in a PBM-heavy pharmacy actually triggers serious cash flow problems, how the timing gap between paying your wholesaler and getting reimbursed by PBMs creates a financial squeeze, and what you can do to offset it.** **Show Notes:** 1. **Introduction** [0:00] 2. **Cash Flow Challenges in Pharmacies** [0:10] 3. **Impact of Rapid Growth on Cash Flow** [2:45] 4. **Strategies to Mitigate Cash Flow Issues** [3:54] 5. **Financial Consequences of Pharmacy Growth** [6:19] 6. **Controlling Your Pharmacy Cash Flow** [7:17] **Links mentioned in this episode:** Join our DiversifyRx Facebook Group for FREE: https://www.facebook.com/groups/diversifyrx/ ----- #### **Becoming a Badass Pharmacy Owner Podcast is a Proud to be Apart of the Pharmacy Podcast Network**
Welcome back to Last Month in Healthcare! This month, Spencer and Nathaniel sit down without a guest to unpack the biggest healthcare headlines and regulatory shifts from April 2026.From state-level crackdowns on PBMs to a surprising loophole that allows urban hospitals to siphon rural hospital aid, the guys dissect the policy changes and market moves that are actively reshaping the industry. They also discuss the affordability crisis driving a 26% surge in ACA Bronze plan enrollment, Amazon's aggressive new play into the GLP-1 and primary care market, and why CMS is finally (and officially) killing the fax machine by 2028.Plus, Spencer plays a game of "Blind Ranking," attempting to properly order the top 10 best practices and features of a modern self-funded health plan (including pass-through PBMs, cash-pay surgery networks, and pharmacogenomics) without knowing what's coming next.Thank you to this year's sponsor, Walk On Clinic!If you'd like your question answered on next month's episode, call/text 469-213-6381 and leave us a voicemail/text.Chapters: (00:00:00) Intro & Sponsor Shoutout: Walk On Clinic (00:01:42) Bipartisan State Healthcare Regulations & PBM Oversight (00:04:40) ACA Shifts: The Rise of Bronze Plans & HSA Eligibility (00:08:38) The FTC's Vague New Healthcare Task Force (00:10:10) The Rural Hospital Aid Loophole Exploited by Urban Hospitals (00:11:27) Amazon Launches a $149/mo GLP-1 & Primary Care Program (00:15:18) CMS is Finally Ending the Fax Machine (Saving $781M) (00:16:48) Game: Blind Ranking the Best Self-Funded Plan Features (00:24:45) PSA: Watch Out for These Hidden Carrier Contract Clauses
Welcome back to Last Month in Healthcare! This month, Spencer and Nathaniel sit down without a guest to unpack the biggest healthcare headlines and regulatory shifts from April 2026.From state-level crackdowns on PBMs to a surprising loophole that allows urban hospitals to siphon rural hospital aid, the guys dissect the policy changes and market moves that are actively reshaping the industry. They also discuss the affordability crisis driving a 26% surge in ACA Bronze plan enrollment, Amazon's aggressive new play into the GLP-1 and primary care market, and why CMS is finally (and officially) killing the fax machine by 2028.Plus, Spencer plays a game of "Blind Ranking," attempting to properly order the top 10 best practices and features of a modern self-funded health plan (including pass-through PBMs, cash-pay surgery networks, and pharmacogenomics) without knowing what's coming next.Thank you to this year's sponsor, Walk On Clinic!If you'd like your question answered on next month's episode, call/text 469-213-6381 and leave us a voicemail/text.Chapters: (00:00:00) Intro & Sponsor Shoutout: Walk On Clinic (00:01:42) Bipartisan State Healthcare Regulations & PBM Oversight (00:04:40) ACA Shifts: The Rise of Bronze Plans & HSA Eligibility (00:08:38) The FTC's Vague New Healthcare Task Force (00:10:10) The Rural Hospital Aid Loophole Exploited by Urban Hospitals (00:11:27) Amazon Launches a $149/mo GLP-1 & Primary Care Program (00:15:18) CMS is Finally Ending the Fax Machine (Saving $781M) (00:16:48) Game: Blind Ranking the Best Self-Funded Plan Features (00:24:45) PSA: Watch Out for These Hidden Carrier Contract Clauses
In this episode, guest Antonio Ciaccia, president of consulting firm 3 Axis Advisors and founder/CEO of non-profit 46brooklyn Research, joins host Dan Karnuta for a discussion about U.S. drug pricing. The model is opaque because it runs on inflated list prices and hidden discounts created by government policy and industry incentives. Instead of competing on price, drug companies raise prices and offer rebates through intermediaries like pharmacy benefit managers (PBMs), who control which drugs are covered. This system weakens normal market forces and concentrates power in the middle of the supply chain. Karnuta is an associate professor in the Naveen Jindal School of Management's Organizations, Strategy and International Management Area as well as director of its Professional Program in Healthcare Management.
In this episode of the AI at Health series on The Beat Podcast, host Sandy Vance sits down with Venky Ananth, Executive Vice President and Head of Healthcare at Infosys, for a wide-ranging and energizing conversation about what it actually means for AI to transform healthcare at scale. Venky brings a refreshingly honest and structured perspective to a conversation that is often dominated by hype, breaking down why AI is fundamentally different from every other technology wave healthcare has been through, laying out the five areas where Infosys is seeing real traction with payers, providers, and PBMs right now, and sharing the story behind two exciting developments: the acquisition of Optimum Health IT and the Pacesetters podcast and executive leadership community. If you are a healthcare leader trying to figure out where to start or how to think about AI as a whole-enterprise challenge rather than a point solution, this episode is essential listening. In this episode, they talk about: AI is not a point solution; it is a new operating system that will touch every function in every organization Healthcare is broken, fragmented, and frustrating, and AI is the first technology with the potential to fix all three at once Legacy modernization must come before AI adoption because you cannot layer intelligence on top of broken processes AI can now reverse engineer legacy systems that used to depend entirely on tribal knowledge The five pillars of AI transformation are strategy and engineering, legacy modernization, data, process reengineering, and physical AI Training AI on your own private data is the competitive wedge that separates leaders from followers Agents are the new team members, and organizations need to rethink how humans and agents orchestrate workflows together Infosys acquired Optimum Health IT, the number one-ranked Epic implementation partner according to KLAS, to deepen its provider capabilities Epic now covers an estimated 220 to 230 million distinct patients in the US and is growing internationally The Pacesetters podcast and annual executive gathering bring together CIOs, CTOs, academics, and analysts for candid, off-the-record dialogue about the future of healthcare A Little About Venky Ananth: Venky is a technology and transformation executive with deep experience leading a global business unit, scaling high-performance organizations, and delivering large-scale change through AI, cloud, and modern growth operating models. His career has focused on helping enterprises modernize core systems, improve operational efficiency, and unlock new growth through platform innovation and disciplined execution. He founded and scaled Infosys Helix, a cloud-native platform business that continues to shape payer and health platform modernization. In addition, he has led global teams across engineering, delivery, consulting, and product, giving him a broad view of strategy, technology, operations, and organizational scale. He operates at the intersection of technology, business model transformation, and leadership development, with a track record of strengthening enterprise performance and building organizations capable of sustained growth. Beyond his operating role, I host PaceSetters, a CXO leadership platform featuring conversations with leaders from healthcare, academia, private equity, and technology.
