Latest / Becker’s Healthcare Podcast / Lowering Drug Costs: Rethinking PBMs, Pricing and Patient Access with Dr. Ezekiel Emanuel & Miriam Paramore

Transcript

Lowering Drug Costs: Rethinking PBMs, Pricing and Patient Access with Dr. Ezekiel Emanuel & Miriam Paramore · Becker’s Healthcare Podcast

• 0:00
  - This is Scott Becker with the Beckers Healthcare
• 0:03
  - Podcast.
• 0:03
  - I'm thrilled today to visit with two brilliant
• 0:06
  - leaders in health care. We're dealing today with
• 0:09
  - doctor Ezekiel Emanuel
• 0:11
  - and Miriam Paramore.
• 0:13
  - We're gonna talk today about
• 0:15
  - affordability of pharmaceuticals, a form affordability of drugs,
• 0:19
  - which is a huge problem in our country,
• 0:21
  - has been for as long as I can
• 0:22
  - remember,
• 0:23
  - getting worse in some spots with niche and
• 0:25
  - specialty drugs, getting better in some place with
• 0:27
  - generics and some other opportunities where people are
• 0:29
  - going to market. But, doctor Emanuel, of course,
• 0:32
  - is famous,
• 0:34
  - and and and Miriam Peremore is brilliant. So
• 0:36
  - we've got famous and brilliant with us. Nice.
• 0:38
  - Looking forward to to visiting with the both
• 0:41
  - of you. Miriam, can can I ask you
• 0:43
  - to take a moment to introduce yourself? And
• 0:45
  - then, doctor Emmanuel, I'll ask you to do
• 0:47
  - the same.
• 0:48
  - Thank you, Scott. It is really a pleasure
• 0:50
  - for me to be here. I'm I've known
• 0:52
  - you from afar for my whole career,
• 0:54
  - so really appreciate the chance to talk with
• 0:56
  - you.
• 0:58
  - I'm Miriam Paramore. I'm the founder and CEO
• 1:01
  - of Rx Utility, and I'm not famous. But
• 1:04
  - in health care, I am known because I've
• 1:06
  - been in health care for so long, always
• 1:08
  - on the health care technology and health IT
• 1:11
  - side.
• 1:12
  - And, the business are of Arch Utility is
• 1:15
  - focused on helping people save money on medicine,
• 1:17
  - so it's a kind of a very mission
• 1:19
  - driven business. And I had the good fortune
• 1:22
  - to recently meet Zeke,
• 1:24
  - And I I said, I've read your book,
• 1:26
  - his ice cream book, which I love.
• 1:28
  - And,
• 1:29
  - and he said he sort of put me
• 1:31
  - on the spot. Like, he was asking me
• 1:32
  - questions that I I'm testing. You read, Rosique.
• 1:34
  - You were testing me. Had I read it?
• 1:36
  - And I had read it. And so I
• 1:37
  - said, yeah. I have these questions. And
• 1:39
  - then, it evolved into a a quick conversation.
• 1:42
  - What were what are two things you would
• 1:44
  - do to lower the cost of meds if
• 1:46
  - you could do anything right now? And, Scott,
• 1:48
  - the two things we talked about in our
• 1:50
  - op ed just came out of my mouth,
• 1:51
  - and then Zeke was interested, and we built
• 1:54
  - on it. And,
• 1:55
  - so, you know, just happy and thrilled to
• 1:57
  - be here.
• 1:59
  - Fantastic. And and and wanna dig into this
• 2:01
  - closely. There's so much activity going on and
• 2:04
  - people trying to find ways to make drugs
• 2:06
  - more affordable,
• 2:07
  - and I'd love to hear what you're doing
• 2:09
  - and what it looks like. Doctor Emmanuel, can
• 2:12
  - you take a moment, tell people about sort
• 2:14
  - of your background?
• 2:15
  - You worked in the White House at one
• 2:17
  - point, I believe, or with the federal government,
• 2:20
  - have been crafting health care policy for a
• 2:22
  - long time,
• 2:23
  - brilliant leader and thinker. Tell us about your
• 2:25
  - background both as a physician and as a
• 2:28
  - as a health care policy person.
• 2:30
  - So I'm an oncologist.
