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TRICARE and the Fight for Military Pharmacy Access | PBM Reform · Pharmacy Podcast Network

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Speaker 2: Welcome to the Pharmacy podcast Network.
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Speaker 3: Hey, welcome back to the PBM Reform Podcast, brought to
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Speaker 3: ten thousand downloads and listeners. Episodes like the fire Armis
1:00
Speaker 3: Fight Back Act that was live on Capitol Hill that
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Speaker 3: we did a recording with Greg.
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Speaker 4: Greg.
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Speaker 3: This show has just exploded since you guys have been helping.
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Speaker 3: I want to give a shout out to the APCI team.
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Speaker 3: Thank you so much for your support of the PBM
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Speaker 3: Reform Podcast. Greg, you take it away.
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Speaker 5: Awesome, well excited.
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Speaker 2: We got a great guest for this week's or this
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Speaker 2: month's episode, and one for folks who follow pharmacy closely,
1:29
Speaker 2: who follow PBM reform closely, and follow really just I
1:33
Speaker 2: would say healthcare policy closely. This name will be really familiar,
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Speaker 2: but we have John Vinson who is the CEO of
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Speaker 2: the Arkansas Pharmacy Association. John, thank you so so much
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Speaker 2: for joining us. And I think is this your first
1:45
Speaker 2: time on this podcast. If so, that's crazy because we
1:49
Speaker 2: we you know, we sure talk enough.
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Speaker 1: I've been on before. It's good to see you again.
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Speaker 1: Greg and Todd. Thanks for having me.
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Speaker 5: Okay, all right, so you were you were on.
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Speaker 2: Probably right when when Todd was host then, because I
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Speaker 2: never forget a conversation with you, so I remember if
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Speaker 2: it was if it.
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Speaker 5: Was you and I on that.
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Speaker 2: But anyway, awesome, awesome to have you back then. We
2:11
Speaker 2: got a lot of good stuff to cover, you know,
2:16
Speaker 2: exactly the state Association. I think most people would think
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Speaker 2: that we'd start with with PBM reform at the state level,
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Speaker 2: particularly because Arkansas is one of the absolute leaders in.
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Speaker 5: PBM reform at the state level.
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Speaker 2: Uh and there's just sort of this pedigree of leading
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Speaker 2: on PBM reform. But we're going to be I think something,
2:36
Speaker 2: do something a little counterintuitive, and that is we're going
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Speaker 2: to talk federal first. If that's okay with you, great,
2:44
Speaker 2: very good. So I think we're going to open it
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Speaker 2: up and talk a little bit about tricare. And the
2:48
Speaker 2: reason is try has been hot right lately. You know,
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Speaker 2: Senator Warren uh and Chairman Tubberville held a hearing on
2:58
Speaker 2: the pharmacy program in Tricare a couple what two three
3:03
Speaker 2: weeks ago now the week seemed to click by. And
3:06
Speaker 2: that's something that you paid a cute attention to. You're
3:08
Speaker 2: someone you know particularly you know you live in sort
3:12
Speaker 2: of this state world. But Tricare is a program that
3:15
Speaker 2: you have paid I would say, like razor close attention to.
3:18
Speaker 2: I think there's a couple of reasons for that. Let's
3:21
Speaker 2: let's kick off with you just kind of walking through
3:23
Speaker 2: why in your opinion, Tricare matters as much as it does.
3:27
Speaker 1: Yeah, thanks Greg. So that hearing was on July fifteenth.
3:30
Speaker 1: There's been a couple, but the one on the fifteenth
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Speaker 1: was specific to Traccare in the US Armed Services Senate
3:38
Speaker 1: Personnel Committee. Thank you for testifying in that particular hearing.
3:43
Speaker 1: I know a lot of national organizations and other state
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Speaker 1: associations are dialed in on this issue, but going back
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Speaker 1: to the early two thousands, just about every community pharmacy
3:56
Speaker 1: in our state participated in that network and they were
3:59
Speaker 1: proud to take care of America's finest are military, they're
4:03
Speaker 1: family members and retired military that are Tricare beneficiaries. There's
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Speaker 1: about ninety five thousand in this country, almost one hundred
4:11
Speaker 1: thousand lives covered by the program, largest employer program in
4:15
Speaker 1: the country.
4:17
Speaker 2: And the point of pride, you said, right, and that's
4:20
Speaker 2: always the impression I get. Are you independent pharmacists have
4:24
Speaker 2: it has been a point of pride to care for
4:26
Speaker 2: Tricare families.
4:28
Speaker 1: Yeah, Arkansas has a couple of Air Force bases, an
4:31
Speaker 1: army National Guard in our state, a lot of amazing
4:35
Speaker 1: human beings that protect our country, love our country, protect
4:39
Speaker 1: our country when we want to serve them, help them
4:41
Speaker 1: and their families access to care in our state. And
4:46
Speaker 1: in recent years, because of some things we're going to
4:48
Speaker 1: talk about in a minute, the majority of pharmacies in
4:52
Speaker 1: our state are no longer in network with Tricare. And
4:55
Speaker 1: it primarily happened after twenty twenty two. I know you
4:58
Speaker 1: shared some of the data from Arkansas. You work with
5:02
Speaker 1: a lot of stores in our state, almost one hundred
5:05
Speaker 1: pharmacies that your group that you work with, the APCI,
5:09
Speaker 1: that work with stores in lots of rural areas and
5:12
Speaker 1: underserved areas. But we went from nearly seven hundred plus
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Speaker 1: pharmacies in our state, participating to now less than forty
5:23
Speaker 1: five percent of the community pharmacies in our state. Walmart
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Speaker 1: is not in network. They have one hundred and twenty
5:29
Speaker 1: six locations. There are two hundred and fifty independent pharmacies
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Speaker 1: that are no longer in network. And what's crazy, Greg is,
5:39
Speaker 1: Arkansas has about five hundred cities in its state. You know,
5:43
Speaker 1: in the state they're incorporated. About half of those two
5:48
Speaker 1: hundred and fifty have at least one pharmacy in them.
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Speaker 1: All seventy five counties but for Tricare beneficiaries, fifty six
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Speaker 1: or more than twenty five percent do not participate in
6:00
Speaker 1: trick Care and seven counties and roughly ten percent of
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Speaker 1: the counties don't have a single pharmacy that participates in TRACK.
6:08
Speaker 4: Here and there are.
6:08
Speaker 1: Areas stunning, Yes, it's really, it's unbelievable. There are areas
6:13
Speaker 1: where there are sixty eighty miles areas where there is
6:18
Speaker 1: no access at all for patients in that program. And
6:22
Speaker 1: what's infuriating about it is the person who has a
6:26
Speaker 1: federal contract dictated in federal law thanks to US Congress
6:31
Speaker 1: in twenty fourteen, they get guaranteed mail order prescriptions, they
6:35
Speaker 1: get guaranteed fair dispensing fees to cover both their operations
6:40
Speaker 1: and their delivery. And yet that same entity who fills
6:44
Speaker 1: those prescriptions then it's turned around and incentivized to run
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Speaker 1: its competitor pharmacies, the local pharmacies in Arkansas out of
6:53
Speaker 1: business and out of trickcre And that program, even though
6:57
Speaker 1: it operates differently than other programs, should not have somebody
7:01
Speaker 1: who's both a pross taker and a press setter doing
7:05
Speaker 1: both functions, and when they do, bad things happen, they're
7:09
Speaker 1: incentivized to do the wrong thing.
7:11
Speaker 2: Yeah, I think I think the way I had framed
7:13
Speaker 2: it maybe was it's almost like a poster taught child,
7:17
Speaker 2: you know, for why there shouldn't be vertical integration, why
7:20
Speaker 2: PBMs shouldn't own pharmacies. And so you just covered a
7:24
Speaker 2: lot of ground. I want to break it down a
7:26
Speaker 2: little bit for for listeners, but before we get into
7:28
Speaker 2: the details, and you have you've got some You've got
7:31
Speaker 2: some great details. And I think my lead in here
7:34
Speaker 2: is you spent a lot of time looking at tricare
7:39
Speaker 2: you have right? You know, considering you you know a
7:41
Speaker 2: lot of what you do is work on state healthcare policy.
