Cultivating Innovation with Optum Rx’s Jen McGonigle

Melanie Marcus: Our guest today is Jen McGonigle, a senior vice president at Optum Rx, where she leads the roughly 400-strong enterprise capabilities team, leveraging technology across systems and platforms. And their goal, every day they go to work, is to help people live healthier lives.   

So, it’s quite fitting that Jen is our first guest of the season where we’re focused on systemic innovation.  

From where Jen sits in her role as a technology leader, she sees how this kind of innovation truly makes a positive, tangible difference for patients and those who care for them.   

As Jen shares on today’s episode, all her team thinks about is how to apply emerging technology to ease the administrative burden on providers and get patients the therapy they need quickly and affordably.  

That’s easier said than done. But as Jen says, “I get a lot of joy out of figuring out how technology can solve hard business problems.” 

And with that, let’s hear how she puts her joy to good use in our collective mission to help healthcare heal itself.  

Well, it’s great to have you on the show today, Jen! 

Jen McGonigle: Thank you, Melanie. It’s good to be here. 

Marcus: I’ll start with a question about innovation to lay the context for our discussion, and then we'll circle back to hear about your journey and how your career in healthcare got started. Now I just read an article in IEEE Spectrum about electronic health records and quote “screen time” for providers where technology is keeping providers glued to their screens. 

So my question follows: You’ve worked at the intersection of healthcare and technology for over 20 years. How would you respond to someone who says that technology only gets in the way of patient care? 

McGonigle: There are definitely some challenges with technology and the fact that doctors spend an average of four and a half hours a day entering data into their EMRs. But I would say that the benefits of technology far outweigh the cons. Just imagine going through COVID without the benefit of telehealth visits. Or, because of technology, we have faster access to comprehensive medical records or digital health monitoring, remote patient monitoring, digital engagement with patients. Nobody wants to call the call center anymore. You want to take care of everything on your app, on your phone.  

And I also think about exploring AI and all the possibilities that are enabled with that. Even things like AI-enabled ambient listening and AI scribes that could take them away from looking at the EMRs while they're in the doctor's office with their patient, and then letting them have that face-to-face conversation, but still capturing the needed information. 

Marcus: Oh, that's great. Gives us a peek into what we're going to be talking about today. 

Let's just step back though for a few minutes. We find it really useful to give our listeners a perspective on where you came from to bring you to this career in healthcare and to some of those perspectives. So, can you share a little bit about your background with listeners? Where'd you grow up? 

McGonigle: I grew up in Iowa. So I didn't grow up on a farm by any means, but I have detasseled corn. My childhood was your typical Gen X childhood. I was outside all day playing with neighborhood kids, playing any sort of sport that had a ball. 

Marcus: So, where did you study and what did you study? 

McGonigle: I studied at Mankato State. They've since changed the name and it's Minnesota State Mankato. I studied finance and international business. I was always kind of drawn to the idea of business consulting and just really fascinated with how companies made money. So, finance was a natural path for that. 

Marcus: Was there anything in your childhood that sparked healthcare as a potential path? 

McGonigle: My first kind of big exposure or, the exposure that left a meaningful imprint on me, was seeing my grandfather at Mayo when he was fighting cancer. But at the time, it didn't really draw me into healthcare. It wasn't until much later when I decided to leave Accenture and go to UnitedHealth Group, and that was about 23 years ago. 

And I kind of fell in love with our company's mission to help people live healthier lives and to help the entire healthcare system work better for everybody. So I've been a lifer there. I intend to retire here, but, that's kind of where it started, was that first day on the job. 

Marcus: What excites you about healthcare today? 

McGonigle: The opportunities. There's so many challenges and it's so personal. You know, Optum Rx, which is the area that I work in, every prescription is a patient, so making sure that that patient gets the right medicine at the right time, when they need it, at an affordable price. 

It doesn't get any more personal than that. And so, knowing that there's barriers out there to patients getting their meds, or sometimes patients can't afford their meds. The healthcare system is expensive and there's opportunities to take the waste out and take the cost out. I just love all of those challenges. 