On this special LIVE from HIMSS 2026 Gil is joined by two-time TEDx speaker Christina Madison, PharmD, FCCP, AAHIVP, the founder and CEO of The Public Health Pharmacist, for a candid, wide-ranging conversation about the profession's inflection point. From the chronic misdiagnosis of cardiovascular disease in women, to the existential threat posed by PBMs and automation, to the urgent fight for pharmacist provider status, Dr. Madison articulates a bold vision: community pharmacists aren't just pill dispensers, they are public health's most accessible, underutilized, and undercompensated front line. To stream our Station live 24/7 visit www.HealthcareNOWRadio.com or ask your Smart Device to “….Play Healthcare NOW Radio”. Find all of our network podcasts on your favorite podcast platforms and be sure to subscribe and like us. Learn more at www.healthcarenowradio.com/listen
The Nurses Report on America Out Loud with Ashley Caputo, RN, FMP – This episode of The Nurses Report explores how Pharmacy Benefit Managers shape access to medications, often leading to delays and denials. It examines carve-outs, ERISA limits, and real patient impacts while highlighting the growing need for transparency, advocacy, and patient-centered decision-making in today's healthcare system...
Congratulations to Logan Eury and his new wife Emily, got married today, May 1, 2026! This C.O. Bigelow Collab Introduces the 188-Year-Old Pharmacy to a New Generation Abbode is taking over the Carolyn Bessette-Kennedy-approved shop for a month-long pop-up. https://fashionista.com/2026/05/co-bigelow-abbode-pop-up-carolyn-bessette-impact The article highlights how a pop-up and renewed interest in C.O. Bigelow has been fueled by the cultural resurgence of Carolyn Bessette-Kennedy's minimalist style, amplified by media and social buzz. This renewed attention has driven significant foot traffic and sales, showing how storytelling, nostalgia, and “quiet luxury” aesthetics can translate into real retail impact. Q&A: Mayo Clinic leaders share strategies for managing high-cost drugs without breaking the bank | Asembia AXS26 Summit https://www.managedhealthcareexecutive.com/view/q-a-mayo-clinic-leaders-share-strategies-for-managing-high-cost-drugs-without-breaking-the-bank-asembia-axs26-summit Mayo Clinic leaders emphasize that managing high-cost drugs requires clear definitions, structured formulary review processes, and multidisciplinary collaboration to balance cost, access, and clinical value. They highlight the importance of evaluating safety, efficacy, financial impact, and site-of-care decisions together, while noting that non-340B systems face increasing pressure from rising costs and reimbursement constraints. Ultimately, success depends on stronger alignment between health systems, manufacturers, and payers to sustain access without compromising quality of care. Where Gross-to-net Pressure Actually Lives After Launch Today's guest post comes from Cindy Baksh, Chief Product Officer at ConnectiveRx. https://www.drugchannels.net/2026/05/where-gross-to-net-pressure-actually.html The article explains that “gross-to-net pressure” isn't driven by a single factor, but by a combination of rebates, discounts, fees, and policy changes that continue to reshape how drug pricing actually works behind the scenes. As the industry shifts toward a “net pricing” model, traditional rebate-driven strategies are weakening, forcing manufacturers, PBMs, and pharmacies to rethink how value and profits are generated. Today's featured guest is Dr. Ndidiamaka Okpareke PharmD for Congress Dr. Ndidiamaka “Didi” Okpareke, PharmD, is a pharmacist, entrepreneur, and political candidate running for Congress in New Mexico's 1st Congressional District. A first-generation Nigerian-American, she built her career in healthcare after graduating from the University of New Mexico College of Pharmacy and went on to found and lead a successful compounding pharmacy serving her community. Motivated by nearly two decades of patient care experience, Okpareke entered the political arena to address challenges such as healthcare access, rising costs, and the shortage of providers in New Mexico. Running as a Republican, she emphasizes strengthening healthcare systems, supporting economic growth, and preserving opportunity for future generations, positioning herself as a community-focused leader bringing frontline healthcare insight into public policy. This special episode highlights how TJM Labs is redefining pharmacy operations through AI-driven automation, bringing together insights from industry leaders Bhavesh Patel, PharmD—CEO of Carepoint Pharmacy—and Jonathan Adly, PharmD, MBA—CEO of TJM Labs. At the center of the conversation is how modern pharmacies are facing rising prescription volumes, staffing constraints, and increasing operational complexity, and why traditional manual workflows can no longer keep pace. TJM Labs addresses this challenge by deploying AI-powered “digital workers” that automate tasks like prescription intake, data entry, and patient communication—allowing pharmacy teams to shift their focus back to patient care and clinical decision-making. Through the lens of both operator and innovator, the discussion explores how AI is not replacing pharmacy professionals, but augmenting them—reducing burnout, improving accuracy, and enabling scalable growth. With automation handling up to the majority of repetitive workload and delivering measurable ROI, TJM Labs represents a new model where technology and pharmacy expertise work together to create more efficient, patient-centered operations.
The Nurses Report on America Out Loud with Ashley Caputo, RN, FMP – This episode of The Nurses Report explores how Pharmacy Benefit Managers shape access to medications, often leading to delays and denials. It examines carve-outs, ERISA limits, and real patient impacts while highlighting the growing need for transparency, advocacy, and patient-centered decision-making in today's healthcare system...
The Speaker of the Tennessee House of Representatives Cameron Sexton (R) gives us insight to the last bills passed during this legislative session. Here are some of the main points. AIRPORTS- From the 9 member board of the Nashville Airport Authority, 6 state appointments and 3 local appointments. Sexton says, "We put in a lot of money, we have done a lot of things to help the airport, and so we are saying we want some picks on the board. The mayor still has picks, the governor and 2 Speakers have picks. When asked why change the Airport Authority when it is already successful? Sexton added, "It's not a power grab, I would say if you're investing $50, $100, $150 million dollars into something, wouldn't you want to have people on the board to make sure that your investment is doing well?" AFFORDABILITY- Sexton says that the state has temporarily reduced taxes several times, Cracked down on PBMs, struck down laws preventing hospitals from expanding and created workforce housing. Sexton says, "We are already an affordable state and will continue to be that way." SCHOOL VOUCHERS AND ESA- Although the state of Tennessee ranks 47th out of 50 states for student funding per capita, Sexton believes private schools with students who already attend private school are justified in receiving the $7530 Education Freedom Scholarship (an increase from last year from $7295) to go directly to pay a portion of private school tuition. The 3.2% increase would remain consistent with per-pupil base increase in the TISA formula, but less per student than what is given to private schools. When it comes to testing, public schools use TCAP, and was required for students using Education Savings Account money for private school, but without TCAP used, how will private schools show student competency? "The private schools are going to tell us what standardized test they are using. Because we want to know what that is. What I think we need to do is look at those tests, look at the TCAP and allow the public schools to use whichever national standardized test that they want to and that's fair... It would be a fascinating argument which they would choose." NewsChannel 5+ can be seen on Spectrum/Charter Ch. 182 and over the air on Ch. 5.2. Inside Politics also streams live Fridays at 7pm and Saturdays at 3pm on our website: https://www.newschannel5.com/live3 as well as the NewsChannel 5 Now app on Connected TVs through Roku, AppleTV, AndroidTV, etc. The episode will air throughout the weekend on NewsChannel 5+ Sat. at 5:30am, 3pm, Sun. at 1am, 9am, 7pm, Mon. at 2:30pm and Tues., 3pm unless pre-empted.See omnystudio.com/listener for privacy information.