7:45
Speaker 2: Obviously try you know, the problems in tricare is something
7:49
Speaker 2: that that your members have felt acutely, that your member's
7:51
Speaker 2: patience I think have felt acutely. But just why as
7:55
Speaker 2: a state executive, just what was the catalyst to you
7:59
Speaker 2: really diving in, Because I'm gonna be honest, I don't
8:03
Speaker 2: know a lot of state execs that have sort of
8:06
Speaker 2: done the work that you have regarding what is the
8:09
Speaker 2: impact to patients in the state and how many pharmacies
8:12
Speaker 2: are in, how many pharmacies are out, and so a
8:16
Speaker 2: why the interest and be I'd just be interested to
8:19
Speaker 2: here's sort of the process in terms of how you
8:23
Speaker 2: dug into that and sort of got a handle on
8:26
Speaker 2: just how vast the impact was.
8:28
Speaker 4: I think there's two reasons.
8:30
Speaker 1: One, when we do strategic planning with our board of
8:32
Speaker 1: directors to figure out what our profession needs to best
8:36
Speaker 1: serve patients, it became abundantly obvious that it didn't matter
8:41
Speaker 1: how many scope of practice bills we introduced, how much
8:45
Speaker 1: fair payment bills we introduced for both clinical services and
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Speaker 1: for PBM services, and how many PBM reform bills we passed.
8:54
Speaker 1: When you don't have access to the patient at all
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Speaker 1: because your direct competitor is blocking access in order to
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Speaker 1: steer patients to their own pharmacies in the program like
9:04
Speaker 1: Trick here. It just became apparent that it was important.
9:08
Speaker 1: And then the second thing that I think acutely made
9:11
Speaker 1: it even more important was our state was the first
9:15
Speaker 1: to introduce legislation to stop conflicts of interest that are
9:19
Speaker 1: bad to drive up prices, to drive down access, to
9:24
Speaker 1: drive away competition. And that was of course Acts sixty
9:27
Speaker 1: four that is now tied up in federal court and
9:30
Speaker 1: litigation that brought it to the forefront as well, because
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Speaker 1: one of the key areas that's being litigated is trick
9:38
Speaker 1: here and how whether or not it's preempted from state
9:42
Speaker 1: law for that program to have those melt or pharmacies
9:46
Speaker 1: that exclude enacted in an anti competitive way to local pharmacies.
9:50
Speaker 1: So it became, you know, either way that case goes,
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Speaker 1: it made it clear that we need to work on
9:56
Speaker 1: federal policies. And of course the big three year Medicare
10:01
Speaker 1: track care federal employees, I know, managed care, Medicaid, and
10:04
Speaker 1: Medicaid that's there also for yeah, that's there as well.
10:07
Speaker 1: But you can do a little bit more in the
10:09
Speaker 1: state with managed care Medicaid.
10:11
Speaker 2: It's an important point, right, states can touch Medicaid, manage care.
10:15
Speaker 2: You know, they can touch Medicaid in certain ways, but
10:18
Speaker 2: have had a hard time I'm not waving the white
10:20
Speaker 2: flag on this, right, but certainly have had a hard
10:22
Speaker 2: time reaching you know, the Medicare market, Tricare market, federal
10:28
Speaker 2: employee health benefits plan market.
10:29
Speaker 5: For sure, I'll tell them go ahead.
10:33
Speaker 4: Yeah.
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Speaker 1: It also struck me because the Express Groups is arguing
10:36
Speaker 1: that state laws shouldn't apply to them, that they should
10:40
Speaker 1: be preempted from state regulations that deal with track care.
10:44
Speaker 1: But at the same time they're asking for the state
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Speaker 1: to license and oversee them. So I don't know how
10:50
Speaker 1: you can be preempted, but at the same time you
10:52
Speaker 1: want a license.
10:54
Speaker 2: That's a great Yeah. I think that's a great point.
10:57
Speaker 2: Something that's always fascinated me. Your federal program or even
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Speaker 2: even Arissa right, which obviously Arkansas led the nation in
11:05
Speaker 2: the you know, pcm A v. Rutledge all the way
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Speaker 2: up to the you know, really all the way up
11:10
Speaker 2: to the Supreme Court, right and one. But I agree, right,
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Speaker 2: I think there's I just think there's so many interesting
11:18
Speaker 2: issues in terms of them trying to use some of
11:20
Speaker 2: these federal programs as a shield on the PBM side.
11:24
Speaker 2: But the reality is when they're acting as a healthcare provider,
11:27
Speaker 2: when they're acting as a pharmacy, states enjoy broad discretion
11:31
Speaker 2: in licensing providers. Right, there's a there's a there's a reason,
11:35
Speaker 2: and this is going to be ridiculous, but there's a
11:37
Speaker 2: reason why. You know, a nurse or a PA or
11:41
Speaker 2: a pharmacist can't do non invasisve heart surgery under their
11:44
Speaker 2: state license. And you know a PBM doesn't get to
11:48
Speaker 2: trump that by arguing preemption from state licensing laws and
11:53
Speaker 2: scope of practice laws. So I love the point you
11:55
Speaker 2: touched on. I don't think he gets touched on enough,
11:57
Speaker 2: right to the extent that they want to act as
11:59
Speaker 2: a farm see and they own a pharmacy. It's a
12:02
Speaker 2: very different analysis from a preemption perspective than an INSURE
12:07
Speaker 2: or PBM preemption analysis.
12:10
Speaker 1: And then how did I get the data? The data
12:12
Speaker 1: is on their website. You can as a patient, as
12:15
Speaker 1: a taxpayer, you can go to the track your website
12:18
Speaker 1: and look by zip code every pharmacy in your state
12:22
Speaker 1: to see that.
12:24
Speaker 2: Wow, I'm sure it was painstaking. But I'll tell you what,
12:28
Speaker 2: Like again, you've got to better handle in your state
12:32
Speaker 2: than anyone I've talked to in terms of what was
12:35
Speaker 2: you know, what's the impact of sort of these practices
12:38
Speaker 2: and these policies at a state level. Driving at a
12:42
Speaker 2: tricare tremendous, and so that's how you did it. Something
12:45
Speaker 2: else I thought was interesting is in some of the complaints,
12:48
Speaker 2: you know, particularly ESI's complaint in the state of Arkansas. Boy,
12:53
Speaker 2: you know, they divulge some fascinating information and trying to
12:57
Speaker 2: kind of wield trycare as a pre I don't know
13:00
Speaker 2: if you say sword or shield, right, but in trying
13:04
Speaker 2: to argue preemption, I mean, one of the things that
13:07
Speaker 2: stunned me. I'm not showing me to get this exactly right,
13:10
Speaker 2: but I think if you do the math based on
13:12
Speaker 2: what they said, something like fifty percent of the mail
13:14
Speaker 2: order prescriptions in Arkansas come from the tricare program.
13:21
Speaker 5: Stunning, right.
13:21
Speaker 2: It shows you just how massive of a program tricare is.
13:26
Speaker 5: For SI, Yeah it is.
13:29
Speaker 1: And I would say too, we have a US senator
13:32
Speaker 1: who serves on armed Services, So you know, when you're
13:37
Speaker 1: in a state where you have a one senators on
13:40
Speaker 1: US Armed Services and the other Senator John Boseman, so
13:43
Speaker 1: Cotton Armed Services and then Senator John Boseman's on veterans affairs.
13:48
Speaker 4: So both of our senators US senators.
13:50
Speaker 1: Serve in capacities that have an interest in what happens
13:54
Speaker 1: with our military and their families. Senator Cotton's Healthcareason Riley
14:01
Speaker 1: Larson took a great interest in this. Earlier this year
14:04
Speaker 1: in March, he introduced a bill, a companion bill to
14:08
Speaker 1: a House bill, the Rix Access to Act. That Senate
14:12
Speaker 1: Bill forty one six, I believe is the number that
14:15
Speaker 1: would fix reimbursement. Yeah, I mean, there's it's a good start.
