RxSense: Changing the Game in PBM

RxSense: Changing the Game in PBM

Rick Bates, CEO & Co-Founder, RxSenseRick Bates, CEO & Co-Founder, RxSense Opportunity favors the bold – this is a lesson that Rick Bates learned early on, and has used to redefine the way the pharmacy ecosystem operates for his clients today. Bates can be labeled an entrepreneurial genius, with more than two decades of experience in leading a host of healthcare companies, and being able to stir innovation in an industry that lacks it the most. His intention behind running his initial venture, SingleCare, launched in 2014—a digital retail marketplace offering consumers savings on their prescriptions—as the CEO and Co-Founder, was to find a way to reduce the costs of medicines by eliminating middlemen in drug distribution and providing the best price points for consumers at retail pharmacies. It was the incredible success of this venture that sparked his idea of controlling all aspects of the business, including claims adjudication, and led to his acquiring DataRx, a PBM catering to the infrastructure needs of other PBMs. His team rebuilt DataRx’s technology from the ground up into a cloud-based, cutting-edge enterprise technology. The ability now to operate all aspects of the business directly and control both pricing and adjudication offers SingleCare a distinct competitive advantage.

Fast-forward to 2019, and the company has been rebranded RxSense, significantly broadened its ability to serve as a B2B enterprise platform solution partner to the PBM industry through its investments in its leading-edge technology, and driven impressive expansion of its direct-to-consumer brand, SingleCare. (RxSense currently meets the lowest-price needs of over six million consumers directly through SingleCare.)

RxSense stands as a one-stop, flexible enterprise technology partner for private-label PBM solutions, helping companies across the U.S. to realize their vision for a unique pharmacy benefit experience and to manage all the components of the pharmaceutical value chain, to optimize the financial performance of their plans and help better manage costs for consumers and businesses. “RxSense’s technology promotes ease of use, accuracy of benefit implementation, flexibility to make plan benefit changes, and access to real-time visibility into plan performance data for our customers,” begins Rick Bates, CEO of RxSense.

Revolutionizing the PBM Ecosystem

RxSense did not manifest success overnight, which is why it is essential to understand how it began, eventually changing the game in the pharmacy benefit management industry with their innovation streak. RxSense’s pharmacy benefit management (PBM) solutions were born with a singular focus to better navigate the labyrinth of benefits management by breaking the death grip of legacy systems. To put that in perspective, one can say, “Nothing is as exotic as a glass of vintage red wine; the older the better.” However, unlike wine, software doesn’t get better with age. This is precisely the reality of the PBM sphere: long neglected software that pervades the industry is fraught with extended development timelines to keep up with modern benefit designs, lacks the flexibility customers and members demand, and inhibits access to data and accuracy of implementation. Software modernization takes a backseat to the relentless pursuit of incremental profit within mature organizations. And, you might wonder what’s wrong with that pursuit? Nothing. That’s the paradox.

But, to live up to the demands of the new digital transformation economy, RxSense is on a mission to eliminate reliance on outdated software with tools like their Implementation Wizard and a thoroughly modern architecture. “For too long, this industry has been plagued with legacy systems that lack innovation, are incredibly inefficient, inflexible, and have challenges around accuracy and transparency. These platforms cannot function well to meet the real-time needs of customers. The objective of our technology platform is to create a modern and flexible tool that is highly efficient and customizable across a range of potential customers,” says Simon Brown, COO.

RxSense offers an enterprise solution for private-label PBM services. In an effort to meet the real-time needs of the customers, RxSense owns, operates and makes available a turnkey solution with all the components a modern PBM needs: adjudication, retail pharmacy networks, rebate administration, contact center, specialty and mail solutions, as well as robust business analytics. Built around a flexible cloud-based technology, RxSense currently manages over $3 billion of annual managed pharmacy program drug spend. But what truly sets RxSense apart is its ability to provide customers direct access to understand the configuration of their plan and the real-time analytics to ensure it is operating as intended.

The biggest challenge is affordability and having visibility into where consumers can get the best price for their prescribed medicine

The unparalleled flexibility of cloud-based technology enables RxSense’s clients to witness a smooth transition from legacy systems to a modern platform in record time. Through their Implementation Wizard, RxSense streamlines pharmacy benefit setup, auto-completing complex coding on the back-end by entering selections in layman-friendly drop-down, radio-button and fill-in-the-blank fields in the front-end tool. This enables the client to self-serve set-up, if that’s their goal, or to collaborate with RxSense’s implementation team to achieve an as-intended implementation. “So often, legacy systems in this industry don’t allow clients to ensure their planned edits, copay structures, and other benefit dynamics are implemented as they’ve specified. To ensure that, we deliver complete transparency,” explains Bates. With the ease of the Implementation Wizard, a thorough QA function, and real-time view into plan performance data, RxSense is able to deliver an unprecedented B2B experience.