Tennessee lawmakers have passed a major pharmacy reform bill aimed at pharmacy benefit managers, or PBMs, by barring companies from owning both a PBM and a pharmacy. The legislation is widely seen as targeting CVS Health, which owns Caremark and operates pharmacies across the state. Supporters say the bill is designed to curb vertical integration, restore fair competition, and protect independent pharmacies from reimbursement practices they view as harmful to patient access and community pharmacy survival. CVS has pushed back hard, warning that the new law could force it to shut down its 134 Tennessee pharmacy locations and trigger a legal challenge. The company argues the measure would reduce access for patients and does not directly address broader PBM issues like pricing or formularies. This Tennessee fight reflects a larger national battle over PBM reform, pharmacy ownership, market power, and the future of prescription drug access.
Joseph Kleiman, President of Buzz Health, is working to improve price transparency and affordability of prescription drugs. He states that providing price transparency as early as possible in the prescription process is critical for prescribers, patients, and health plans to make better, more cost-effective decisions. To achieve true transparency, all parties in the ecosystem must cooperate and share data, moving beyond pricing visibility to fully integrate systems and use real-time information to improve patient adherence and lower costs. Joseph explains, "Buzz Health really focuses on improving the process behind the scenes, developing technologies that sit within the prescription ecosystem, creating opportunities to improve price transparency, early adoption, and integrated benefits for members." "We work with everybody from pharmacies to PBMs to payers to employer groups. Anybody we believe has an opportunity that, with technology and early adoption of price transparency and adherence, could benefit them and the members they serve." "What's interesting is that, like most things, the earlier you have information, the easier it is to make actionable change, things with long-term impact. So if you have price transparency and you have it early on, a prescriber can make more informed decisions. A patient, rather than showing up at a pharmacy counter, can make decisions earlier on. So again, it's kind of like the earlier you have anything in making a decision, the easier it is for you to make a really actionable change all the way up through a PBM or health plan. If they see gaps in coverage and they have that information, they can make changes early on as well." #BuzzHealth #PrescriptionDrugs #Pharmacies #HealthcareIT #PriceTransparency #PrescriptionAffordability #PharmacyTech #MedicationAccess #HealthcareTransparency #PrescriptionPricing #PatientCare #HealthTech #PharmacyBenefits #HealthcareInnovation #PatientOutcomes #MedicalTechnology buzzhealth.com Download the transcript here
Joseph Kleiman, President of Buzz Health, is working to improve price transparency and affordability of prescription drugs. He states that providing price transparency as early as possible in the prescription process is critical for prescribers, patients, and health plans to make better, more cost-effective decisions. To achieve true transparency, all parties in the ecosystem must cooperate and share data, moving beyond pricing visibility to fully integrate systems and use real-time information to improve patient adherence and lower costs. Joseph explains, "Buzz Health really focuses on improving the process behind the scenes, developing technologies that sit within the prescription ecosystem, creating opportunities to improve price transparency, early adoption, and integrated benefits for members." "We work with everybody from pharmacies to PBMs to payers to employer groups. Anybody we believe has an opportunity that, with technology and early adoption of price transparency and adherence, could benefit them and the members they serve." "What's interesting is that, like most things, the earlier you have information, the easier it is to make actionable change, things with long-term impact. So if you have price transparency and you have it early on, a prescriber can make more informed decisions. A patient, rather than showing up at a pharmacy counter, can make decisions earlier on. So again, it's kind of like the earlier you have anything in making a decision, the easier it is for you to make a really actionable change all the way up through a PBM or health plan. If they see gaps in coverage and they have that information, they can make changes early on as well." #BuzzHealth #PrescriptionDrugs #Pharmacies #HealthcareIT #PriceTransparency #PrescriptionAffordability #PharmacyTech #MedicationAccess #HealthcareTransparency #PrescriptionPricing #PatientCare #HealthTech #PharmacyBenefits #HealthcareInnovation #PatientOutcomes #MedicalTechnology buzzhealth.com Listen to the podcast here
In this episode of The Dish on Health IT, Tony Schueth is joined by Dr. Thomas Keane, National Coordinator for Health IT at ONC, along with Alix Goss and Janice Reese. The conversation moves between policy, standards, and real-world implementation, with Tony often grounding the discussion in the practical friction points the industry continues to face. Tony opens by noting that “ONC is ONC again,” setting a lighter tone while also framing the broader conversation around where federal health IT policy is headed. He highlights Dr. Keane's unusual background spanning engineering, clinical practice, and federal leadership, asking how that path shaped his perspective on impact. Dr. Keane explains that his transition into policy was driven by exposure and opportunity, but importantly, he continues to practice medicine. Tony picks up on that point, noting how rare it is for a National Coordinator to still be actively practicing, reinforcing the value of having a policy leader grounded in real-world care delivery. Interoperability at the “Speed of Trust” Tony then shifts the conversation to one of his core themes: interoperability as infrastructure. He references Dr. Keane's framing of interoperability needing to operate at the “speed of trust,” and pushes on the tension between that vision and the reality of legacy systems still dominating the market. Dr. Keane responds by walking through ONC's dual-track approach. On one hand, rulemaking like HTI-5 is pushing toward a FHIR-based, API-driven future. On the other, ONC recognizes that legacy standards are deeply embedded and must continue to be supported. He also points to the CMS Health Tech Ecosystem initiative as a powerful example of how government can accelerate progress by convening stakeholders rather than relying solely on