14:20
Speaker 1: That bill probably by itself is not going to move
14:23
Speaker 1: by itself, but it could move as part of a package.
14:25
Speaker 1: And one of the components of that bill, the mandatory audit,
14:30
Speaker 1: of course, has been introduced in collaboration with Senator Warren
14:34
Speaker 1: in Massachusetts across the Isle as well as in the
14:37
Speaker 1: House and past the House, and we hope that that
14:40
Speaker 1: moves later this year. But one thing that struck me
14:43
Speaker 1: in the hearing where you testified, Greg, and I'm going
14:45
Speaker 1: to talk about your testimony for a minute, but one
14:48
Speaker 1: of the reasons why when you go back to two
14:51
Speaker 1: thousand and three when express Scripts first got the contract,
14:54
Speaker 1: so they've had it for twenty three years. In twenty fourteen,
14:58
Speaker 1: the federal government vote into Federal Code Beautiful, Yeah, guaranteed
15:04
Speaker 1: protection and guaranteed filling to the prescriptions by PBM on
15:08
Speaker 1: pharmacy over local pharmacies for brand name mail or farm
15:13
Speaker 1: or prescriptions.
15:15
Speaker 5: I think brand name maintenance meds.
15:17
Speaker 4: Yeah, brand name maintenance meds.
15:19
Speaker 1: And they've allowed them through congressional action, given data that's
15:25
Speaker 1: not been ever validated by an independent audit, that it's
15:29
Speaker 1: less expensive to do it this way with their program.
15:33
Speaker 1: And in the hearing there were two or three things
15:35
Speaker 1: where Admiral Smith testified and you were testifying, and the
15:41
Speaker 1: pharmacists from Clovis, New Mexico was testifying, the pharmacy owner
15:46
Speaker 1: as well as the express Scripts president. And in that discussion,
15:51
Speaker 1: I think there were two big issues to me, well,
15:53
Speaker 1: really three. One should your competitor be setting the process
15:58
Speaker 1: of its competition in terms of dispensing fee and access.
16:02
Speaker 1: I think that's a big no, but that's one of
16:04
Speaker 1: the big themes. Number two is express Scripts paid more,
16:10
Speaker 1: paid higher dispensing fees and higher admin fees and higher
16:14
Speaker 1: delivery fee fees than local small business pharmacies in Arkansas,
16:19
Speaker 1: And then are they really cheaper?
16:21
Speaker 5: You know?
16:21
Speaker 1: One of the things in two thousand and eight, Congress
16:24
Speaker 1: passed a bill that guaranteed that on brand name drugs
16:28
Speaker 1: that prescriptions filled at retail would be eligible for the
16:31
Speaker 1: federal supply schedule rate and post adjudication rebates.
16:37
Speaker 4: As she's got a.
16:37
Speaker 2: Huge deal, right, it's a huge deal, and it's something
16:39
Speaker 2: that you don't hear DJA talking a whole lot about.
16:43
Speaker 1: No matter of fact, Admiral Smith didn't mention at all
16:46
Speaker 1: in the hearing at all. He didn't mention it. You
16:48
Speaker 1: brought it up. He didn't acknowledge it, didn't comment on it.
16:51
Speaker 4: And certainly and they didn't deny it.
16:54
Speaker 1: But there's never been an audit to look and see
16:57
Speaker 1: what that post adjudication price is. On top of that,
17:01
Speaker 1: you and Senator Moore and provided proof from their own
17:04
Speaker 1: data that mail order generic prescriptions are more expensive at
17:08
Speaker 1: the mail order pharmacy. So if they're but yeah, if
17:11
Speaker 1: they're more expensive, then why are more and more generic
17:14
Speaker 1: prescriptions being forced and sent and incentivized through copay advantages
17:19
Speaker 1: to mail it or pharmacy.
17:20
Speaker 2: And it's such a you know, Tricare is unique, right
17:23
Speaker 2: like for like, there's no question about it. But you know,
17:25
Speaker 2: if you if you dig into DHA's own reports, you
17:29
Speaker 2: know it tells a very different story from what's communicated
17:31
Speaker 2: to Tricare families, Tricare beneficiaries, you know, which is always
17:35
Speaker 2: mail orders, cheaper mail orders. Cheaper mail order is cheaper.
17:38
Speaker 2: And indeed, what's so unique about the program is there's
17:41
Speaker 2: literally copay tiers built into the federal code that appear
17:45
Speaker 2: almost punitive for Tricare families that want to use a
17:50
Speaker 2: retail pharmacy. Right it's I think it's like for a
17:52
Speaker 2: thirty day generic it's like sixteen dollars in twenty twenty six,
17:56
Speaker 2: for a ninety day at mail order, it's something like
17:59
Speaker 2: fourteen dollars. And they communicate this everywhere to Trycare families
18:03
Speaker 2: and Trycare beneficiaries DHA as well as the PBM, And
18:07
Speaker 2: so you know, if you're looking at it's like, oh
18:09
Speaker 2: my god, it costs me three hundred percent more in
18:12
Speaker 2: out of pocket to get ninety days filled at retail.
18:16
Speaker 2: But the reality is in practice, they use a lesser
18:20
Speaker 2: of logic at the retail pharmacies and they reimburse the
18:23
Speaker 2: mail order at the maximum, and so in fact retail
18:27
Speaker 2: despite what it looks like in the code with these
18:29
Speaker 2: copay tiers, the reality is express Script's mail order on
18:33
Speaker 2: generics can be massively more expensive for Tricare families than
18:39
Speaker 2: retail pharmacies.
18:41
Speaker 5: And and you know, I think.
18:43
Speaker 2: DHA's own reporting also reflects that in the aggregating on
18:47
Speaker 2: average in the generic market. And then as a result,
18:51
Speaker 2: and I don't recall the exact percentages, but what we
18:54
Speaker 2: saw is leading into sort of this twenty twenty two
18:57
Speaker 2: decision to call the network. By between thirteen fifteen thousand pharmacies,
19:02
Speaker 2: Tricare families were I would go so first to say
19:04
Speaker 2: flocking to retail pharmacies and mail order was losing market share.
19:09
Speaker 2: And so what happens there's this decision, under the auspices
19:12
Speaker 2: of cost savings right to call this retail network, which
19:18
Speaker 2: I would argue, or at least seemingly disproportionately seemed to
19:21
Speaker 2: impact independent pharmacy access to these networks.
19:24
Speaker 1: The other thing that motivated me, you said, why does
19:27
Speaker 1: the state exec care so.
19:28
Speaker 4: Much about this?
19:29
Speaker 1: We had state legislators during the session testifying, if you
19:34
Speaker 1: want to see hundreds of pharmacies close, then let's do
19:39
Speaker 1: nothing and act like Tracare acts. Basically, the worst employer,
19:45
Speaker 1: the worst pharmacy program, the worst access in the entire
19:49
Speaker 1: country is Trickcare.
19:51
Speaker 4: So Trackcare is.
19:52
Speaker 1: The model of how not to do it for every
19:55
Speaker 1: other program, whether you're talking about state and poise, two
19:59
Speaker 1: and four year public universities, municipally, city and county employees, medicaid,
20:05
Speaker 1: managed care, medicaid, on and on, for all the state
20:09
Speaker 1: regulated plans that are state funded plus employer plans, or
20:13
Speaker 1: risk is self funded bigger companies.
20:17
Speaker 4: If we don't do anything.
20:19
Speaker 1: The testimony was basically, this is how it's going to
20:21
Speaker 1: end up because the PBM in the track Care program
20:25
Speaker 1: has completely, with Congress's help, rigged it in a way
20:29
Speaker 1: that's heads they heads, they win, and everybody else loses
20:33
Speaker 1: till everyone loses.
20:35
Speaker 2: Yeah, So so well put right from my perspective, there's
20:38
Speaker 2: there's one winner here, and it's you know, it's it's
20:40
Speaker 2: the contracted PBM. But boy, you've mentioned it, I think
20:45
Speaker 2: in passing at least two or three times here.