• 2:32
  - And,
• 2:32
  - for the first, I would say twenty years
• 2:35
  - of my life,
• 2:36
  - known as a bioethicist
• 2:38
  - working on things like end of life care,
• 2:41
  - research ethics,
• 2:42
  - and allocating resources.
• 2:45
  - Between two thousand and nine, two thousand eleven,
• 2:48
  - I was in the White House at the
• 2:49
  - Office of
• 2:50
  - management budget and the National Economic
• 2:53
  - Council,
• 2:55
  - working on the Affordable Care Act and a
• 2:57
  - variety of other things like, the food plate,
• 3:00
  - and global,
• 3:03
  - health supports,
• 3:04
  - such as PEPFAR.
• 3:05
  - And then I came to the University of
• 3:07
  - Pennsylvania,
• 3:09
  - where I was,
• 3:10
  - I am a professor and a vice provost
• 3:13
  - of global initiatives
• 3:14
  - and continue to work on mainly health policy,
• 3:18
  - as well as,
• 3:19
  - some bioethical issues around allocating things like the
• 3:22
  - COVID vaccine. That was something I spent a
• 3:25
  - lot of time on. And for the last
• 3:27
  - few years, I've really been focused on,
• 3:30
  - we've gotta
• 3:31
  - dramatically reform,
• 3:34
  - disrupt, whatever phrase you wanna use, our health
• 3:36
  - care system, and how to think about,
• 3:39
  - that,
• 3:40
  - to get make it,
• 3:42
  - get universal coverage,
• 3:44
  - reasonable and sustainable cost, and consistent high quality
• 3:48
  - and diminishing disparities.
• 3:50
  - And, obviously, a major focus of the affordability
• 3:53
  - and cost problem are drugs.
• 3:55
  - And I was lucky enough to meet, Miriam,
• 3:58
  - who has
• 3:59
  - a number of brilliant ideas.
• 4:01
  - And,
• 4:02
  - we crafted, I think,
• 4:04
  - a simple,
• 4:06
  - cost saving measure that is good for patients,
• 4:09
  - good for the country.
• 4:11
  - You don't come across those every single day.
• 4:14
  - Thank you. I'm gonna ask you three very
• 4:16
  - quick follow-up questions, then we're gonna turn to
• 4:19
  - Miriam in in in in how we're gonna
• 4:21
  - try and save money on drug costs. But,
• 4:24
  - doctor Emmanuel,
• 4:26
  - the first concept is, do you work with
• 4:28
  - Kevin Mahoney at all at University of Pennsylvania?
• 4:30
  - Do you get to visit with Kevin who's
• 4:32
  - All the time.
• 4:34
  - Right. Actually, I think Kevin and I are
• 4:36
  - having a dinner with some people,
• 4:39
  - in, ten days.
• 4:41
  - But he is an unusually thoughtful and gifted
• 4:44
  - leader as you know. He's got this incredible
• 4:46
  - ability to be a leader
• 4:48
  - and make sure that he doesn't
• 4:51
  - feel like a top down leader, just a
• 4:53
  - tremendous vision on how to build and work
• 4:55
  - with people. And what he's done at University
• 4:58
  - of Pennsylvania or Penn Medicine is truly remarkable.
• 5:01
  - The the the second question is on oncology
• 5:04
  - one, and this goes to the heart of
• 5:05
  - so many things we talk about and think
• 5:07
  - about.
• 5:08
  - 27,000
• 5:09
  - oncologists in the country practicing or somewhere around
• 5:11
  - there. 27 to twenty eight thousand.
• 5:14
  - Two million new diagnoses of cancer a year.
• 5:18
  - Every oncologist
• 5:19
  - that we work with or see
• 5:22
  - is exhausted,
• 5:23
  - burnt out, and is information overload.
• 5:26
  - Is there a solution to that? Are there
• 5:29
  - solutions to this?
• 5:31
  - And and we'll come back to drug pricing
• 5:33
  - in a second because it's such an important
• 5:35
  - but is there a and and the same
• 5:37
  - with universal coverage. Most of us in health
• 5:39
  - care are huge fans of universal coverage. We
• 5:41
  - want coverage for all, but I'm a believer
• 5:43
  - that coverage for all without fixing the supply
• 5:45
  - problem is somewhat of an illusory discussion. It's
• 5:48
  - somewhat a political platitude discussion,
• 5:50
  - you know, by many people, coverage for all.