regulation. Tony brings Janice Reese into the discussion to ground this vision in implementation reality. Janice emphasizes that the biggest barriers are not the APIs themselves, but the underlying trust infrastructure. She outlines identity, security, consent, and directory services as the key gaps preventing interoperability from scaling nationally. Imaging as a Case Study in Misaligned Incentives Tony pivots to diagnostic imaging, framing it as a clear example where standards exist but adoption lags. He references the continued reliance on physical media like CDs and asks whether the issue is less about technology and more about incentives and certification. Dr. Keane agrees and shares a detailed example from his time as a radiologist, describing how consolidating imaging workflows improved efficiency and reduced turnaround times. He uses this to illustrate the broader point: the technology exists, but economic and operational incentives often work against seamless data exchange. He also notes that ONC's recent RFI is intended to better understand these barriers and inform future rulemaking. Tony keeps the tone light with a quick aside about McDonald's and queue efficiency, but uses it to reinforce a serious point. Even when better systems exist, organizations sometimes stick with less efficient models because they are familiar or expected. Prior Authorization: Progress, but Still Fragmented Tony then moves into prior authorization, referencing CMS-0057 and Da Vinci use cases as signs of progress, particularly on the medical side. He contrasts that with the ongoing fragmentation in pharmacy prior authorization and asks how ONC is thinking about bridging that gap. Dr. Keane emphasizes that standards alone are not enough. Real progress depends on making those standards usable in practice. He points to ongoing work with EHR vendors, PBMs, and intermediaries to ensure that real-time prescription benefit tools deliver complete and accurate information that clinicians can trust. Tony and Alix build on this by connecting real-time benefit checks to broader price transparency efforts, suggesting that combining these capabilities could fundamentally change how patients and providers make decisions together at the point of care. Price Transparency: Still Not Patient-Friendly Tony directly challenges the current state of price transparency, asking how the industry moves beyond “check-the-box” compliance to delivering something that is actually usable for patients. Dr. Keane acknowledges that while progress has been made, much of the data remains too complex and not sufficiently tailored to individual patients. He notes that CMS continues to iterate on requirements, but that making cost information actionable at the point of care remains an ongoing challenge. AI: From Hype to Real Utility Tony transitions to AI with a callback to a joke Dr. Keane made about AI either transforming healthcare or reducing it to three bullet points. He uses that setup to ask whether AI can realistically make complex healthcare data usable for patients and clinicians. Dr. Keane answers with a firm yes, pointing to existing use cases in radiology and clinical workflows where AI is already improving accuracy and efficiency. He shares examples of AI identifying stroke patterns, highlighting abnormalities in imaging, and even summarizing clinical reports. Tony then brings the conversation back to risk, asking about overreliance on AI and how policy should address bias and accountability. Dr. Keane is clear that responsibility still sits with the clinician, noting that physicians are trained to recognize bias and must independently validate AI-driven insights. Janice and Alix add that AI's success ultimately depends on the quality and standardization of the underlying data. Without consistent, trusted data, AI will simply amplify existing gaps. Information Blocking and Enforcement Tony closes the main discussion by turning to information blocking, asking what message ONC has for organizations that continue to restrict data access under the guise of technical or legal constraints. Dr. Keane outlines a range of enforcement mechanisms, from corrective action plans to potential financial penalties. He emphasizes that while ONC prefers to work with organizations to resolve issues, the expectation is clear: data must flow. Final Call to Action: Data Liquidity As always, Tony ends with a call-to-action question. If there were one thing the industry could do starting tomorrow, what would it be? Dr. Keane's answer is direct: make data liquid. He ties this back to reducing administrative burden, improving price transparency, and enabling better patient decision-making. The goal is a system where data flows seamlessly, at the direction of the patient, to support care and operations. Janice and Alix close by reinforcing that the industry does not lack standards or policy direction. The real challenge is aligning stakeholders and scaling adoption.
Pharma and tech companies are working more closely together than ever. As proven by the news of Merck and NVidia's new partnership, for example. But while the idea of using AI for drug discovery has been around for a while now, patient access has an awfully long way to catch up to the promise of these new therapies. In a new pharmaphorum podcast, web editor Nicole Raleigh speaks with Dean Erhardt, founder of D2 Solutions, an end-to-end strategic partner delivering industry-leading consulting and purpose-built technologies to pharma manufacturers, hospitals, pharmacies, payers & PBMs. The conversation focuses on the disconnect between distributions, reimbursements, and patient services, particularly when it comes to speciality medicines, as well as patient access today versus the state of patient access tomorrow, and the benefit or otherwise of price protection guarantees with PBMs, when it comes to new therapies. You can listen to episode 256 of the pharmaphorum podcast in the player below, download the episode to your computer, or find it – and subscribe to the rest of the series – on Apple Podcasts, Spotify, Overcast, Pocket Casts, Podbean, and pretty much wherever else you download your other podcasts from.
In this episode, Suzanne Spradley and Chase Cannon discuss two recent circuit court decisions and their impact on employer-sponsored group health plans. Suzanne first discusses a Sixth Circuit decision involving a state law that attempts to regulate PBMs. Suzanne and Chase walk through Supreme Court precedent that appears to be driving states to enact PBM laws, and they explain how ERISA preemption is at the heart of it all. Suzanne concludes the podcast by outlining another federal decision relating to a fiduciary breach claim of an employer group health plan.