20:48
Speaker 5: Right, But when you.
20:50
Speaker 2: For context, this stuff was passed by Congress right, like
20:54
Speaker 2: the we have this uneven playing field where on paper
20:58
Speaker 2: it's cost prohibited to use retail pharmacies for certain medications,
21:04
Speaker 2: and then for other medications, retail pharmacies are literally blocked out.
21:08
Speaker 2: They can't fill those prescriptions, you know, even if they
21:12
Speaker 2: wanted to.
21:13
Speaker 5: And this is it's.
21:15
Speaker 1: Codified, yeah, and it's you know, if you're comparing to
21:20
Speaker 1: federal programs in our state, if only forty five percent
21:24
Speaker 1: of the pharmacies or a network, which is the truth,
21:27
Speaker 1: only forty five percent are in at the same time,
21:30
Speaker 1: nearly one hundred percent are in Medicaid. So patients with
21:34
Speaker 1: Medicaid just as important as patients that are military military
21:39
Speaker 1: families in terms of access and care. Medicaid families have
21:44
Speaker 1: double the access compared to track are stunning.
21:47
Speaker 2: I mean that's stunning when you put it in that perspective, right,
21:50
Speaker 2: Medicaid beneficiaries have almost double the access to retail pharmacies
21:56
Speaker 2: in Arkansas.
21:58
Speaker 5: And then you can try care benefit.
22:00
Speaker 1: You must say, I know most of our listeners know,
22:03
Speaker 1: but that includes compounding, same day access, antibiotics, annavirals, pain medicines,
22:09
Speaker 1: compounding long term care, assisted living support, all the things
22:15
Speaker 1: that you can't get through mail order, mean, they're lost
22:18
Speaker 1: to these families. And you heard my statistic earlier in
22:22
Speaker 1: fifty six cities in our state they have a pharmacy,
22:26
Speaker 1: but they don't participate in truck here and it's.
22:29
Speaker 4: A real problem.
22:31
Speaker 2: Wow, it is, you know, something I don't want to
22:33
Speaker 2: get lost, and I don't know that I put a
22:35
Speaker 2: fine enough point on it in the hearing. But you know,
22:39
Speaker 2: DHA likes to talk about the you know, cost driver
22:42
Speaker 2: being brands. But when we saw sort of this exodus
22:46
Speaker 2: of between twelve to fifteen thousand retail pharmacies in late
22:51
Speaker 2: twenty twenty two early twenty twenty three under the auspices
22:54
Speaker 2: of cost savings, I think what gets lost is you
22:57
Speaker 2: know that DHA's owned data reflects that retail pharmacy dispense
23:01
Speaker 2: as high as I think eighty eight percent of the
23:03
Speaker 2: drugs they dispense their generics. And one of the reasons
23:06
Speaker 2: is the federal code blocks their ability to dispense brand
23:09
Speaker 2: a maintenance medications. And so to try to say, hey,
23:11
Speaker 2: we're going to call this retail network for cost savings,
23:15
Speaker 2: brands are a big driver. And then the reality is
23:18
Speaker 2: that retail pharmacies are just spending eighty eight percent generics.
23:21
Speaker 2: It doesn't reconcile, does it, right, It doesn't you know,
23:25
Speaker 2: this notion that somehow that was going to lead to
23:27
Speaker 2: cost savings.
23:28
Speaker 5: It just it just.
23:29
Speaker 2: Doesn't reconcile with their own data from my perspective. So
23:35
Speaker 2: I want to I want to make sure we have
23:36
Speaker 2: time to talk about you know, your your just amazing
23:39
Speaker 2: work and your association's amazing work in states, but just
23:44
Speaker 2: just to stay at this point. So let's say twenty
23:46
Speaker 2: twenty two, late twenty twenty two, early twenty twenty three,
23:49
Speaker 2: we sort of see this exodus, you know, then you
23:52
Speaker 2: pass you know, the Vertical Integration Act with six twenty
23:56
Speaker 2: z Act six twenty four. Yes, yeah, so you pass
23:59
Speaker 2: Act six twenty four and that was what twenty twenty five,
24:02
Speaker 2: and so it really it sounds like you're these last
24:07
Speaker 2: few years, you've really honed in on what's going on
24:10
Speaker 2: and trycare for sort of these twin reasons, which is
24:14
Speaker 2: the exodus of pharmacies. And then on top of that,
24:17
Speaker 2: you know what's transpired and connection with Act six twenty four,
24:22
Speaker 2: Arkansas has fast become a you know, a central player
24:25
Speaker 2: in this right you mentioned, Senator Cotton, you know, introducing legislation.
24:30
Speaker 2: I think your policy expertise has has certainly helped shape
24:34
Speaker 2: and create sort of this this understanding that hey, there
24:38
Speaker 2: needs to be an audit. You know, you've you've played
24:40
Speaker 2: so significantly at the at the state level for for
24:45
Speaker 2: so long, and I think somehow sometimes people think federal
24:48
Speaker 2: can be incredibly daunting, and certainly things move slower federally.
24:53
Speaker 2: But I mean, man, like you've you know, you're you have,
24:56
Speaker 2: you have had a hand in shaping try care policy
24:59
Speaker 2: and really a very very short time and it's just
25:01
Speaker 2: a fraction of what you spend your time doing. That
25:05
Speaker 2: Is that an any thoughts on that?
25:08
Speaker 4: I think that's fair.
25:09
Speaker 1: And I would say that PUTT and NCPA and APCI,
25:13
Speaker 1: American Pharmacies, there are a lot of groups nationally that
25:17
Speaker 1: help provide information for sure. Yeah, like you and I've
25:22
Speaker 1: had a lot of conversations about this and track here
25:24
Speaker 1: I didn't understand. I mean, I'm learning just in the
25:27
Speaker 1: last six months what the problems are and why and
25:31
Speaker 1: how it's evolved that way. But it's taken some time
25:34
Speaker 1: to really dig in and understand it. Now that I
25:37
Speaker 1: understand it, I feel like we can at least in
25:38
Speaker 1: our state advocate for change, and we've got to get
25:42
Speaker 1: these federal programs changed. I mean, fixing things at the
25:45
Speaker 1: state level is literally only half the battle. And Congress
25:50
Speaker 1: many times has made up of former state legislators who
25:53
Speaker 1: listen and look back to what their state has done. Yes,
25:56
Speaker 1: so I think they go hand in hand and working
25:59
Speaker 1: with our federal partners.
26:01
Speaker 5: Yeah.
26:01
Speaker 2: Well, I'll tell you one thing I was excited about,
26:03
Speaker 2: and this is a little bit of a change of subject,
26:04
Speaker 2: but I think related was the reintroduction of Pharmacists Fight
26:07
Speaker 2: Back Act in December, and you know, there there was
26:12
Speaker 2: a press conference and you know, two bills sixty six
26:16
Speaker 2: O nine, sixty six ten, sixty six ten very recently
26:19
Speaker 2: marked up by House Oversight, which we're really excited about.
26:22
Speaker 2: But to see you know, just sort of just leaders
26:26
Speaker 2: on healthcare policy at the state level, particularly pharmacy policy
26:30
Speaker 2: at the state level, show up, you know, in support
26:33
Speaker 2: of that fight, I thought was was really cool, right,
26:37
Speaker 2: and there were you know, you were there, you know,
26:40
Speaker 2: Randall out of Louisiana, Ben out of Kentucky who we
26:45
Speaker 2: had on just I think it was last week we
26:48
Speaker 2: released a podcast with Ben. Obviously Kentucky does great work.