• 5:52
  - I want coverage for all, but I recognize
• 5:54
  - coverage for all without fixing supply
• 5:57
  - is is is almost garbage. It's almost it
• 5:59
  - it's almost a talking point, but you need
• 6:01
  - both. You need to fix supply and be
• 6:03
  - able to take care of people. What I
• 6:04
  - would think about more is health care for
• 6:06
  - all versus coverage for all, and they're very
• 6:07
  - different things. So how do you think about
• 6:09
  - this cancer oncologist shortage
• 6:11
  - and think about coverage for all versus health
• 6:13
  - care for all? Well, I'm not sure it's
• 6:15
  - so much of a shortage
• 6:17
  - as,
• 6:18
  - you have a situation where oncologists
• 6:22
  - are peppered with a lot of administrative
• 6:24
  - hassles,
• 6:25
  - and the support structures,
• 6:28
  - are,
• 6:29
  - diminishing.
• 6:30
  - You know, almost every patient has multiple prior
• 6:34
  - authorizations.
• 6:36
  - They take a lot of time. They take
• 6:37
  - a lot of distraction.
• 6:39
  - They delay care. You've got a lot of
• 6:41
  - oncologists having to deal with drug shortages
• 6:44
  - of chemotherapy
• 6:45
  - agents,
• 6:47
  - and I think all of this combines
• 6:50
  - to create an environment
• 6:52
  - where doctors are distracted rather than primarily focused
• 6:56
  - on,
• 6:57
  - delivering good patient care. I do think this
• 7:00
  - is a case, Scott, and this is a
• 7:01
  - whole another topic,
• 7:03
  - where AI could help a lot.
• 7:05
  - Having AI,
• 7:07
  - manage
• 7:08
  - patients'
• 7:09
  - side effects from chemotherapy
• 7:12
  - is probably something that's,
• 7:14
  - I say easily,
• 7:15
  - but very doable in the next few years.
• 7:19
  - And I think that could,
• 7:21
  - really reduce the workload of
• 7:24
  - doctors,
• 7:25
  - and the pressures on them solving the prior
• 7:28
  - authorization
• 7:29
  - problem.
• 7:31
  - So if,
• 7:32
  - doctors,
• 7:33
  - providing guideline concordant care, there's no prior authorization
• 7:36
  - related to it. I think those are the
• 7:38
  - kinds of changes
• 7:40
  - that we really do need to see,
• 7:43
  - in health care to make it more workable
• 7:45
  - for physicians.
• 7:47
  - I think that's well well stated. I I
• 7:49
  - do think there's a lot more to it
• 7:50
  - than that, but I do think those are
• 7:52
  - very important parts. I mean, with AI right
• 7:54
  - now, I talked to oncologists who are having
• 7:56
  - 50 of their patients summarized for them very
• 7:58
  - quickly,
• 7:59
  - and now the oncologist is overwhelmed trying to
• 8:01
  - figure out what to do with those 50
• 8:02
  - patients. I mean, it's really a fascinating challenge,
• 8:04
  - and AI is very, very important. But I
• 8:06
  - do think it's a little bit of both.
• 8:07
  - But, Mary, let me turn it to you.
• 8:08
  - Sorry about that. Yeah. No. No. That's fine.
• 8:11
  - I just wanted to jump in and add,
• 8:13
  - from a patient's point of view. My sister,
• 8:16
  - was diagnosed with breast cancer two years ago,
• 8:18
  - had a double mastectomy.
• 8:21
  - I spent an hour,
• 8:22
  - and and then reconstruction
• 8:24
  - and complications
• 8:25
  - with reconstruction,
• 8:27
  - and then,
• 8:28
  - so many side effects from the drug she's
• 8:31
  - supposed to take to keep,
• 8:34
  - certain things suppressed,
• 8:36
  - after she has she was luckily stage one.
• 8:40
  - It had was in her lymph nodes a
• 8:42
  - little bit, but it was caught really early.
• 8:44
  - But,
• 8:45
  - severe side effects
• 8:47
  - and and watching the fragmentation and going through
• 8:50
  - with it, holding her hand, having her get
• 8:53
  - to the hospital. Literally, this happened at 05:15
• 8:56
  - in the morning for her double mastectomy
• 8:58
  - to go to the window to check-in, and
• 9:00
  - and they said,
• 9:01
  - Cigna has denied your anesthesiologist.