Nearly one billion prescriptions are abandoned at the pharmacy counter every year, often because patients are blindsided by the cost.This week, co-host Halle Tecco is joined by Wendy Barnes, President and CEO of GoodRx, to discuss the chaos of prescription drug pricing, the murky world of Pharmacy Benefit Managers (PBMs), and how digital tools are changing patient affordability. They break down the layered system of manufacturers, payers, and pharmacies that creates inconsistent pricing, and explore the current push for greater transparency.We cover:The cascade of drug pricing: from initial manufacturer costs and rebates to payer and pharmacy contracts, which results in vast price variability for consumersWhat it would take to get to price transparency in drug pricingThe current pressures on PBMs, including efforts to ban "spread" and the practice of offshoring rebate contracting for tax advantagesWhy pharmacies haven't gone online like other areas of consumer goodsThe future of medication access, including the growth of pharma's direct-to-patient programs and the low current adoption of home delivery despite widespread retail pharmacy closures— About our guest:Wendy Barnes is the President and CEO of GoodRx. She has over 30 years of leadership experience across the pharmacy and medical benefit industry. Most recently, Wendy served as CEO of RxBenefits, where she led the company in providing pharmacy benefit support to more than 2,000 self-insured clients, representing over 3 million lives. Prior to that, she served as President of Express Scripts Pharmacy, overseeing operations for 100 million beneficiaries. Her leadership spans roles at Rite Aid, Premier Inc., and the U.S. Air Force, where she served as a Medical Service Corps Officer. She holds a B.S. degree in Biochemistry from the United States Air Force Academy and an M.B.A. degree from the University of Alaska Anchorage.—
Prescribing medication has become unfathomably complex these days, with rules interposed between the patient and physician by pharmacies, payers, and pharmacy benefit managers (PBMs). Drew Hunsinger, Executive VP, Corporate Strategy at DrFirst, points out that a single medication may have multiple indications (conditions for which it can be prescribed) and rules vary by indication. Colin Banas, MD, Chief Medical Officer, says that 90% of new medications are considered specialty medications with associated complex rules.Learn more about DrFirst: https://drfirst.com/Healthcare IT Community: https://www.healthcareittoday.com/
Josh Golden, SVP of Strategy at Judi Health, returns to the Astonishing Healthcare podcast for a timely discussion about the world of drug pricing and what's shaking things up. Josh shares insights from his two decades of experience working with many of our country's largest employers and navigating [very heavy, sometimes scary] pharmacy benefit manager (PBM) contracts. He explains why the industry still relies on Average Wholesale Price (AWP) despite its known flaws, how Maximum Allowable Cost (MAC) lists have been used to drive hidden pricing arbitrage, and why the market is shifting so rapidly toward transparency and alignment.The discussion covers the need for plan sponsors to understand the true cost of pharmaceuticals and how four massive forces are colliding to form "lightning in a bottle" that will drive systemic change in the pharmacy ecosystem. As reforms across the state and federal levels pressure the industry to adapt, plan sponsors must seek forward-thinking PBM partners that prioritize transparent pricing and decisions that benefit the plan and lead to better care for members.HighlightsJosh emphasizes the sordid history of AWP manipulation and explains why it remains a predominant, yet deeply flawed, pricing benchmark in PBM contracts.PBMs frequently deploy MAC lists to extract hidden value, creating wide pricing variations for plan sponsors, pharmacies, and patients.The healthcare industry is moving toward cost-plus economics, making more realistic and reliable pricing benchmarks even more important.Four major trade winds are accelerating PBM reform: state regulations, retail pharmacy closures, transparent cash prices for expensive drugs like GLP-1s, and plan sponsor class action lawsuits.Related ContentWhat is NADAC & How Does It Differ From AWP?Why this benefit leader switched to a more modern, transparent PBMWhat Is the Role of a Pharmacy Benefits Manager (PBM)?Health Benefits 101: The Importance of a Transparent PBM ModelFor more information about Judi Health and this episode, please visit Judi Health - Insights.
Healthcare stays expensive because the system hides prices and quality from the people paying for care, especially employers. We talk with Katie Talento about how CAA 2026 transparency and Department of Labor fiduciary rules could expose PBM practices, reshape contracting, and give plan sponsors real leverage if enforcement follows.• Why invisible prices and invisible quality break the healthcare market • How incentives and lobbying protect opacity across hospitals, PBMs, insurers and drugmakers • Why Washington lacks ERISA and employer-plan expertise • What CAA 2026 changes for PBM disclosures and fiduciary responsibility • How “check the box” compliance can fail without enforcement • How employers can use machine readable files plus claims data for network analysis • Why cash-pay and direct contracting get blocked by network contract provisions • What near-term reforms could bend the cost curve, including stronger HSA and ICHRA modelsYou can find me at katytolento.com
Mississippi Today health reporters Gwen Dilworth and Sophia Paffenroth review what the Legislature did (or didn't) accomplish with PBMs, Medicaid, abortion drugs and other health policy issues this session.
This time on CodeWACK! What challenges do employers face when providing health coverage to their employees? And what role do health insurers and Pharmacy Benefit Managers—prescription drug middlemen known as PBMs—play in shaping costs, coverage, and access to care? To find out, we spoke with Chuck Melendi, who has more than three decades of experience in healthcare leadership, advocacy, and industry strategy. He spent 25 years at Johnson & Johnson, where he tackled issues including drug pricing, payer negotiations, policy, and commercial strategy. Chuck retired from Johnson & Johnson in early 2025 and went on to launch Disruptive Dialogue, a podcast and consulting platform where he shares insights from inside the U.S. healthcare system – while exploring ideas for reform. This is the first of a two-part series.
We're back with our monthly rundown of the top headlines in health tech!Today, Halle flies solo to share the biggest stories that shaped Q1, from the rising pressures on PBMs to how consumers are using AI.Stories covered:What's happening to PBMs (it's not pretty)New data from Rock Health on consumer use of AISocial media companies find liable for addictive designHealthcare hiring is slowing as efficiency becomes the focusHave we finally bent the healthcare cost curve in the United States?—The Heart of Healthcare podcast was nominated for a Webby award! We'd so appreciate if you could create a quick account and vote for us here. —
This time on CodeWACK! What challenges do employers face when providing health coverage to their employees? And what role do health insurers and Pharmacy Benefit Managers - prescription drug middlemen known as PBMs—play in shaping costs, coverage, and access to care? To find out, we spoke with Chuck Melendi, who has more than three decades of experience in healthcare leadership, advocacy, and industry strategy. He spent 25 years at Johnson & Johnson, where he tackled issues including drug pricing, payer negotiations, policy, and commercial strategy. Chuck retired from Johnson & Johnson in early 2025 and went on to launch Disruptive Dialogue, a podcast and consulting platform where he shares insights from inside the U.S. healthcare system – while exploring ideas for reform. This is the first of a two-part series. Check out the Transcript and Show Notes for more!
This time on CodeWACK! What challenges do employers face when providing health coverage to their employees? And what role do health insurers and Pharmacy Benefit Managers—prescription drug middlemen known as PBMs—play in shaping costs, coverage, and access to care? To find out, we spoke with Chuck Melendi, who has more than three decades of experience in healthcare leadership, advocacy, and industry strategy. He spent 25 years at Johnson & Johnson, where he tackled issues including drug pricing, payer negotiations, policy, and commercial strategy. Chuck retired from Johnson & Johnson in early 2025 and went on to launch Disruptive Dialogue, a podcast and consulting platform where he shares insights from inside the U.S. healthcare system – while exploring ideas for reform. This is the first of a two-part series. Check out the Transcript and Show Notes for more!
On this episode of the Astonishing Healthcare Podcast, we sit down with return guest Bridget Mulvenna, Vice President of National Business Development at Judi Health, to break down the biggest pharmacy drivers of 2026. Bridget offers insights into how plan sponsors and benefits brokers and consultants can strategically evaluate pharmacy benefit managers (PBMs) by looking beyond unit costs and focusing on drug mix - formulary decisions and the shift to biosimilars, prior authorization approval rates, the generic dispensing rate (GDR), and much more.The discussion covers the growing need to understand what challenges employer plan sponsors face, and why bringing a consultative approach to the table to help solve them is so important. How will moving to a biosimilar-first approach lower net drug costs for plan sponsors? How can a plan cover GLP-1s given their evolution and greater price transparency, expanding clinical indications, and direct-to-plan pricing models? And of course, Bridget shares her views on the sudden acceleration of state and federal PBM reform. As new legislation forces the industry to adapt, plan sponsors must seek forward-thinking platforms already aligned with the changes to provide better pricing and care for members.HighlightsBridget emphasizes the financial advantages of adopting a biosimilar-first approach, which can significantly lower net drug costs for plan sponsors despite smaller rebate checks.GLP-1s are transformative medications - price transparency, expanding clinical indications, and direct-to-plan pricing models will influence future plan designs.Evaluating PBMs beyond unit costs is critical: formulary management, prior authorizations, and other clinical programs have the greatest impact on total pharmacy spend.The rapid acceleration of state and federal PBM reform is astonishing, and alignment with future proof organizations is essential, because there's more to come.Related Content6 recommendations for PBM procurement and Rx benefits optimizationAH102 - PBM Reform Update: Health Policy Changes Slowly, Until it Doesn't, with Lloyd FioriniReplay - PMPM vs Clinical Guarantees: A Pharmacist and an Actuary Explain How to Create Predictability Around Pharmacy SpendAH064 - Empowering Plan Sponsors: Data Access & Analysis, with Bridget MulvennaFor more information about Judi Health and this episode, please visit Judi Health - Insights.