Marcus: And that's why you're here. Because this podcast is all about there's a better way and finding better ways in healthcare, in your case, to get patients on their medications more affordably and faster.  

What are some of your biggest wins so far in that venture? 

McGonigle: It's hard to pick just one. It's like picking your favorite kid. It's not possible. But, I do run the Enterprise Capability team at Optum Rx. And there's about 400 people on the team in total. And I would say the biggest impact I've had probably is being able to create a culture of innovation, a culture of collaboration, where I've got 400 team members who wake up every day and all they think about is, “How can I improve the patient, the provider, the client, our internal team member experiences?” And then also, “How can I apply technology and emerging technologies to automate things? Automate things that are administrative so that our pharmacists can work at the top of their license.” 

It's exciting to have that kind of an impact on such a broad group of people. Because everybody is focused on innovation, we've been able to bring to market some really great solutions for affordability. 

Optum Savings IQ last year helped. I think it was $1.3 billion worth of financial aid we were able to connect our patients to. It was really meaningful. Um, PreCheck MyScript for real-time benefit checks, proactive savings alerts letting our patients and members know when they can go to a cheaper alternative or find a pharmacy where they can get their drugs cheaper. 

And then provider solutions, which I know we're here to talk about today, but some really exciting things and innovations are happening in that space. 

Marcus: So as you know, healthcare is complicated. How do you not only cut through that complexity, but then choose the right place to cut through? 

McGonigle: Oh gosh. Yeah, it is complex and it's super personal for every patient that is in the healthcare system. What I love about technology and how it can help is it can really free up clinician time if you do it right. So if you can automate administrative tasks, for example, in prior authorization with our team, we're leveraging AI to help them sift through the chart notes so that they don't have to scroll through 40 pages looking for discrete clinical elements that they need to decide that PA case. So that saves them a lot of time, and it actually improves their accuracy.  

If we can use technology to provide clinicians with the right information at the right time. 

We let them work at the top of their license so they're happier. We are driving improved patient safety and efficiency. A good example of that is a pharmacy management platform that we stood up a year ago. It's called Pharmacy Central. And it's where we let the platform do all of the heavy lifting. We let it do all of the administrative tasks. It's smart enough to show our pharmacists the right information at the right time, and it improves their productivity. But more importantly, we also saw an improvement in patient safety. So by giving them the right information at the right time and letting technology help, we reduced class I errors by 94%. 

And those are the bad ones. It's the wrong drug, wrong dose, wrong directions. And so not only can technology help the team members become more efficient, but patient safety followed and that was an amazing win. 

Marcus: Those are great examples. I mean, you're doing this at scale every time you do it, so the numbers are dramatic. One of the things we think a lot about at Surescripts is systemic innovation and not just solving a solution point to point, but rather, solving the problem. 

And it sounds like that's a little bit of what you're talking about. Where you can go into a complicated, challenging area and solve it with multiple parties involved. 

McGonigle: Sometimes you can make incremental progress and it's enough. But when something is so broken or so archaic, those incremental improvements really aren't enough. 

So I agree with you 100%. And today in healthcare, the problems are big enough where things just need to be completely overhauled and reimagined, because incremental improvements won't get us to where we need to be. One thing that my team has been focused on when we're doing these types of systemic innovations is making sure that we know what problem we're trying to solve. Being really methodical about making sure we've got deep and comprehensive understanding of the problem at hand. Knowing what that full end-to-end process is for all the stakeholders involved and knowing all of the pain points that we can go after. So the team does kind of go slow to go fast. 

The other thing that's helped us is this co-creation aspect. We like to co-create the solution with the end users at our side. And we couple that with intentional change management and marketing to those end users to ensure that they know and they're excited about the change that's coming their way. 

Because you're really moving somebody's cheese if you're taking them from a screen [they know]. Which, you would look at the screen and see, if we start with a legacy system and it's a hundred fields smooshed onto a screen and there's no guided workflow, you would think that that's terrible. But that pharmacist is used to it. That's what they're used to seeing. And so if you're going to change and you're going to automate some of their tasks, you're changing the way they work and they may not be as excited as you think they're going to be. 