• 9:05
  - And
• 9:06
  - so, that's literally she's going in, and so
• 9:08
  - that's prompted me to write, would you like
• 9:10
  - some anesthesia with your surgery,
• 9:13
  - which was a piece I put out on,
• 9:15
  - you know, linked. There's nothing more ridiculous
• 9:17
  - than these sorts of things, Scott. But the
• 9:20
  - other piece I wanted to say about supply
• 9:22
  - and demand,
• 9:24
  - the amount of work that patients who have
• 9:27
  - a serious illness or lots of illnesses with
• 9:31
  - multiple doctors,
• 9:32
  - the fragmentation
• 9:33
  - around just one quote episode or treatment journey
• 9:37
  - like my sister had, which had a good
• 9:38
  - outcome,
• 9:40
  - there is insufficient
• 9:42
  - communication with patients about how all these things
• 9:45
  - interact.
• 9:46
  - You have a supposedly a primary care doctor,
• 9:48
  - then you have, like, this lymphoma
• 9:51
  - people. You've got the surgeon who says something
• 9:53
  - other than the oncologist.
• 9:56
  - You have reconstruction
• 9:57
  - people who don't talk to these other people.
• 9:59
  - You have side effects management after the fact.
• 10:02
  - And what my sister and her good friend,
• 10:05
  - who I spent two hours with this weekend
• 10:07
  - talking about my sister's much more severe,
• 10:10
  - it's the HERS triple negative.
• 10:13
  - Not the not the triple positive, Zeke, but
• 10:15
  - the triple negative, something like that. So she
• 10:17
  - is a much longer or or much more
• 10:20
  - difficult situation.
• 10:22
  - Scott, they are both using chat
• 10:26
  - to try to get answers they cannot get
• 10:28
  - from the health care system. They cannot get
• 10:30
  - the answers from the doctors.
• 10:32
  - The doctors don't talk to each other, and
• 10:35
  - they recently found that both these women, who
• 10:38
  - I love,
• 10:40
  - this supplement interaction
• 10:42
  - and that supplements that they were supposed to
• 10:45
  - be taking,
• 10:46
  - they shouldn't be taking in certain cases because
• 10:49
  - of the drug regimen they're on. The amount
• 10:51
  - of time that was brought up to either
• 10:53
  - of them by anybody,
• 10:55
  - zero. Zero. Yeah. No. But I but I
• 10:57
  - think what happens is I think so much
• 10:59
  - what you're saying is completely correct. I could
• 11:01
  - not agree more. The anesthesia before surgery is
• 11:04
  - saying, oh, that's an add on is is
• 11:06
  - is crazy, of course. That just is insane.
• 11:09
  - Insane. Concept of the doctors don't talk to
• 11:11
  - each other, the teams don't talk to each
• 11:13
  - other, people working in silos, is one of
• 11:15
  - the reasons why fifty years after my grandma
• 11:17
  - used to go to Mayo Clinic, people are
• 11:19
  - still going to Mayo Clinic, still going to
• 11:21
  - Cleveland Clinic because they've still got the whole
• 11:23
  - team approach. Oh, of course. A lot of
• 11:25
  - zaps. Of course, a lot of people to
• 11:27
  - go with a lot of, of of of
• 11:29
  - artificial intelligence and a lot of technology.
• 11:32
  - And and just like the experience of your
• 11:34
  - sister and her friend,
• 11:36
  - all of us are going to CHEPT whenever
• 11:38
  - we've got a symptom today as a starting
• 11:41
  - point. But but what happens is it's not
• 11:43
  - reducing the need for doctors
• 11:45
  - because you still need doctors and nurse practitioners
• 11:47
  - and PAs on the back end to actually
• 11:50
  - deal with people that and I I it
• 11:52
  - it sort of trust plus verify. We need
• 11:55
  - great technology and AI.
• 11:57
  - Systems know they're under invested in care navigation.
• 12:00
  - I think systems as a whole you'll talk
• 12:02
  - to the greatest systems of the city here
• 12:03
  - in Chicago, and they'll tell you very clearly,
• 12:06
  - we've underinvested in care coordination, care navigation,
• 12:09
  - partly because we don't get paid for it
• 12:11
  - even though we know what's a real need.