26:53
Speaker 2: But I thought that was I think it's cool to
26:55
Speaker 2: see folks sort of with that track record and that
26:58
Speaker 2: pedigree starting to sort of pay attention, you know, not
27:01
Speaker 2: starting to, but you know, paying attention to what is
27:03
Speaker 2: happening at the federal level and making their mark. To
27:06
Speaker 2: your point, right, like a great work's obviously been done
27:09
Speaker 2: on Tricare. I think the putt you know, audit Trycare
27:12
Speaker 2: program has has really garnered a lot of attention. NCPA
27:16
Speaker 2: has been you know, critical I think also in sort
27:18
Speaker 2: of this process of securing it. But but nonetheless, like
27:21
Speaker 2: I think you're being modest, right, I think you've I
27:24
Speaker 2: think you've helped shape where folks are looking and the
27:26
Speaker 2: rocks they are looking under, and helped make really draw
27:30
Speaker 2: some attention to Trycare and that program. So I think
27:35
Speaker 2: I think we've we've we've talked a good bit about Trycare.
27:39
Speaker 2: We could do probably like a five episode special on
27:42
Speaker 2: the work that you have done at the state level.
27:48
Speaker 2: And I want to talk about some of the work
27:49
Speaker 2: you've know at the state level. But you know, you
27:51
Speaker 2: mentioned sort of champions flowing up right, and legislators and
27:56
Speaker 2: leaders at the state level and federal folks looking to
27:59
Speaker 2: them or evolving and then becoming But boy, Arkansas has
28:04
Speaker 2: some Arkansas has some pharmacy champions and some champions for
28:07
Speaker 2: patient access to care, doesn't it.
28:10
Speaker 4: Yeah, that's the You just hit the nail on the head.
28:12
Speaker 1: The patient access to care is what all of this
28:16
Speaker 1: is about, you know, fair better pricing, fair competition, access,
28:22
Speaker 1: and ultimately patient outcomes.
28:25
Speaker 4: We had, you know, lots of.
28:27
Speaker 1: Patients and patient advocates testify this last session, more so
28:31
Speaker 1: than ever before. And one of the things that's really
28:36
Speaker 1: changed a lot of hearts and minds just learning and
28:39
Speaker 1: learning from others is we've gotten the input in the
28:43
Speaker 1: partnership from our oncology partners, so our oncologists, the pharmacists
28:48
Speaker 1: who work with a lot of chemotherapy drugs and oncology drugs,
28:52
Speaker 1: as well as the physicians apr ns and pas that
28:55
Speaker 1: prescribe them. One of the most staggering statistic and you
28:59
Speaker 1: think about this, when you go into the emergency room
29:03
Speaker 1: or hospital and you have sepsis, you expect your drugs
29:08
Speaker 1: to treat your infection to be available right then and there,
29:12
Speaker 1: because every minute you delay increases your likelihood of increase
29:17
Speaker 1: morbidity and mortality. Well, chemotherapy is the same thing. For
29:21
Speaker 1: every four week delay and access to a chemo drug,
29:25
Speaker 1: your mortality goes up by ten percent on average. So
29:29
Speaker 1: every day literally increases mortality risk. And that's been central
29:34
Speaker 1: to a lot of the discussion around whether it is
29:39
Speaker 1: narrow networks of drugs that are limited distribution to primarily
29:44
Speaker 1: mail or PBM pharmacies, whether it's the anti competitive acts
29:48
Speaker 1: of owning a pharmacy as well as setting network rates
29:52
Speaker 1: and prices and access to pharmacy from an anti competition perspective,
29:57
Speaker 1: fair and reasonable reimbursement methodolog g's better enforcement of our
30:02
Speaker 1: existing laws, and also needed litigation in the market. We've
30:07
Speaker 1: we've been trying to either pass legislation better enforce in
30:12
Speaker 1: all of those areas.
30:14
Speaker 4: And I know.
30:15
Speaker 1: I've been on before some other groups and I've said, oh,
30:18
Speaker 1: it's an acronym. Arkansas is the natural state that's L
30:22
Speaker 1: for litigation, E for enforcement, A for stopping anti competitive acts,
30:26
Speaker 1: and F for fair reasonable payment models.
30:29
Speaker 4: And I was at the McKesson.
30:32
Speaker 1: I did share a meeting and somebody came up to
30:34
Speaker 1: me and goes, you know that spells flee L F
30:37
Speaker 1: L e A. That's what we're trying to kill, or
30:40
Speaker 1: the pesky little fleas that are destroying Yeah, patient access,
30:44
Speaker 1: So I may have to change the acronym order there,
30:46
Speaker 1: with fair and reasonable reimbursement being number one, but switch it.
30:50
Speaker 2: Switch it around. Well, you know, I'm glad you mentioned oncology.
30:56
Speaker 2: You know, we talked so much about vertical integration just
31:00
Speaker 2: in this industry, and you know it's impact and obviously
31:03
Speaker 2: steering is is front and center, but sometimes I do
31:06
Speaker 2: think what gets lost is central to kind of the
31:09
Speaker 2: steering strategy by the big PBMs are targeting the sickest
31:13
Speaker 2: patients that there are, right, they're targeting them. They're restricting
31:17
Speaker 2: their access to their oncologists, to their pharmacists, and you know,
31:21
Speaker 2: they're steering into those channels. And then on top of that,
31:24
Speaker 2: what we see so often is not only are they
31:26
Speaker 2: you know, disrupting care, interrupting care, delaying care, but then
31:30
Speaker 2: they're marking these medications up hundreds, two thousands and thousands
31:35
Speaker 2: of percent on the sickest patients that there are right
31:38
Speaker 2: literally patients that are fighting for their lives, patients where
31:42
Speaker 2: where time matters, money matters, and you know, we're seeing
31:47
Speaker 2: the required mail order. We're seeing the delays, but we're
31:50
Speaker 2: also seeing just massive price manipulation as well.
31:55
Speaker 4: Yeah, it was it just the FTC reports.
31:57
Speaker 1: We've seen the insurance Department in West Virginia and Tennessee
32:01
Speaker 1: found that same thing the Mississippi Bord of pharmacy. If
32:05
Speaker 1: you've read the news lately, there are certain PBMs in Arkansas, Alabama,
32:11
Speaker 1: and Florida who are just refusing to cooperate with audits.
32:14
Speaker 1: It's not just the FDC, it's also now at the
32:17
Speaker 1: state level where they're just shifting, shaping, refusing to cooperate,
32:22
Speaker 1: which gets back to what should the penalties be and
32:25
Speaker 1: the enforcement side of it and response to that.
32:28
Speaker 4: We got work to do.
32:29
Speaker 2: But we had a lot of work to do, right
32:30
Speaker 2: because one of the things we see across the country
32:33
Speaker 2: is even when they lose, it can be a good
32:35
Speaker 2: day in the office for PBMs. Right if they get
32:38
Speaker 2: a you know, if a big PBM gets whacked with
32:41
Speaker 2: a fine for a practice that they made hundreds of
32:44
Speaker 2: million dollars on, that's still not a bad day in
32:47
Speaker 2: the office for them, is it? Maybe not even necessarily
32:49
Speaker 2: a determin I agree. Okay, so this is a digression,
32:54
Speaker 2: but one thing I thought was cool you mentioned patients
32:57
Speaker 2: that came to testify, you know, patient advocates, and I
33:01
Speaker 2: thought one thing, I'd love to give a shout out
33:03
Speaker 2: a to you all for recognizing her and also to her.
33:06
Speaker 2: But at your association meeting, I want to say it
33:09
Speaker 2: was early June. You guys recognize somebody who I admire greatly,
33:13
Speaker 2: which is Loretta Boosing. If you want to give a
33:16
Speaker 2: shout out to her and talk a little bit about
33:18
Speaker 2: sort of how you recognized her, I thought that was
33:20
Speaker 2: a really cool moment.
33:21
Speaker 4: Yeah, she's awesome.
33:22
Speaker 1: She and her husband came and our board recognized her
33:27
Speaker 1: with the Patient Advocate of the Year award. It's only
33:30
Speaker 1: the second time we've given that award out and actually
33:34
Speaker 1: the first time it was given it was given to
33:36
Speaker 1: Governor Sarahuckabee Sanders and her efforts to highlight patient access
33:41
Speaker 1: in the New York Times and signed legislation kind of
33:45
Speaker 1: to a national level. But Loretta has been a good partner,
33:49
Speaker 1: not just in Arkansas, but across the entire country.