So, involving them in that change management process has really been beneficial so that they understand and get excited about it. 

Marcus: [Your role is] Senior Vice President at Optum Rx Enterprise Capabilities. Can you just define for us “enterprise capabilities”? 

McGonigle: Yeah. So at Optum Rx, enterprise capabilities really includes all of our systems and platforms, processes and digital portals that help patients and our providers and our clients and our team members, like our pharmacists, ensure that the patients and members get the prescriptions efficiently with quality. 

Examples include our Rx claim adjudication platform. We have a benefit plan setup platform. We've got client portals, prior authorization systems. We've got affordability and price transparency capabilities, and pharmacy management platforms like Pharmacy Central that I talked about earlier. 

And so my team is really focused on leveraging technology to make the patient and provider experience more streamlined and easy. They help all of the Optum Rx team members automate administrative functions, making sure they have the right information at the right time so they can do their jobs. Whether it's helping a pharmacist verify a prescription or helping a pharmacist render a clinical decision on a prior auth case. 

Marcus: Let's pick that apart a little bit and talk just about the patient. Because you said you talk about the patient experience and the provider experience. So let's talk about the patient experience for a few minutes. You know, what progress have you made on the patient experience so far in the last year or so? 

McGonigle: The focus for us has always been on patient safety. And driving more self-service capabilities. Like I mentioned earlier, nobody really wants to pick up the phone and call a call center. You want to be able to do everything on a digital portal or digital property or your mobile phone. And then affordability and price transparency is huge. The rising costs of drugs. Making sure that we can help our members afford their medication so that they actually take their medications. It’s a really big deal.  

So, patient safety. Some examples of what we're excited about with our home delivery pharmacy: We've been able to apply technology to create best-in-class backend dispensing accuracy, and our accuracy is 99.998% accurate, which is amazing. And you compare that to retail at 98.5%. There's a huge difference in safety there.  

So if we can apply automation, AI-enabled pill validation and then pharmacist clinical oversight, that helps us achieve that. When you think about affordability and price transparency, we need to give our patients tools to find lower cost drug alternatives 

And then I mentioned earlier Optum Savings IQ. You know, $1.3 billion in patient aid is a really big impact and helping those members afford their medications and if they can afford their medications, they're taking their medications and they're adherent and they have better outcomes. 

Marcus: What are some of the challenges and obstacles that you're working on now or that you see in place to ensure that quality patient experience? 

McGonigle: Yeah, I think the biggest obstacle for patients is what we just talked about with affordability. When you think about the already high and rising drug costs, that's got to be the greatest patient challenge. We've got a lot of products and capabilities out there in Optum Rx to help patients, whether it's the Optum Savings IQ or the Proactive Savings Alerts where we'll scan and know what they're paying for their meds and we'll find them those alternatives that are cheaper. 

MyScript Finder, we've got products called Price Edge, Critical Drug Affordability List. But even with all of those capabilities, the cost of brand drugs just continues to rise and patients struggle to afford them. 

Marcus: That is an access problem. So that's the patient experience.  

Can you talk about where we're at with the provider experience and some of the big priorities that you have? 

McGonigle: Yeah. We really strive to be easy to work with. One, we want to understand what are the provider's preferences for communication? How do they want to be communicated with? And if we can capture in all of those communications, and quite often it means, “Communicate with me digitally, securely within my EMR—don't fax me.” So, you know, we're kind of on an antifax campaign and trying to move everything towards those digital secure communications directly into the EMRs. And we're also trying to eliminate unnecessary communications. So if a prior authorization comes in and it's missing clinical data. Or a script comes into one of our pharmacies and it's missing clinical data. How can we leverage our clinical data sources internally to go find it ourselves versus clogging up their inbox with an email or getting them on the phone and calling them? We're trying to reduce those unnecessary communications, too.  

Clinical data automation has been a really big focus of ours. So if we have access to clinical data, how can we fish for it ourselves? How can we prepopulate any of those missing data elements within the prior authorization or within a script? 