• 12:12
  - So, like, when you get through your
• 12:14
  - very complex surgery, you end up going to
• 12:17
  - one of the more local institutions for your
• 12:18
  - follow-up on radiation therapy just because the care
• 12:21
  - coordination at the greatest academic medical center is
• 12:24
  - still a is still a challenge and a
• 12:26
  - real challenge. So I think I agree with
• 12:27
  - everything you're saying, but but I would the
• 12:29
  - only thing I
• 12:31
  - say is that I I do believe that
• 12:33
  - we are
• 12:34
  - that regardless of all the things that go
• 12:36
  - right with technology and as they evolve and
• 12:39
  - so forth, we're still gonna need I'm a
• 12:41
  - trust but verify person. I'd like to have
• 12:43
  - more oncologists.
• 12:44
  - All of us are in age where we've
• 12:45
  - seen so many people die from cancers. We
• 12:47
  - found the bench was much shorter than we
• 12:49
  - thought it was, you know, in in terms
• 12:51
  - of oncology. But but, Mary, let me turn
• 12:53
  - to drugs
• 12:54
  - and and what you see there and and
• 12:56
  - and where you folks are facing and and
• 12:58
  - what you're trying to accomplish there. I mean,
• 13:00
  - obviously, you've had people like Mark Cuban with
• 13:02
  - with cost plus try and pull this up
• 13:04
  - a little bit. You've seen Civica
• 13:06
  - coming out of Intermountain,
• 13:08
  - try and provide an ability or a bunch
• 13:09
  - of not for instance. We're trying to find
• 13:11
  - a a generics alternative
• 13:13
  - for just generics that couldn't be fine so
• 13:15
  - people end up back with
• 13:16
  - with with,
• 13:18
  - higher cost, non generic drugs.
• 13:21
  - What is the approach of Rx Utility, and
• 13:23
  - and how are you guys approaching this? And
• 13:25
  - and and what do you see out there?
• 13:27
  - So we got two different things. And and
• 13:29
  - when we go back to Zeek, we'll talk
• 13:31
  - about the policy recommendations
• 13:33
  - for a minute. But to talk about sort
• 13:35
  - of medication affordability
• 13:36
  - and price transparency,
• 13:38
  - there really is no price transparency
• 13:40
  - around medication
• 13:42
  - until the individual health care consumer
• 13:45
  - steps up to the pharmacy counter and is
• 13:47
  - told what they owe. Okay?
• 13:49
  - And that is happening at exactly the same
• 13:51
  - time, Scott, that we have more price points
• 13:53
  - for the same drug than we've ever had
• 13:55
  - before.
• 13:56
  - So we have a whole new channel of
• 13:58
  - pricing that used to exist until last year
• 14:01
  - called direct to consumer or direct to patient
• 14:03
  - manufacturer pricing.
• 14:05
  - We have,
• 14:07
  - people who pay
• 14:09
  - on the made up number called list price,
• 14:12
  - which is a completely fake number,
• 14:15
  - when they get to the pharmacy counter if
• 14:17
  - they haven't met their $10,000
• 14:19
  - deductible like me. Okay? But guess what? But
• 14:22
  - the payers, the PBMs and the employers,
• 14:25
  - they all pay off of net.
• 14:27
  - So that's a good example of something that's
• 14:30
  - a positive outcome out of PBM reform.
• 14:33
  - Right? But it but it has to be
• 14:36
  - selected. You the self insured employer, the plan
• 14:38
  - sponsor,
• 14:39
  - still has to opt in to this idea
• 14:42
  - of true rebate pass through to the point
• 14:44
  - of sale. And, of course, we've got the
• 14:46
  - enforcement
• 14:47
  - issue.
• 14:48
  - So in in addition to that, we've got
• 14:50
  - the rise of the use of cash
• 14:53
  - because we've already paid premiums,
• 14:55
  - but then we find out that we're paying
• 14:57
  - a $15 out of pocket co pay when
• 15:00
  - it would cost you $2 if you paid
• 15:02
  - cash.
• 15:03
  - Right? So we've got the rise in the
• 15:05
  - price of cash. Mark Cuban's made a lot
• 15:07
  - of noise. GoodRx made a great
• 15:10
  - shift in our industry when they said, we
• 15:12
  - think people should know what drugs cost. A
• 15:14
  - thousand years ago, it's really been twelve years
• 15:16
  - since they started that business.
