Medical Benefit Issues in 2017 with RJ Health Systems

Having personally dismissed 99% of these CEO missives, I wrestled with the need, never-mind the value of this communication. My objective since taking the reins of RJ Health Systems in 2015 has largely been to distinguish us from the jargon-filled, oftentimes frenzied industry heavyweights we operate alongside in service to Payors and Providers in the Medical Benefit drug industry.

So, by authoring a “Year in Review” or “Year Ahead” blog, I am feeding into the persona of self-fulfilling importance I have sought to stand apart from. But, given my penchant (some call it a crutch) for visual aids, I thought I could get away with sharing my eight favorite images and supporting captions to illustrate RJ Health Systems’ place in the health care data landscape.

—From the desk (image folder) of Paul D. Rector—

1. Swirling the Drain

Swirling the DrainSource:

It’s clear to RJ Health Systems that the trend to identify, and resolve, in the specialty drug industry is medical benefit drug spend. About 50% of specialty drug spend occurs on the medical benefit and this trend is growing near double-digit rates.¹ A preoccupied CFO (pictured above left) seeks medical cost containment opportunities elsewhere as medical benefit drug costs (above right) drain his budget.

2. Virtual Reality’s Impact on Medical Benefit Health Care Costs

Virtual Reality's Impact on Medical Benefit Health Care CostsSource:

In 2016, we caught a glimpse of the impact screens stuck to our heads may have on healthy living. Pictured above, a crowd of lemmings sit listlessly as their brains are tricked into activity and engagement by an evil genius. It’s hard to imagine Virtual Reality will help address our health and wellness challenges when one can, “get out there into the world” by sitting on our rears.

3. Site of Care Migrating in the Wrong Direction

Site of Care Migrating in the Wrong DirectionSource:

Since 2012 or even earlier, dominant provider organizations have been “reclaiming” practice groups in order to control distribution and profits. The image above represents a “before/after” scenario captured in the South China sea, reminding us of the ramifications of unchecked expansion in control.

4. Value-Based Schemes are an Age-Old Dilemma

Value-Based Schemes are an Age-Old DilemmaSource:

The lack of an arbiter of value has always been the sticking point for value-based relationships – providers, payors, and manufacturers are not aligned, leaving buyer and seller to haggle about a deal on arbitrary terms. Ultimately, you need all, or at-least more than two stakeholders at the table to properly monitor and deliver a value-based model in any complex market. Bart Simpson, pictured above, probably has that skeptical look thanks to the fine line between arbitrary deals and the need for an effective arbiter of value.

5. Toothless Mandates Hurt Everyone

Toothless Mandates Hurt EveryoneSource: Imgur

With RJ Health Systems supporting over 75% of the U.S. Payor market, we have come across a sizable segment of these organizations that have data mandates that go unmonitored, rendering them, and their underlying purpose harmful to the system as a whole. Above, the mascot for toothless mandates expresses her underwhelming displeasure for such unchecked policies.

6. A Year Later and Still No Y2K Effect with ICD-10’s

A Year Later and Still No Y2K Effect on ICD-10sSource:

Admittedly, we wagered on a significant, transformative impact when the 9th edition disease classifications were transformed to ICD-10’s. Why wouldn’t we – there was a four-fold increase in the volume of ICD-10 codes that covered Medical benefit drug therapies? Nonetheless, we have found that on the surface nearly 50% of claims are paid without a verifiable ICD-10 code. Pictured above, you’ll find our best guess as to what is happening in the marketplace – we are of course biased, but still hopeful this trend will change and diagnosis utilization will become a powerful cost containment tool in 2017.

7. Smarter Savings Tools for Pharmacy and Claims Operations in the Medical Benefit Drug Industry

Smarter Savings Tools for Pharmacy and Claims Operations in the Medical Benefit Drug Industry


As our customers know, in 2016 we invested in time-savings and data-mining tools within our ReimbursementCodes subscription service. By combining all RJ Health Systems data sets and enhancing the user experience we have taken a workflow process that once took 10-steps and reduced it to less than half the clicks. Pictured here is a loyal RJ Health Systems claims supervisor taking the time-savings to the bank.

8. Giving Birth to RJ Analytics in 2017

RJ Analytics Medical BenefitSource:

The year ahead will bring many more R&D initiatives that improve the accessibility and application of RJ Health data. In 2016, we entered into Medical drug trend analytics partnerships with several Mid and Large-sized Health Plan customers. These partnerships have already yielded a series of cost containment strategies that we’ll share with our customers in 2017. Pictured above is our pride-and-joy, RJ Analytics who reminds us all of how adorable trend data can be!

Please reach out to me at to explore these topics together in the year ahead.

Cheers to a prosperous New Year for our partners, customers and colleagues!


Paul D. Rector
CEO, RJ Health Systems