Marcus: Can you clear up some of the misconceptions about prior authorization? What's good about prior authorization? 

What is it—for all of our listeners—and why does it exist? 

McGonigle: One misconception is that prior authorizations always lead to denials, and that's not the case. PAs are a tool to ensure that the medications are medically appropriate, and they're cost effective. And many PAs are approved without any issues whatsoever. 

What's good about prior authorizations? They're really important for ensuring safe and appropriate, evidence-supported uses of drugs. And they help with patient safety and they also help with affordability. So I would say that's the goodness around prior authorizations. 

We do know that it is fraught with challenges. We know that it creates abrasion and creates administrative burden for our providers. So, while it can take time away from providing patient care, it can also delay patients also into getting on a therapy. That's a problem that we've recognized for a while and we are really committed to making sure that prescriptions are affordable and we're also making sure that the pharmacy experience is simpler for patients and providers. 

So, we've done a couple things. We recently announced that we are removing  authorizations on 80 drugs, which is about 10% of our pharmacy prior authorizations. And so, how can we stop asking for unnecessary provider authorizations? If we have to have a PA, make sure that that process is as streamlined as possible and removes the friction and takes the administrative burden away from the providers. 

Marcus: That's exciting and groundbreaking. So, how can prior auth be improved? 

McGonigle: Well, it takes a lot of time for the physicians and their staff right now. More clinical documentation is being asked for in prior authorizations, and the physicians want to spend time with their patients. They don't want to spend time in front of their EMRs entering data or filling out prior authorizations. 

I think it was two and a half years ago, Melanie, where I had my very first Surescripts Network Alliance meeting with you guys. And we were talking about prior authorizations as a root cause for burnout. That was kind of exciting to be able to hear the pain points and to be able to partner with people across the industry on what potential solutions could look like. 

And two months later, Melanie, we got our teams together and they were solving the problem. It's amazing how we can talk about a problem as an industry stakeholder group, come up with solutions, and then pull people from across the industry together to solve these really hard problems. 

Marcus: It is amazing. And that advisory council, for our listeners, is a Surescripts advisory council where we have representation from across our Surescripts Network Alliance. Which means from different segments of healthcare, EHRs, PBMs, pharmacies, and so forth.  

I'm excited to have you describe what this is that we did together. 

McGonigle: OK, this is exciting. So, we have a solution. We worked really closely with Surescripts, Optum Rx did, to automate the submission and the approvals of pharmacy prior authorizations. Our companies built two solutions that work seamlessly together. And so these two solutions work in tandem to automate the submission of the prior authorizations. We do all of that in under 30 seconds. And it takes the manual administrative burden off the provider's back, and it also gets patients onto therapy faster.  

So, what it looked like previously is the provider writes their prescription, they send it to the pharmacy. The pharmacy might run a trial claim and find out that it gets rejected because it needs a prior authorization. And then there's some back and forth that goes on. The pharmacy would reach out to the provider and say, “Hey, I need you to complete this prior authorization.” The physician would complete the prior authorization. They would send it back. The PBM would render a clinical decision, either approve or deny it.  

In the meantime, the patient who had their prescription written, they think they can just go to the pharmacy and pick it up. So they go to the pharmacy. They're like, “I'm here for my prescription.” And the pharmacist tells them, “I can't give it to you because the claim was denied and a prior authorization was required.” And so they have to walk away and come back a couple days later, which is a terrible patient experience. And so, when we thought about all those pain points, we wanted to make sure that we could create the prior authorization on behalf of the provider. And we wanted to make sure that we could do an automated approval really quickly to remove that patient abrasion when they walk up to the pharmacy and they can't bring their meds home with them.  

So today, with our solution, when a provider is in their EMR and they're writing the prescription for the patient. Optum Rx’s Precheck MyScript runs a real-time benefit check. And it runs to see if a prior auth is needed. And if a prior auth is needed, the provider can initiate the PA within their EMR. 

So a clean prescription then is sent to the pharmacy. The pharmacy can adjudicate the claim, dispense the prescription. The patient walks up. They're able to walk home with their drugs with no delays. It's a total 180 from what the previous experience was. 