An advanced hierarchy enables flexible drug formulary changes, for example, a change to apply across the whole organization or only at a specific group level, while maintaining the connection to the master formulary and any subsequent updates, automatically. “Our tools enable users to make real-time formulary changes, if necessary,” adds Bates. “And, eligibility can be consumed 1) through an automated secure ftp process, or 2) with secure credentials, added or changed directly in real-time by an authorized user, or, again, 3) through a drag & drop spreadsheet load process in real-time.” Leaving no stone unturned, RxSense’s technology platform’s consumer tools allow users to compare actual prices—the actual member out-of-pocket price based on current deductible status and other benefit factors—to enable them to make the most cost-effective choices while adhering to their drug regimen.

While the company aims to help PBMs achieve a new level of service excellence through its enterprise technology, RxSense’s consumer brand SingleCare offers their services to consumers directly. SingleCare leverages a proprietary mobile technology platform to manage the entire transaction for its members and offers a secure, HIPAA compliant portal (and app) where members can find the lowest cash-pay pharmacy price, build their profiles and track their history. “The biggest challenge is affordability and having visibility into where consumers can get the best price for their prescribed medicine,” says Bates. There are many reasons a consumer would turn to SingleCare: no insurance, under-insured, restricted formularies, or looking for the lowest price during the high-deductible period of their benefit coverage. SingleCare enables consumers to pay less and improve their medication adherence.

The Secret Sauce

No matter how bold or ambitious RxSense’s growth plans are, their business’s success stands on a solid foundation underpinned by three interdependent components: the business expertise, the technology team, and the product team. RxSense is leveraging these intertwined components to create a next-gen business model.

“The difference between a good platform and an excellent platform is the collaborative efforts of the technology, business, and product teams,” points out Simon Brown, COO. Having worked in the trenches of the healthcare and financial industries, the business architects at RxSense pour into RxSense’s technology evolution rich industry experience, learning, wisdom and first-hand frustration with legacy systems.

This business expertise is then married to the state-of-the-art technology and out-of-the-box architecture ideas brought in by a team of skilled engineers. Lastly, the third part of the triangle—the product team—sets the direction of an administrative layer designed with the end client/customer in mind. This team of business architects, cloud-savvy engineers and designers deliver a fresh B2B and B2C experience. “Right from the get-go, our design principles were around enabling clients to harness the practical power of a modern system—for example, a contact center agent who has all the history of a claim in a single view to minimize the time needed to help a member. And we have succeeded in building something that changes the game,” Brown adds.

Built from scratch, the heart of RxSense’s PBM platform is an asynchronous rules-based engine, the core of claims adjudication. One of the design principles used is the concept of “time travel.” This principle enables the platform, at an administrative level, to show the configuration of the plan in a moment in history. This unique feature proves more efficient than legacy systems for researching historical claims, which usually involves checking multiple screens and even using system engineers to get access to data. RxSense allows users to choose both a date of service and a processing date, making it a breeze to reach inquiry resolution much faster. The platform is also built to create flexibility through the “rules and sets” principle: “It’s a way of creating a library of rules and definitions within the platform that can be applied to any client at any hierarchy level,” explains Bates. This enables complex benefit builds or replications to be accomplished in minutes – increasing efficiency and speed-to-market.

Another critical component powering RxSense is RXiQTM, a data analysis environment that provides clients a modern solution that is completely customizable to deliver actionable data and reporting, and business analytics. It consists of dashboards, reports, and tools that can be used to query and drill down into the underlying information to understand the details of plan performance—with appropriate secure access—at any level of the hierarchy. The real-time capability of the platform gives business leaders an edge, early warning on trends or events that allow them to forecast, pivot or plan in the timeliest fashion, via email or other notifications. In the world of big data, the cutting-edge RXiQ tool allows clients to leverage the most, with the most immediacy, out of their data.

Envisioning Healthier Outcomes

The experience of one B2B client: a large potential client reached out to RxSense in late 2017. Facing problems with infrastructure in terms of visibility into drug pricing, and comprehensive data and reporting on their customer base, the organization was losing revenue and market share and needed to implement an effective enterprise infrastructure to tackle their problems. By the first week of February 2018, RxSense had completed a successful implementation of the client’s business on the RxSense enterprise platform and the organization witnessed instant results. With RxSense’s transparency, tools, and access to real-time performance data, the client was better able to understand and manage their business, leading to exponential growth of over 50 percent in revenues within the first year.

"Right from the get-go, our design principles were around enabling clients to harness the practical power of a modern system — for example, a contact center agent who has all the history of a claim in a single view to minimize the time needed to help a member. And we have succeeded in building something that changes the game"

With a vision to deliver better, more cost-effective health to consumers, plan sponsors, and private-label PBMs, RxSense, with its team of nearly 200 goal-oriented employees, delivers solutions that pave the way for a healthier and more affordable future. “The whole pharmacy management industry is headed toward a new financial model, greater efforts to minimize waste and driving administrative efficiency, and that can’t be done through manual work efforts,” adds Bates. In order to achieve this, as of 2019, the company will further invest in AI and machine learning technologies that enable even more precise and immediate real-time response to trends and market factors, with the ultimate goal of driving down costs, improving clinical outcomes, and eliminating administrative waste.

- Abhishek Patil
    March 12, 2019