Last year, his independent pharmacy spent $13 million on brand-name drugs for patients processed by the three biggest Pharmacy Benefit Managers (PBMs) which earned a profit margin of 0.01%.In this episode, Halle speaks with Alec Ginsberg, owner and fourth-generation pharmacist at C.O. Bigelow, the oldest surviving apothecary–pharmacy in the United States. Alec is fighting against the forces squeezing independent pharmacies and charting a course for the future of the pharmacist.We cover:How the roll-up of PBMs, health plans, and retail pharmacies changed everythingWhat led him to remove his pharmacy's Rx-filling robotThe dramatic decline of independent pharmacies along with the closures of big box pharmacy storesThe one health policy he would put in place today to save independent pharmaciesThe history of the pharmacist's role and what's nextWhat he really thinks about compounding pharmacies and the Hims vs. Novo lawsuit—About our guest: Alec Wade Ginsberg is the fourth-generation pharmacist, owner, and Chief Operating Officer of C.O. Bigelow Apothecary, America's oldest pharmacy, founded in 1838 and still operating in New York City's West Village. With a Doctor of Pharmacy degree from the University of North Carolina Eshelman School of Pharmacy, Alec bridges the clinical world of pharmacy with the realities of modern consumer culture.At Bigelow, he oversees the brick-and-mortar beauty retail and pharmacy operations, navigating everything from prescription drug shortages to the pressures of today's PBM-dominated marketplace. Beyond the counter, Alec is the founder and writer of Drugstore Cowboy, a weekly newsletter that dissects the intersection of drugs, business, and consumer culture — making the hidden mechanics of the U.S. healthcare system both understandable and entertaining for thousands of readers.His work has been featured across national media, and he's become a trusted voice for translating complex pharmaceutical issues — from GLP-1s to compounding to drug pricing — into plain English. Alec's mission is simple: to make Americans smarter about the pills in their cabinets and the system that puts them there.—Show notes:Drugstore Cowboy - Alec's free and super interesting newsletterC.O. Bigelow - The Nation's Oldest ApothecaryVirtual GLP-1 startups: Pill mills or the future of obesity care?—
If you'd like your question answered on next month's episode, call/text 469-213-6381 and leave us a voicemail/text.Each month on Last Month In Healthcare, producer Nathaniel joins me to discuss the previous month's podcasts, headlines, and listener-submitted questions.This month, we're joined by Jeff Bak from Imagine360!Together, we react to the latest headlines from March, including the new CMS rule enforcing actual dollar amounts in hospital price transparency files. We also discuss Medicare expanding coverage for GLP-1s to treat obesity, Roche's massive $65M investment in NVIDIA AI chips for drug discovery, and the Department of Labor's new PBM fee disclosure rules. Plus, we react to the shocking story of two insurance executives sentenced to 20 years for a $233 million ACA enrollment fraud scheme.Then, Jeff and I play a game of "Blind Ranking" where we have to rank the worst practices in health insurance (like PBM spread pricing, ER upcoding, and surprise balance billing) without knowing what is coming next. Finally, we answer a listener question about the viability of ICHRAs (Individual Coverage HRAs) as an alternative to brutal fully-insured renewals in 2026.Thank you to our sponsor, Walk On Clinic! Visit walkonclinic.com to learn more about their on-site health clinics.Chapters:0:00 - Intro & Live Show Announcement3:08 - CMS Enforces Dollar-Amount Price Transparency6:54 - Medicare Expands GLP-1 Coverage to Obesity12:15- Roche Buys $65M in NVIDIA AI Chips for Drug Discovery15:45 - The DOL Proposes New PBM Fee Disclosure Rules19:40 - Insurance Execs Sentenced to 20 Years for $233M ACA Fraud22:20 - Game: Blind Ranking the Worst Practices in Health Insurance30:41 - Ask Spencer: Are ICRAs a Smart Option After Huge Renewals?
This episode's Community Champion Sponsor is Ossur. To learn more about their ‘Responsible for Tomorrow' Sustainability Campaign, and how you can get involved: CLICK HEREEpisode Overview: The prescription journey has become one of healthcare's most frustrating operational bottlenecks – fragmented pricing, disconnected systems, and zero transparency when it matters most.Our next guest, Joseph Kleiman, is transforming this broken experience as President of Buzz Health.With over 25 years building and scaling businesses, Joseph brings a rare combination of operational execution and strategic vision to one of healthcare's toughest challenges.What started 15 years ago as BuzzRx – a pharmacy discount platform – has evolved into a comprehensive pricing transparency engine embedded directly into clinical workflows.From provider systems to pharmacies to payers, Joseph shares how Buzz Health is delivering real-time cost visibility across the entire prescription ecosystem.Join us to discover how upstream pricing intelligence is reducing friction, improving adherence, and making medication affordability actionable at the point of care. Let's go!Episode Highlights:Joseph Kleiman emphasizes solving real healthcare problems by staying close to patients, pharmacies, payers, and PBMs before building solutions.Buzz Health evolved from BuzzRx discount cards to RxCompare technology, embedding real-time prescription pricing across the entire healthcare ecosystem.Successful pricing transparency requires minimal IT lift through API integrations that work alongside existing legacy systems without disruption.Moving pricing intelligence upstream to the doctor's office gives patients actionable cost information before leaving the waiting room.The future prescription ecosystem will integrate vouchers, copay cards, and health plan rates into one centralized transparent pricing engine.About our Guest:Joseph Kleiman is President of Buzz Health, where he leads the company's strategy, partnerships, and operations to help expand access to more affordable prescription medications and improve price transparency across the healthcare ecosystem. With more than 25 years of experience building and scaling businesses, including BuzzRx as Chief Financial and Operating Officer, Kleiman has a strong track record in strategic planning, operational leadership, and growth. Previously, he founded the consulting firm Projixx, served as Chief Operating Officer of 944 Media, and co-founded Bullseye Wireless.Links Supporting This Episode: Buzz Health Website: CLICK HEREJoseph Kleiman LinkedIn page: CLICK HEREMike Biselli LinkedIn page: CLICK HEREMike Biselli Twitter page: CLICK HEREVisit our website: CLICK HERESubscribe to newsletter: CLICK HEREGuest nomination form: CLICK HERE
Join us on the latest episode, hosted by Jared S. Taylor!Our Guest: Karthik Ganesh, Chief Executive Officer at OnMed.What you'll get out of this episode:Karthik Ganesh describes healthcare as both his profession and his vehicle for making the world better.His 26-year career spans health plans, PBMs, value-based care, consulting, and tech-enabled care delivery.At OnMed, he focused on amplifying product strengths while neutralizing blind spots rather than reinventing what already worked.He believes AI should empower clinicians and improve workflows, while the human element remains the last mile in care.OnMed's work in underserved communities is showing strong adoption, with many patients identifying the care station as their medical home.To learn more about:Website https://www.onmed.com/ Linkedin https://www.linkedin.com/company/onmedcarestation/Our sponsors for this episode are:Sage Growth Partners https://www.sage-growth.com/Quantum Health https://www.quantum-health.com/Show and Host's Socials:Slice of HealthcareLinkedIn: https://www.linkedin.com/company/sliceofhealthcare/Jared S TaylorLinkedIn: https://www.linkedin.com/in/jaredstaylor/WHAT IS SLICE OF HEALTHCARE?The go-to site for digital health executive/provider interviews, technology updates, and industry news. Listed to in 65+ countries.