Marcus: Amazing. And the impact to the provider and the patient and even the pharmacy. Let's talk about that. What's the impact? 

McGonigle: Oh gosh. So, we talked already about removing the administrative burden so that the providers and their clinical staff don't have to create and fill out the PA question set. One thing that is important to note is that we've been live for one year with our solution and we've had 100% accuracy. So that's really important. Everything that's gone through this automated approvals process has been audited by a pharmacist. So we're 100% accurate. Um, 61% of the approvals can be automated, which is huge.  

Going back to the provider burden that we've removed. So, they don't need to manually complete the PAs for the drugs that are in scope for this. We've seen a 68% reduction in PA denials caused by lack of information. So that's exciting because Surescripts is able to reach into the EMRs and attach all the required elements. We don't get those PA denials anymore. And then there’s an 88% reduction in PA appeals because we get it right the first time, which is pretty cool. 

Marcus: That's amazing. And patients are picking up their medications. 

McGonigle: They are. They're getting on to therapy faster. 

We did a white paper and it showed that our PreCheck prior authorization solution resulted in a 43% reduction in time from when the PA was submitted to the paid claim. So that's huge. Four days faster, it's a big impact. 

Marcus: Four days. Oh, that's amazing. 

McGonigle: And pharmacies. 

Marcus: Pharmacy! I was going to say. 

McGonigle: You know, they don't have to go chase PAs. They get fewer claim rejects and they have fewer walkaway rates, which is good too. 

Marcus: Right. Absolutely. I mean, the pharmacists themselves. I watch them spending time on the phone trying to chase down those prior auths. 

McGonigle: Can I read you a quote real quick? 

Marcus: Please, I love quotes. 

McGonigle: We've been live for a year, as I mentioned before, and Cleveland Clinic was our first pilot partner. And they've been just a phenomenal partner to work with. And Dr. Eric Boose, he's their Associate Chief Medical Information Officer, this is a quote that he provided within the first couple months of it going live.  

Eric said, “It's amazing to take what is already there in the chart to automate prior authorization without any effort from the physician, pharmacist or staff. I feel the promise and excitement of automation actually happening and working and hope it grows quickly.” 

So, it's pretty cool, positive feedback. 

Marcus: Amazing. Very exciting. That is making an impact. That's systemic innovation for sure. When you've got collaboration, then an impact to so many people involved, providers, prescribers, pharmacists and then patients. 

You shared that great quote from Dr. Boose. Here's a great quote from a customer. When they turned it on, there was a snowstorm apparently coming. And they said, “You know what? The snowstorm is coming. The prior auth went through, came back in subseconds.  And this patient would not have been on their medication if it had come through tomorrow.” 

These are all great impacts. Systemic innovation at work.  

Well, let's look a little more broadly, collaborating across healthcare. Because that's what we've been talking about. How else do we collaborate across healthcare? How should we collaborate if there were really no bounds? 

McGonigle: Kind of like what you do as Surescripts, bringing industry leaders together, I would love to see a more frequent gathering of large industry players. Payers, PBMs, EMR vendors, pharmacies, network partners like Surescripts. How can we come together to solve really hard challenges? Because I think if we just picked a couple of the biggest pain points and we committed to partnering for the benefit of all the stakeholders, I think we could have meaningful change. 

I mean, we proved it here. I think that there's other problems that we could be working across the industry together. These aren't easy things that you can solve alone in your own silo. They've got to really work for everybody in the industry. 

Marcus: There's a rise of so many new technologies. Telehealth. You've got data and analytics rising. There's so many new technologies coming about. What are you most excited about? 

McGonigle: We've never seen the rapid advancement in technology like we have in the past few years. So that's what I'm really excited about. When you think about artificial intelligence and machine learning and agentic AI, it's really unlocking some amazing opportunities.  

It can help us make healthcare more personalized. It can help make sure that patients and providers get information more efficiently when they need it in near-real time. It can reduce the administrative burden for our clinicians and help them work at the top of their license. I mentioned earlier, the ambient listening and AI scribe.  