33:52
Speaker 4: She's very brave, very well.
33:54
Speaker 1: So yeah, it's not you know when you talk about
33:57
Speaker 1: your own family or your own access issues, or you're
34:00
Speaker 1: fearful that your benefits will be cut off or that
34:04
Speaker 1: your employer will be mad at you. And it takes
34:07
Speaker 1: a lot of time and sacrifice to kind of put
34:09
Speaker 1: yourself out there in such a public way. And she's incredible,
34:14
Speaker 1: she and her family for being brave and for speaking
34:17
Speaker 1: up and finding for so many. You know, there was
34:20
Speaker 1: a in the discussions in the hallways of the Capital.
34:23
Speaker 1: One of our legislators, in response to hearing her testimony,
34:27
Speaker 1: shared with me that he had just had a patient
34:30
Speaker 1: come in that had an autoimmune disorder of the eye
34:34
Speaker 1: called uv iitis and needed a specialty drug and got
34:38
Speaker 1: the pri authorization approved and then it was forced of
34:41
Speaker 1: course to a single pharmacy through the mail, and that
34:45
Speaker 1: patient never got it filled even though it was approved
34:48
Speaker 1: for whatever reason. You know, in the phone tree, if
34:51
Speaker 1: somebody can't talk or figure out how to answer the
34:54
Speaker 1: phone and coordinate with the patient, Which gets back to
34:58
Speaker 1: this is not just a commodity, it's an actual delivery
35:01
Speaker 1: of patient care, which includes a relationship and coordination of
35:05
Speaker 1: care and follow through to ensure that diseases that are
35:08
Speaker 1: laughed threat and are treated. And you know, he heard
35:12
Speaker 1: Loretta's story and shared with us that this particular patient
35:17
Speaker 1: had gone without this medicine for several weeks and had
35:21
Speaker 1: permanently lost seventy five percent of her vision terminally.
35:26
Speaker 2: Yeah, I mean that power of a personal story, right,
35:29
Speaker 2: Like I do think drug pricing and sort of some
35:33
Speaker 2: of these PBM practices, it can be esoteric to people, right.
35:36
Speaker 2: You can be talking about these giant aggregate numbers hundreds
35:39
Speaker 2: of millions of dollars, billions of dollars, or you know
35:42
Speaker 2: markups over Nate act, you know, thousands of percent, and
35:46
Speaker 2: it's easy to get caught up in sort of these
35:48
Speaker 2: esoteric concepts. But I think you know something Loretta always
35:51
Speaker 2: does well and sort of the experience you just shared, right,
35:54
Speaker 2: is like when a patient tells the story of how
35:57
Speaker 2: PBM practices have impacted their care or their loved ones care,
36:02
Speaker 2: it it brings it home, right. I mean I've I've
36:05
Speaker 2: heard patients testify in Georgia and other states and you know, boy,
36:10
Speaker 2: you could have heard a pin drop at the end,
36:12
Speaker 2: right like it can you know, that personal story I
36:16
Speaker 2: think can suck the oxygen out.
36:18
Speaker 5: Of her room. Sometimes I agree, and it.
36:21
Speaker 2: Takes, you know, for patients, boy, it takes. It takes
36:25
Speaker 2: guts to do it, right. I mean, they're not they're
36:26
Speaker 2: not professional speakers. And I've seen Loretta right show up
36:30
Speaker 2: to states where she has no like contacts in rooms
36:34
Speaker 2: with you know, lines of people lined up, professionals on
36:38
Speaker 2: the other side, and get up and tell her family
36:42
Speaker 2: story and you know, pretty I think that takes a
36:45
Speaker 2: lot of guts. So thought it was really cool that
36:48
Speaker 2: that you all recognized her. So I thought that was neat.
36:50
Speaker 2: Now you mentioned you mentioned Governor Sanders. She's turned out.
36:56
Speaker 2: I would, I would argue to be one of the
36:58
Speaker 2: most prominent sort of like national I don't want to
37:01
Speaker 2: say spokespeople, right, but really an advocate, one of the
37:04
Speaker 2: one of the strongest and most prominent advocates for for
37:08
Speaker 2: PBM reform.
37:09
Speaker 5: Is that. I don't think that's hype look to say,
37:11
Speaker 5: would you agree? Now?
37:12
Speaker 4: I agree.
37:13
Speaker 1: She You know, she's a cancer survivor herself. I don't
37:17
Speaker 1: know how many of you know that, but she's herself,
37:20
Speaker 1: she's a patient. Yeah, she's a patient. She's a survivor.
37:24
Speaker 1: And I think she really gets it. I mean, she
37:27
Speaker 1: understands she's like the rest of us, fighting this broken
37:31
Speaker 1: system and trying to find good reforms that put the
37:35
Speaker 1: patient first and put patients over profits in our policy reforms.
37:39
Speaker 1: And we're proud of her for doing that in our
37:42
Speaker 1: state and also elevating the conversation across the country.
37:47
Speaker 2: Yeah, it's cool. And you know, every now and then,
37:50
Speaker 2: you know, she'll push something out on social media. I
37:52
Speaker 2: want to say, was it last week? I think she
37:54
Speaker 2: pushed she pushed something out. Yeah, and you just you know,
37:59
Speaker 2: just power full message and it catches on when she
38:01
Speaker 2: does it.
38:02
Speaker 5: It's amazing.
38:03
Speaker 1: Yeah, the video started out with PBMs. You can't explain
38:06
Speaker 1: it in one sentence.
38:08
Speaker 5: There's a reason.
38:10
Speaker 2: Yeah, that's right, man. Uh that ain't that ain't no
38:13
Speaker 2: lie is it? Arkansas has a lot of other champions too,
38:18
Speaker 2: as well as some pharmacists in you know, in the
38:21
Speaker 2: state capitol. I would argue you guys have not not
38:26
Speaker 2: only a pedigree of winning, but a pedigree of cultivating
38:31
Speaker 2: again champions for patient access to care, champions for PBM reform.
38:36
Speaker 2: Is there is there a secret?
38:37
Speaker 5: Sauce?
38:37
Speaker 2: I think so often when you're in other states, you
38:39
Speaker 2: look at a state like Arkansas and it's like, oh
38:41
Speaker 2: my god, you know, they struck lightning and something happened
38:44
Speaker 2: over proverbially overnight, but but there's been I'm gonna suspect
38:48
Speaker 2: don't want take words anyone. I suspect that there's there's
38:51
Speaker 2: a lot of work over a long period of time that.
38:54
Speaker 5: Builds upon previous work. But I'd love to hear hear
38:57
Speaker 5: your thoughts.
38:58
Speaker 1: I think this secret saw says no one cares more
39:02
Speaker 1: about this issue and how it affects our communities and
39:06
Speaker 1: our patients, and those stories that I just shared than
39:09
Speaker 1: the pharmacists of the United States of America and what
39:13
Speaker 1: you saw recently in Alabama and Kansas and Montana and
39:18
Speaker 1: Kentucky and Tennessee and Oklahoma and others. I'm going to
39:22
Speaker 1: leave somebody out New Mexico, West Virginia. There's so many
39:25
Speaker 1: good examples. Louisiana is a huge one. I mean, Louisiana
39:30
Speaker 1: is a huge story. But thinking about you know, Kansas
39:34
Speaker 1: shutting their stores down for a day to come up
39:37
Speaker 1: there first hand in person and explain how this is
39:41
Speaker 1: destroying not only the price of drugs, but access and
39:44
Speaker 1: local the ability to provide that locally is so effective.
39:51
Speaker 1: And that's one of the things Arkansas has done. We've
39:53
Speaker 1: been that.
39:57
Speaker 4: No, it's definitely an ongoing battle.