"I've got a patient in Washington state. He's traveling 100 miles every other week to receive an infusion. We moved this patient into the home and saved the plan $700,000 on this one patient...on gout treatment."Why are infusion drugs quietly destroying your health plan's budget?This week, my guest is Rob LaHayne, Co-Founder of Leap Health. We pull back the curtain on one of the most overlooked and expensive categories in healthcare: Specialty Infusion Care. Because these drugs are administered by a medical professional, they are billed through the medical plan under "J&Q Codes" - subjecting them to massive hospital markups and "buy-and-bill" margin games.In this episode, Rob explains how Leap Health is solving this by taking over the supply chain, procuring the drugs transparently without margin, and redirecting patients to their own homes or convenient infusion centers. We discuss how these J&Q codes are often the hidden culprit behind breached stop-loss deductibles and skyrocketing renewals, and why shifting the site of care is a win for both the employer's budget and the patient's quality of life.If you're a benefits consultant trying to figure out why your client's medical spend is out of control, or an employer tired of paying massive hospital markups for necessary medications, you need to understand J&Q codes.Thank you to our 2026 sponsors!ParetoHealth: ParetoHealth empowers midsize employers with a long-term solution to reduce volatility and lower overall health benefits costs. Visit ParetoHealth.com/Spencer to learn more.Samaritan Fund: A program that connects those who need help to the support they need. We are proud to offer the Samaritan Fund Program. Visit SamaritanFundProgram.com to learn more.Vālenz Health: We're Vālenz Health, your partner in improving health literacy, reducing plan spend, and delivering high-value healthcare. Visit ValenzHealth.com to learn more.Imagine360: Imagine360 helps self-funded employers save on healthcare with smarter health plans. Cut expenses by 20-30% with custom solutions. Contact us today at Imagine360.com.Chapters:(00:00:00) Intro: The Hidden Problem of J&Q Codes (00:04:13) Rob's Background & The Genesis of Leap Health (00:08:24) Why Hospital "Buy-and-Bill" Margins Drive Up Costs (00:13:22) How Leap Health Provides Transparent, Zero-Margin Pricing (00:16:31) Shifting Site of Care: The Power of Home Infusions (00:23:44) Overcoming Headwinds: Patient Engagement & Plan Design (00:27:01) Taking Over the Supply Chain to Bypass the "BUCA" PBMs (00:32:51) Stop-Loss Renewals: Why Identifying J&Q Codes is Critical (00:37:04) Saving $700,000 on a Single Gout Patient (00:41:39) The Future: Unbundling the Health Plan & "Point Solution Fatigue" (00:45:41) Closing Thoughts: Why Consultants Must Request J&Q Code DataKey Links for Social:@SelfFunded on YouTube for video versions of the podcast and much more - https://www.youtube.com/@SelfFundedListen/watch on Spotify - https://open.spotify.com/show/1TjmrMrkIj0qSmlwAIevKA?si=068a389925474f02Listen on Apple Podcasts - https://podcasts.apple.com/us/podcast/self-funded-with-spencer/id1566182286Follow Spencer on LinkedIn - https://www.linkedin.com/in/spencer-smith-self-funded/Follow Spencer on Instagram - https://www.instagram.com/selffundedwithspencer/
Renzo Luzzatti, Founder and CEO of US-Rx Care, discusses the role and practice of the Pharmacy Benefits Managers and the advantages of working with a company that uses a fiduciary model. Inherent conflicts of interest in the traditional PBM model, such as manufacturer rebates and requirements to use PBM-owned pharmacies, drive up prescription drug costs. US-Rx Care eliminates these conflicts by charging a flat administrative fee, with its sole incentive to lower drug costs for the plan and its members. Renxo explains, "We've been around since 2007. We do have about 5 million lives under management, both self-funded employers, which is the bulk of our business. Then we also tap into Medicare health plans and have some programs and offerings that we assist there to lower costs and improve the quality of care. Our approach is unique in that we've taken a fiduciary stance from day one. We can talk about that in a little bit. It is a legal term. It's defined under ERISA, which governs health plans. They have a fiduciary duty to the plan, the members, and the management of the plan assets. And the industry as a whole has shied away from any fiduciary obligation whatsoever, in part because it's rife with conflicts of interest, and you cannot have conflicts of interest as a fiduciary." "That is really at the core of all of the issues and complaints that we're hearing about PBMs - they're driving up the cost of prescriptions rather than having the intended effect, which is to reduce the cost of prescriptions. And I would say in the last four or five years, employers have really started to ask the right questions because they're becoming more and more educated." "For folks like us, we're growing like crazy because the industry finally gets that. The deal that they were getting through their traditional model is not so good. The other thing is when we move to a fiduciary model, savings are typically in the realm of 30% to 50% in the first year, and then we typically see additional savings in year two and three, and then after that, the goal and the intent, which we've been successful at, is to keep costs stable." #USRxCare #PBM #PharmacyBenefits #EmployeeBenefits #HealthcareCosts #FiduciaryResponsibility #BenefitsConsulting #HealthcareTransparency #CostContainment #SelfFundedEmployers #HealthcareReform usrxcare.com Listen to the podcast here
If you'd like your question answered on next month's episode, call/text 469-213-6381 and leave us a voicemail/text.Each month on Last Month In Healthcare, producer Nathaniel joins me to discuss the previous month's headlines and listener-submitted questions.This month, we are officially in the new studio! Nathaniel and I react to the latest headlines from February, including the FTC's landmark settlement with Express Scripts over insulin pricing and the new bipartisan bill aimed at breaking up the "Big Medicine" monopoly of insurers, PBMs, and providers. We also discuss the FDA's crackdown on compounded weight loss drugs (GLP-1s) and the privacy concerns surrounding OpenAI's new ChatGPT Health feature.Plus, we play a new game called "Drug Cost or Car Payment?" where I try to guess whether a monthly prescription is more expensive than the lease payment on a luxury car (like a Porsche 911 Carrera or a Bugatti Chiron). Finally, we answer a listener question about the absolute minimum employee headcount required to go fully self-funded in 2026.Thank you to our sponsor, Walk On Clinic!Chapters:0:00 - Intro: Welcome to the New Studio!1:24 - "PBM Reform Comes To Washington"2:25 - FTC / Express Scripts Settlement5:19 - The Bill to "Break Up Big Medicine"6:34 - The FDA Cracks Down on Compounded GLP-1s7:55 - OpenAI Launches ChatGPT Health12:14 - Game: Drug Cost vs. Car Payment?18:33 - Ask Spencer: Minimum Headcount to Go Self-Funded?