• 15:18
  - The cash is not a price.
• 15:20
  - Cash is a category of prices.
• 15:23
  - Right? There's the direct to patient price. There's
• 15:26
  - the cash discount card price,
• 15:29
  - which Mark Cuban has his own cash discount,
• 15:32
  - you know, etcetera.
• 15:33
  - So you can find at any point in
• 15:35
  - time, your insured price is more expensive than
• 15:39
  - your cash. But if you use a pharma
• 15:40
  - co pay coupon, oh, what's that? We don't
• 15:43
  - tell people those exist.
• 15:45
  - You could actually pay zero
• 15:47
  - for a drug like Dupixent
• 15:50
  - that would otherwise list
• 15:52
  - for between 25 and 4,000
• 15:55
  - 2,500,
• 15:56
  - 4,000 a month,
• 15:58
  - except the net is really only 1,000,
• 16:02
  - but you don't know that
• 16:04
  - as a consumer. So there is complete opacity,
• 16:08
  - and one of the great things that this
• 16:11
  - PBM reform policy does is, again,
• 16:14
  - patients
• 16:16
  - must be able to pay on net
• 16:19
  - if there is something that's a net.
• 16:21
  - And the other thing is they're saying we
• 16:23
  - should include the Trump RX prices in the
• 16:26
  - real time pharmacy benefit check return.
• 16:29
  - But what we really should do, Scott, is
• 16:31
  - include the prices.
• 16:33
  - Trump r x doesn't have all the drugs,
• 16:35
  - and Trump r x isn't always the cheapest.
• 16:38
  - And consumers,
• 16:40
  - I believe, plan sponsors have a fiduciary
• 16:43
  - responsibility
• 16:44
  - to human being individual people like you and
• 16:47
  - me and Zeke,
• 16:49
  - to have a fiduciary responsibility to us about
• 16:52
  - how much is this gonna cost
• 16:55
  - me
• 16:56
  - for this drug?
• 16:58
  - And we have all the data and technology.
• 17:00
  - We just don't make it available
• 17:03
  - to consumers, and it's been an intentional choice
• 17:07
  - by the industry.
• 17:09
  - No question. No question. And and and I'd
• 17:12
  - love to in a moment, I wanna ask
• 17:13
  - you another question as a follow-up question on
• 17:15
  - on drug pricing and drug categories
• 17:18
  - is
• 17:19
  - what I find so fascinating is this GLP
• 17:22
  - one evolution.
• 17:24
  - And and and because it's it's it's potentially
• 17:27
  - a model for other drugs as well. Obviously,
• 17:29
  - not drugs you need for different conditions or
• 17:31
  - when you're in the hospital. But the GLP
• 17:33
  - one thing to me is fasting. Thirty one
• 17:34
  - million people are on GLP ones. Yeah. A
• 17:37
  - huge percentage of those are getting them now
• 17:40
  - not through payers,
• 17:42
  - but a lot cheaper through direct consumer
• 17:45
  - efforts, whether the hims and hers, the rose
• 17:47
  - sparks, all kinds of other ways. And there's
• 17:50
  - so much that's right about that in that
• 17:53
  - and there's so much that's challenging about it,
• 17:54
  - but you've almost got almost one click prescribing.
• 17:57
  - You don't know if really a doctor's reviewing
• 18:00
  - it or not. You really don't know. I
• 18:01
  - don't mean that in a bad way or
• 18:02
  - a good way. You just don't really know
• 18:03
  - because, you know, it goes into a black
• 18:05
  - box and somebody responds. It's okay. But thirty
• 18:08
  - one million people are getting them.
• 18:10
  - And not too long ago, it was a
• 18:12
  - thousand bucks a month, and they were all
• 18:14
  - going through hospitals and health systems and primary
• 18:17
  - care practices and other practices
• 18:19
  - and overwhelming those practices and systems that were
• 18:22
  - already overwhelmed.
• 18:23
  - Now it's being done a completely different way.
• 18:26
  - The cost is cut in half, if not
• 18:27
  - by more.
• 18:28
  - And it seems like
• 18:30
  - by two thirds in a lot of places.