39:59
Speaker 1: And it's a and it's we're learning from some things
40:02
Speaker 1: that other states have passed us on on the fair
40:04
Speaker 1: and reasonable reimbursement standards. We have a Rule one twenty
40:09
Speaker 1: eight and a cost the dispense that's being implemented in
40:13
Speaker 1: certain plans in our state. But it could be better,
40:16
Speaker 1: and we could we could learn from states like Tennessee
40:19
Speaker 1: and Kentucky and others to see how we can better
40:22
Speaker 1: improve that implementation in our state. You know, Oklahoma has
40:28
Speaker 1: some whenever they the AG's Office fines for non compliance,
40:32
Speaker 1: some of those dollars go back to the affected pharmacy.
40:36
Speaker 1: That's so critical because of the time and staffing and
40:40
Speaker 1: harm that was done to file the complaint. To try
40:43
Speaker 1: to resolve it, we our state added a twelve percent
40:48
Speaker 1: penalty per month back to the pharmacy for under payments,
40:53
Speaker 1: for under reimbursements for blow invoice costs as well as
40:57
Speaker 1: blow a cost the dispense reimbursement, and also prompt pay
41:01
Speaker 1: which you and I've talked about that speeds up in
41:04
Speaker 1: the commercial market to match what happens in medicaid. In Medicare,
41:08
Speaker 1: which which ironically has been fixed in some of our
41:11
Speaker 1: federal programs, but still lags behind in our state PBM laws.
41:16
Speaker 1: We finally caught up on that with a penalty of
41:19
Speaker 1: twelve percent interest payments per month back to affected pharmacies.
41:24
Speaker 5: Yeah.
41:26
Speaker 2: So, you know, something that I've always admired about about
41:30
Speaker 2: Arkansas and your work is obviously, you know, you've got
41:35
Speaker 2: to robust legislative advocacy platform. You know, obviously the state
41:39
Speaker 2: has not been afraid to stand its ground and litigate,
41:42
Speaker 2: and you've not been afraid, you know, to advocate for
41:46
Speaker 2: you know, new first of its kind legislation.
41:50
Speaker 5: More than once.
41:51
Speaker 2: But you know, some of the reimbursement work that Arkansas
41:53
Speaker 2: has done hasn't necessarily been exclusive legislative, right, There's been
41:57
Speaker 2: a lot of regulatory work in Arkansas that front as well.
42:00
Speaker 5: Am I right in that, And I think that's that's
42:02
Speaker 5: kind of unique.
42:03
Speaker 2: I think it's important point to dry out right, like,
42:05
Speaker 2: you don't look for you know, you don't look in
42:08
Speaker 2: one arena, right, I mean, you're you're looking for opportunities
42:11
Speaker 2: wherever those opportunities may be.
42:13
Speaker 1: We are, and I would say too, this is something
42:16
Speaker 1: I want to make sure and give credit where credits due.
42:19
Speaker 1: We also have we talked about time and talent. You're
42:23
Speaker 1: talking about strategy, but the final piece of that is money.
42:28
Speaker 1: State associations run off shoe string budgets. They need resources.
42:33
Speaker 1: The states who have resources into their state advocacy efforts,
42:38
Speaker 1: and state associations usually are the venue for that.
42:42
Speaker 4: Not always, but usually I.
42:44
Speaker 1: Would argue they should be because they're the longest lasting.
42:47
Speaker 1: Our association has been here since eighteen eighty one. Wo
42:50
Speaker 1: just for perspective, and you.
42:52
Speaker 5: Know yourself have not been there since eighteen eighty one though.
42:55
Speaker 4: Right, just not quite close, but not quite.
42:59
Speaker 1: But we've had you know, our independent pharmacists, some of
43:03
Speaker 1: our industry partners, wholesalers, particularly Morrison Dixon Smith Drug who
43:11
Speaker 1: I know is in transition right now, McKesson, Amplify. You know,
43:15
Speaker 1: there's the Cardinal one voice. There's a lot of good
43:18
Speaker 1: financial support out there to help us in these efforts,
43:22
Speaker 1: and it's impossible to do it without dollars. So you you,
43:27
Speaker 1: you know, good advocacy effort. You think about pr and
43:32
Speaker 1: media and all that stuff, but the reality is you
43:34
Speaker 1: have to have human beings to help kind of lead
43:37
Speaker 1: the efforts.
43:40
Speaker 2: Yeah, yeah, I agree, and that that does take money, right,
43:44
Speaker 2: whether it's money director of the association or to packs
43:48
Speaker 2: you know, one thing I'll say, and look, obviously not
43:52
Speaker 2: all states are created equal in terms of number of
43:54
Speaker 2: pharmacies or robustness of associations, but having you know, professionals
43:58
Speaker 2: on the ground to understand the political process as well,
44:01
Speaker 2: whether that be you know, executive directors or contract lobbyists.
44:06
Speaker 2: I'll tell you this, I was, you know, I've had
44:08
Speaker 2: the honor and pleasure of visiting Arkansas and watching you
44:12
Speaker 2: all kind of do what you do in the thick
44:14
Speaker 2: of it. And boy, obviously you know, incredibly impressed by you,
44:18
Speaker 2: but super impressed by Debra as well.
44:20
Speaker 4: Yeah, she's awesome. Man.
44:22
Speaker 2: Having fortunate having the right you know, the right team,
44:26
Speaker 2: you know who understand the politics and understand the policy,
44:29
Speaker 2: and you know, it's it's it's I always say this, right,
44:32
Speaker 2: I'm a broken record on it. But I think, you know,
44:35
Speaker 2: outside looking in, if you're a pharmacist in certain states,
44:39
Speaker 2: you know, if you're not super involved in the political process,
44:41
Speaker 2: I think it becomes easy to think that it's that
44:44
Speaker 2: it's not hard to pass a bill and what all
44:47
Speaker 2: goes into it, right, And the reality is it's really
44:50
Speaker 2: hard to pass a bill about anything in any state,
44:53
Speaker 2: and then when you're trying to pass a bill against
44:55
Speaker 2: well funded, organized opposition with you know, almost limitless pockets,
45:00
Speaker 2: it becomes that much harder, and the difference between like
45:02
Speaker 2: victory and defeat can be can.
45:05
Speaker 5: Be so thin.
45:07
Speaker 2: Right again, It's easy to look at like Arkansas in
45:10
Speaker 2: twenty twenty five from the outside looking in and say, man,
45:13
Speaker 2: that was that was easy? But I think you know
45:16
Speaker 2: again I was. I was there for one or two days.
45:17
Speaker 2: I think I can vouch for you. Guys worked pretty
45:20
Speaker 2: dang hard, and opposition was flooding a lot of money
45:24
Speaker 2: into that state to keep the status quo. I don't
45:29
Speaker 2: think you would say it felt easy when you were
45:31
Speaker 2: doing it, would you know?
45:33
Speaker 4: It certainly did not.
45:35
Speaker 1: It's not It's worth it though, not to be a
45:39
Speaker 1: broken record here, but the patient access and the patient
45:44
Speaker 1: care and being able to recruit future workforce to want
45:48
Speaker 1: to be a pharmacists, that is a real issue. Man
45:52
Speaker 1: Like recruiting are the brightest and the most talent into
45:57
Speaker 1: our profession. To to continue to provent these services in
46:00
Speaker 1: our local communities is not going to be easy unless
46:04
Speaker 1: we fix these issues. So that isn't also that is
46:07
Speaker 1: also a driving force for the future.
46:09
Speaker 2: Yeah, that's that doesn't get talked about a lot. So
46:12
Speaker 2: I'm yeah, so so glad, so glad you brought that up.
46:17
Speaker 2: And I think even when you're talking about PBM reform,
46:20
Speaker 2: right like, there are and you'll know more about this
46:22
Speaker 2: than me, But I mean, there are real issues in
46:24
Speaker 2: terms of recruiting students for pharmacy schools now for a
46:29
Speaker 2: number of reasons. But I would argue sort of industry
46:32
Speaker 2: conditions and reimbursements and patient access all fold into that.
