Health Benefits Nation

Health Benefits Nation

September 27-29, 2023 | Orlando, FL

Fast Five Interview

Kristin Begley, Pharm.D
Chief Growth Officer
Capital Rx

Q: What is the top challenge or obstacle facing healthcare today? 

A: It’s tough to pick just one, as there are several issues standing in the way of improving the delivery, effectiveness, and cost of healthcare today. We’d like to see aligned payment models and greater transparency, but today’s financial structures do not incentivize the right stakeholder behaviors. There are also technological hurdles – prescription and medical tech are siloed, interoperability and connectivity are often challenges, and consumer apps can further fragment care. With the right technology and connectivity, you can have any front door delivering the information that patients and providers need to make the right decision(s). But, as a clinician, I’d be remiss if I didn’t say the top three issues that keep me up at night are obesity, mental health, and social determinants of health. The latter is a broader issue that must be tackled in the U.S.; if you are insecure about food, housing, etc., or suffer from addiction, how does anyone expect you to take care of your health? It’s a national crisis that must be addressed.

Q: What has you most optimistic about the future of healthcare?

A: We are in a technological renaissance in healthcare that ranges from infrastructure to personalized medicine. We’re rapidly moving from “shotgun medicine” to precision medicine. After ~20 years, all the talk about value-based payment models finally has momentum. Stakeholders are genuinely starting to move the needle. Stakeholder alignment is crucial for success. If you follow the money, you know what the incentives are. It explains stakeholder behavior. In my opinion, fee-for-service (FFS) and spread pricing will never work in healthcare 2.0. Self-funded plans, plan sponsors, executive directors… all the payers (our clients) are all moving away from FFS and spread pricing, looking at value delivered more deliberately, and with CAA finally rolling out, I’m incredibly encouraged that we have hit the tipping point.

Q: How do you think healthcare stakeholders can bring care closer to consumers/patients?

A: When I think about this question, I think about what prevents patients from helping themselves. I find the top two issues, outside of social determinants of health (SDOH), that make it difficult for patients to care for themselves fall into two categories: making healthcare more affordable and reducing the complexity of finding, receiving, and paying for care.

  • Costs must come down, which is where investment in technology can dramatically help. The whole system is opaque financially and has been built by stakeholders that don’t have an incentive to work together due to misaligned payment models. Everyone from the brokers to carriers and providers has benefitted from inflation and escalating fees, and investment in technology has not been a priority for the “legacy” stakeholders. Meanwhile, Kaiser Family Foundation and others have been running polls for years showing how hard it is for Americans to afford many aspects of their care. If you build a system on top of wasteful and inefficient practices, at what point can you stop and look at how it’s impacting the member, employee, or patient? The “payor” side of the house runs on rails developed before Medicare rules and regulations were put in place and still uses code that new developers no longer learn. Improving operational costs and making care more affordable would help a lot.
  • The system is too complex. This is also a place where technology should bring humanity back to healthcare. We are still far from interoperability between payors, providers, and consumer apps, and because of the misaligned financial incentives and old tech, there is no single front door to enter care. Once “in” the system, simplifying and streamlining the continuum of care, including the revenue cycle, and then explaining everything in a helpful, educational way might bring patients closer to local/regional providers (or leveraging virtual care when appropriate). At the very least, patients should know where to go for care, understand there are moments of being a consumer and moments of being a patient, and be able to find quality care.

Q: What are some of the key trends you are seeing with respect to employer-sponsored healthcare?

A: Given the “talent war,” I think many employers truly understand that their workforces are their most valuable assets. Healthcare coverage, including pharmacy and wellness benefits, is key in fighting the talent war. However, I think a day of reckoning is coming for all healthcare stakeholders. We see benefits and HR directors, C-suites, etc., questioning the value brokers, consultants, and carriers bring to them (including how they make money) with greater frequency; they are exhausted by point solutions banging on the door and the double-counting value. Employers are also becoming more sophisticated in measuring value delivered. Last, the Consolidated Appropriations Act is starting to shine a light on the fact that “trusted advisors” may have been paid more than anyone ever expected, which may have influenced their preferred providers. As employers dig and analyze data, we’ll want to monitor the fallout.

Q: What motivates you to keep doing the work that you do?

A: At my core, I’m a clinician and deeply care about improving healthcare for everyone in America. For decades, I banged my head on the wall in the PBM sector and left feeling: “There is no way to change this. Nobody will fix the oligopoly. Nothing will change the perverse incentives that drive up patient costs, etc.” At one point, I recall thinking that only the government could take on the PBMs and pharma. So, I left and moved into the digital health space, joining a company focused on women’s and family health and helping to move the needle on value-based care. After three years, I was able to re-join former colleagues and trusted mentors at Capital Rx, and the only reason I came back to the pharmacy supply chain is that I believe we have a chance to make a difference in healthcare in this country. We have all the ingredients necessary to make a meal that Americans might enjoy, vs. the entrenched status quo, which keeps serving up high-cost, low-value food. The belief that our technology and service model is what the system needs to reform keeps me going. And it’s a bonus to work with such a talented team of wonderful people every day on a mission that I am truly passionate about.