Just envision a day, whether it's one of our infusion nurses who are in the home of a patient and they're administering the infused treatment. Imagine if they didn't have to turn and swivel and type into their EMR. And they were just having the conversation and the ambient listening was capturing all the relative facts. And then the AI scribe was putting those facts and those notes directly into the EMR in the right spot. It would just be a better personalized experience. 

So, I'm super excited for where advanced and emerging technologies can take us. And we have to make sure that we are using those technologies in a responsible way and there's not bias. And we've got processes to make sure that happens. But the opportunities are absolutely endless. 

Marcus: That's great. What other changes, as healthcare continues to evolve, are top of mind for you in ‘25?  

McGonigle: Rising healthcare costs. And then I would say most recently, a lot of regulatory and legislation changes are top of mind for me. It's a super dynamic landscape. I feel like the goalposts are moving quite often, but it keeps me on my toes. 

Marcus: That's for sure.  

Well now it's time for my favorite part of the podcast where we get to look at the world through rose-colored glasses and leave with some inspiration. You can zero in on something specific or zoom out and look at the big picture or both. If you could snap your fingers and have one major issue in healthcare solved, what would it be? 

McGonigle: That is a tough and good question. If I could snap my fingers and solve one issue, I think I would solve the interoperability of healthcare data. So many of the problems that we encounter in the pharmacy space, in the PBM space, could be solved by having access to the data when we need it. 

And if all the healthcare providers had easy access to the relevant patient clinical data across all the medical records, I can't even imagine how we could improve that provider efficiency and take cost out of the system and make sure that the patients are getting improved care. It’s just better decision making, optimizing care coordination. You could reduce the medical errors, reduce redundant tests so much. And better patient outcomes. So much could be driven from that. 

Marcus: Is there something you wanted to talk about that we haven't talked about? 

McGonigle: I think we covered a lot of really good ground, Melanie. It was super fun to be with you today. It's been just an awesome journey and I'm really proud of the work that we've done to automate the prior auth process. 

Marcus: I’m proud of it, too. And we love geeking out with you.  

What gives you hope and inspiration that healthcare can truly heal itself? 

McGonigle: I would say technology aside, through this process and journey with solving this prior auth problem, I've experienced firsthand the willingness of multiple stakeholders across the industry to come together to solve a really hard problem. So, I have hope that if we could do it for solving this prior authorization problem, we can do it for solving other problems. 

Marcus: Sounds great to me. Well, thanks so much, Jen, for being with us today. 

McGonigle: Thank you for having me, Melanie. It's great to see you. 

Marcus: I want to take a step back and say that what I love about hosting this podcast is the chance to see so many nuanced, valuable perspectives from our guests.   

And that brings us to our guest on this episode, Jen McGonigle.  

We heard a lot about technology and innovation today, but there are three takeaways I want to highlight. 

The first is that we should always put the patient and provider, well … first. No surprise there, of course, but as Jen sees it, “every prescription is a patient.” And that line says everything. Our job isn’t to innovate for its own sake, but to innovate for patients and those who care for them.    

The second takeaway is about problem solving, and to solve problems, we must be methodical. As Jen says, the challenges in healthcare today are big enough that we need to overhaul and reimagine what it takes to solve them. And what it takes is a deep and comprehensive understanding of the problem at hand. 

The third and final takeaway is insightful and somewhat surprising, and it’s what Jen said about building solutions. She advises that we co-create solutions with end users, as she does on her team.  

Wonderful innovations can come out of being methodical, like automating prior authorization, which Jen says is one of the proudest achievements of her career.  

But innovation like this also takes some serious co-creation and collaboration.  

Jen might be the first to tell you that technology isn’t a magic cure-all for what ails us in healthcare … but she believes, as I do, that the benefits far outweigh the cons. And she believes, like I do, that the benefits are flowing—right now—to patients and those who care for them.       

Thanks so much for being a guest on our show, Jen, and for taking part in our first episode of the season. It was great to have you here with me.