46:37
Speaker 1: Yeah, and I will say I'm going to bring it
46:40
Speaker 1: back to track here again. But we've got the big
46:42
Speaker 1: beautiful bill and there's rural health transformation dollars, and there
46:46
Speaker 1: are going to be a lot of states try to
46:49
Speaker 1: address pharmacists as prescribers, pharmacists being able to order labs,
46:54
Speaker 1: pharmacists being able to diagnose for simple conditions similar to
46:58
Speaker 1: the way pharmacists do and Canada, I think Alaska was
47:02
Speaker 1: the most recent state to have success at that and
47:05
Speaker 1: on the clinical side, which I think is exciting, you know,
47:08
Speaker 1: for delivering care. And the worst program for that vision
47:15
Speaker 1: is truck here because you can't even access the patient,
47:18
Speaker 1: so you got Congress on one hand saying we need
47:21
Speaker 1: to invest in doctor a.
47:23
Speaker 4: Pharmacists are awesome.
47:24
Speaker 5: We need to Yeah, I'm so glad you said that.
47:27
Speaker 2: And one of the things, you know, anytime you're like
47:30
Speaker 2: up at a table, you know, there's always things you
47:32
Speaker 2: go back and oh, man, I wish I would have
47:33
Speaker 2: said that, but I you know, there was a question
47:35
Speaker 2: of right, like what can pharmacists offer and provide to
47:39
Speaker 2: improve outcomes? Something like that I'm paraphrasing. And the biggest
47:43
Speaker 2: thing I've regretted is like the pharmacists can't if they're
47:46
Speaker 2: not in the.
47:47
Speaker 5: Network, right, and really articulated that perfectly.
47:51
Speaker 1: What upset me the most about doctor Smith's testimony Admiral Smith,
47:56
Speaker 1: the DHA dipity director, somebody I think Senator Blooman was it.
48:02
Speaker 1: Bloomenthal asked him, doctor Smith, you know kind of bigger
48:07
Speaker 1: picture in the country, what is the one thing that
48:11
Speaker 1: you think needs to change to improve healthcare in America?
48:14
Speaker 1: So like he's not getting him in the weeds. And
48:17
Speaker 1: he could have answered anything. He could have said cost
48:20
Speaker 1: or to high on brand name drugs, we don't have
48:24
Speaker 1: a good research pipeline. Whatever PBM's insured could have answered anything,
48:29
Speaker 1: and his answer was, we can't recruit and retain healthcare
48:34
Speaker 1: professionals into the nation or into our program.
48:39
Speaker 4: Here at the US Department of Defense.
48:41
Speaker 1: And I'm sitting there thinking, doctor Smith, how can you
48:44
Speaker 1: say that's the worst challenge in all of American healthcare
48:48
Speaker 1: and at the same time you are adopting and implementing
48:52
Speaker 1: a completely broken model that destroys the ability to recruit
48:56
Speaker 1: and retain healthcare professionals in rural America. He like, that's
49:00
Speaker 1: the biggest contra indication, you know, contridicate you contradictity.
49:06
Speaker 2: Well said man, Well, look, I think that's probably a
49:09
Speaker 2: pretty pretty good note to end on. I want to
49:12
Speaker 2: ask a few questions and then and then we'll wrap
49:13
Speaker 2: this up. You've been really generous with your time. One is,
49:16
Speaker 2: you know, if you're a pharmacist in a state that
49:19
Speaker 2: maybe doesn't have sort of this track record of reform
49:22
Speaker 2: that Arkansas has, and you know you're you're hungry to
49:27
Speaker 2: see that type of reform, to see that type of change.
49:30
Speaker 2: You know what, what what advice would you give pharmacists who
49:33
Speaker 2: who want to see strides taken similar to Arkansas, Kentucky's,
49:39
Speaker 2: Louisiana's Tennessee's.
49:41
Speaker 1: I think most of the state associations, if not every
49:45
Speaker 1: single one, if they had an investment of time, talent,
49:49
Speaker 1: and finances from the pharmacists in their state, anything.
49:53
Speaker 5: As possible, they could get it done.
49:55
Speaker 4: I mean, I really do.
49:56
Speaker 1: I think any state in the country can get meaningful
49:59
Speaker 1: reforms and.
50:01
Speaker 2: Pharmacy has proved that, right, I mean when you think
50:03
Speaker 2: about it, right, I mean there are states that have
50:06
Speaker 2: turned it around pretty quickly.
50:08
Speaker 1: I agree, time, talent, finances get involved.
50:12
Speaker 5: Very good.
50:12
Speaker 2: Okay, last question, and I don't know if this will
50:15
Speaker 2: be easy one. But you've worked on You've worked on
50:17
Speaker 2: some big bills, man, right, like you've you've passed some
50:21
Speaker 2: meaningful stuff. I'm a big believer in rising tide lifts
50:24
Speaker 2: all ships. I think the work of Arkansas has lifted
50:27
Speaker 2: the ship of of you know, patient access, PBM reform,
50:31
Speaker 2: community pharmacy all over the country.
50:33
Speaker 5: Is there is there?
50:34
Speaker 2: Can you point to one thing, one bill that you've
50:38
Speaker 2: worked on that you're or one fight that you fought
50:42
Speaker 2: that you're most proud of on behalf of yourself and
50:45
Speaker 2: and and your you know your association.
50:48
Speaker 1: You know, there's a lot that I could point to
50:51
Speaker 1: where we know what the result is and what meaningful
50:55
Speaker 1: thing it has occurred as a result of it, like
50:58
Speaker 1: fair and reasonable reimbursem and prompt pay, and the clinical
51:03
Speaker 1: things that we've passed where pharmacists can prescribe vaccines and contraception,
51:08
Speaker 1: strip throat flu test and treat all those things.
51:11
Speaker 4: Those are all important.
51:13
Speaker 1: But I think when it's all said and done, addressing
51:17
Speaker 1: the root cause of the problems, the vertical integration anti
51:21
Speaker 1: competitive acts that break the market. You know, when seventy
51:26
Speaker 1: percent of the independent pharmacies in Arkansas are not participating
51:29
Speaker 1: in track Care because there's a vertical integrated company that
51:33
Speaker 1: steers everybody to themselves on the federal government's dime and
51:36
Speaker 1: track Care, and when seventy percent of every specialty drug
51:41
Speaker 1: is filled at three pharmacies owned by three PBMs Acts
51:46
Speaker 1: six two four, which I know has the final litigation
51:49
Speaker 1: has not ended, but it raises the conversation nationally. It
51:54
Speaker 1: impacts what the Federal Trade Commission does, It impacts what
51:57
Speaker 1: Congress is doing. I think that bill and the work
52:00
Speaker 1: we've done on that will be the thing that and
52:04
Speaker 1: when the dust settles, when you look back twenty years
52:07
Speaker 1: from now, will be the most important work we've done
52:10
Speaker 1: to try to address access to care, fairness and to
52:14
Speaker 1: protect patients from that have cancer in our country.
52:17
Speaker 2: Well said, I'll say this crazy that winning in the
52:21
Speaker 2: US Supreme Court isn't top of your list. It just
52:24
Speaker 2: shows you how much unbelievable work has been done in Arkansas.
52:26
Speaker 2: And I'd also say, I think the work that you've done,
52:29
Speaker 2: you know, with that six' twy four has inspired a
52:32
Speaker 2: movement outside of just pharmacy right vertical integration between insurers and,
52:36
Speaker 2: PBMs or you look at the work of Like American
52:39
Speaker 2: Economic liberties and the Breakup Big Medicine, act and so
52:42
Speaker 2: at the federal, LEVEL i, think you, know there's you've
52:45
Speaker 2: done a lot to be proud. Of BUT i ABSOLUTELY
52:47
Speaker 2: i get. It that's SOMETHING i think when you look
52:49
Speaker 2: back ten fifteen, years you, know the work that was
52:53
Speaker 2: done In arkansas will have opened the door for, really
52:56
Speaker 2: really meaningful. Change so Just, john you, know well back
53:00
Speaker 2: anytime you're a good. Friend can't tell you how MUCH
53:02
Speaker 2: i admire the work you do and thank you so
53:04
Speaker 2: much for being.
53:05
Speaker 4: On thanks very appreciate. It