In this week's episode of Medicine: The Truth, hosts Jeremy Corr and Dr. Robert Pearl unpack a wide range of developments shaping healthcare in America today, including the TrumpRx drug discount program. From new legislation affecting telehealth and pharmacy benefit managers (PBMs) to the rapid spread of measles and growing public concern about vaccine policy, this month's discussion highlights the policy decisions and scientific debates influencing medicine right now. The episode opens with the latest federal legislation passed to avert a government shutdown. While healthcare was not the central focus of this particular political battle, the bill contains several provisions that affect medical practice. These include extensions for telehealth coverage and hospital-at-home programs, reforms targeting PBM transparency and new requirements designed to address “ghost networks” in Medicare Advantage provider directories. Dr. Pearl explains that while these provisions represent incremental progress, they are unlikely to solve the larger problems driving healthcare costs and access challenges in the United States. Here are the other major storylines from episode 104: Healthcare costs remain nation's top concern: A new KFF poll finds that healthcare expenses rank above food, housing and utilities as the economic issue Americans worry about most. Prior authorization frustrations grow: Many patients report delays or denials of care due to insurance requirements, highlighting persistent tension between insurers, physicians and patients. Drug pricing debates continue: Pearl examines a new prescription drug website initiative and explains why it may have limited impact compared with broader policy proposals such as “most favored nation” pricing. Telehealth's uncertain future: Although the latest legislation extends certain pandemic-era flexibilities, the lack of a permanent solution leaves virtual care programs in limbo. PBM reforms move forward slowly: New policies aim to increase transparency and reduce incentives tied to drug list prices, though Pearl notes that meaningful change will depend on future implementation. Site-neutral payment gains attention: A provision requiring unique identifiers for outpatient services could pave the way for policies that eliminate higher reimbursement for hospital-owned facilities providing identical care. Measles outbreaks surge: Nearly a thousand cases have already been reported in 2026, with the overwhelming majority occurring among unvaccinated children. Trust in the CDC declines: Polling shows confidence in the agency has dropped significantly following changes to vaccine recommendations. Independent vaccine review groups emerge: Medical organizations and states are forming new committees to evaluate vaccine evidence as federal guidance becomes more contested. Early colon cancer deaths rise: The death of actor James Van Der Beek at age 48 highlights the growing incidence of colorectal cancer among younger adults and the importance of earlier screening. FDA confusion over a new flu vaccine: The agency initially declined to review Moderna's mRNA-based flu vaccine before reversing course and agreeing to evaluate it ahead of the next flu season. Younger Americans face worsening health trends: New claims data suggest chronic disease is appearing earlier among millennials and Gen Z, driven by lifestyle factors and reduced connection to primary care. Wearable data reveal health disparities: Apple Watch data show significant differences in resting heart rates across states, reflecting variations in lifestyle, access to care and public health conditions. As the episode concludes, Dr. Pearl warns that growing political conflict around vaccines and biomedical research risks undermining public trust in science. The consequences, he argues, could shape American medicine for decades to come. Tune in for more fact-based analysis and discussion of the biggest stories in healthcare. * * * Dr. Robert Pearl is the author of the new book “ChatGPT, MD: How AI-Empowered Patients & Doctors Can Take Back Control of American Medicine” about the impact of AI on the future of medicine. Fixing Healthcare is a co-production of Dr. Robert Pearl and Jeremy Corr. Subscribe to the show via Apple, Spotify or wherever you find podcasts. Join the conversation or suggest a guest by following the show on Twitter and LinkedIn The post MTT #104: TrumpRx, rising measles cases & the politics of vaccine science appeared first on Fixing Healthcare.
Send a textEpisode Summary (Short Version):This week on On The Pen, Dave breaks down the rapid changes reshaping GLP-1 access — from new federal reforms targeting PBMs and possible FDA limits on compounded semaglutide, to Walgreens and Amazon launching cash-pay weight loss clinics.As insurance denials continue and out-of-pocket costs rise, patients are stuck between a shifting policy landscape and a growing direct-to-consumer market. Plus, an AI-designed oral GLP-1 enters Phase 3 trials, signaling how fast obesity medicine is evolving.Visit TRYSHED.COM to learn more today! Use CODE OTP25 to save 25%!
Your benefits plan may be getting more expensive for reasons unrelated to better care. In this episode of Sharkpreneur, Seth Greene interviews Chris Hamilton, Partner at Hotchkiss Insurance and a healthcare industry expert, who explains why employer health costs keep skyrocketing. He breaks down how misaligned incentives in traditional plans drive inflation and why mid-market employers often have far more control than they realize. You'll hear practical, modern strategies such as self-funding, direct agreements, and transparency tools that can improve coverage while reducing total costs for both companies and employees. Key Takeaways:→ Traditional compensation structures can incentivize higher premiums rather than better outcomes for employers and employees.→ When insurers own PBMs and other components, pricing can become a circular profit engine that justifies ongoing rate hikes. → If you reduce the underlying cost of care, the premium required to fund the plan naturally drops.→ The same procedure can vary dramatically in price across facilities, with no reliable correlation to quality. → Employers can contract directly with hospitals and concierge physicians to simplify access, improve care, and reduce both company and employee financial burdens. Chris Hamilton is a Partner at Hotchkiss Insurance in Texas, where he leads the employee benefits consulting practice. He specializes in managing healthcare and insurance costs to improve benefits coverage, reduce expenses, and enhance employee health outcomes. With over a decade of experience in corporate finance, Chris has advised clients across various industries, including private equity and oil & gas. In his free time, he enjoys traveling, working out, attending live music events, and spending time with family. Connect With Chris:Website: https://hotchkissinsurance.com/YouTube: https://www.youtube.com/@chrishamiltonbenefitsinsiderLinkedIn: https://www.linkedin.com/in/chamilton/
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