• 18:32
  - And if you're getting the if you're, you
• 18:33
  - know, if you have the risk tolerance to
• 18:35
  - do the compounded ones even more, but it
• 18:37
  - depends on your risk risk tolerance for that
• 18:40
  - course. Percent cheap for the compounded ones. They
• 18:43
  - are. And and you see Cigna recently I
• 18:45
  - think it was Cigna Aetna recently said they're
• 18:46
  - no longer covering with their employees.
• 18:48
  - They're basically saying, we give up. It's cheaper
• 18:51
  - for you to go that way. Just do
• 18:52
  - it that way. And it doesn't work from
• 18:53
  - an insurance standpoint when the insurance company is
• 18:55
  - getting charged 1,000 a month and premiums are
• 18:57
  - 1,000. They just don't work. Numbers don't work.
• 18:59
  - But it is amazing to me how quickly
• 19:01
  - this corrected itself. It's not perfect,
• 19:04
  - but how much it fixed itself.
• 19:06
  - I don't know if it fixed itself, but
• 19:07
  - how it improved.
• 19:09
  - Took the burden off the health systems, took
• 19:11
  - the burdens off the primary practices,
• 19:13
  - cut the cost dramatically. You mentioned, right, two
• 19:16
  - thirds to 90% if you're willing to do
• 19:18
  - the compounded, you know, which to me still
• 19:20
  - depends what date is, whether I'm scared of
• 19:22
  - that or not versus a named brand. But
• 19:24
  - the name brands got cut in half. The
• 19:26
  - semi compounds got cut by 90%. Absolutely. The
• 19:28
  - compounded. But it but it's fascinating to see
• 19:30
  - that evolution. What is there anything there
• 19:33
  - that's useful for other stuff, or is that
• 19:35
  - just one big category so it's it doesn't
• 19:37
  - necessarily translate to some other pieces?
• 19:39
  - It is useful for other stuff, and I
• 19:41
  - I wanna give this back to to Zeke
• 19:43
  - in a in a moment. But the, Eliquis,
• 19:46
  - one of the number one drugs in the
• 19:48
  - world
• 19:49
  - is now,
• 19:51
  - sold direct to consumer. Do you know what
• 19:52
  - happened to the price of Eliquis?
• 19:54
  - Almost cut in half.
• 19:57
  - List price
• 19:58
  - that patients are paying out of their own
• 20:00
  - pocket when they're in their deductible phase for
• 20:02
  - Eliquis was $600.
• 20:04
  - It's Mark Cuban's favorite example.
• 20:06
  - Do you know what the list price of
• 20:08
  - Eliquis is now? $349.
• 20:12
  - And do you know if you get it
• 20:13
  - from a Canadian
• 20:14
  - pharmacy, it's $249.
• 20:17
  - But what what happened, Scott, when we went
• 20:20
  - direct to consumer, but it it just shows
• 20:22
  - the power of consumerism in a real market.
• 20:25
  - Yeah. If
• 20:26
  - consumers want it, they're going to get it,
• 20:29
  - and the manufacturer
• 20:31
  - slash supply chain is going to
• 20:33
  - respond.
• 20:34
  - I thought it was wonderful when Eliquis got
• 20:37
  - on that list. My prediction,
• 20:39
  - more and more and more of that will
• 20:41
  - happen.
• 20:41
  - It creates an opportunity for us in the
• 20:44
  - health care system at large. And, Zeke, you
• 20:46
  - tell me what you think, but this is
• 20:48
  - very analogous to our recommendation
• 20:51
  - of just make the tier one generics
• 20:54
  - free
• 20:55
  - because of all of the benefit that it
• 20:57
  - has on adherence and better outcomes,
• 21:00
  - and then
• 21:01
  - put these drugs that are OTC
• 21:03
  - and every other similar country, Scott, that have
• 21:06
  - been around for decades and they're safe.
• 21:08
  - Make them OTC because all we're doing
• 21:11
  - is inflating the administrative
• 21:14
  - cost,
• 21:15
  - depressing
• 21:16
  - access,
• 21:17
  - and hurting people on affordability basis like Zeke's
• 21:20
  - patient that was in our article. Those are
• 21:24
  - simple things that short of total reform,
• 21:28
  - you know,
• 21:29
  - how just huge wins. They're huge wins that
• 21:31
  - are out there to be had. And and
• 21:32
  - your point on
• 21:34
  - when a consumer's paying it for it directly,
• 21:36
  - there's this old adage in business and, obviously,
• 21:40
  - Zeek has got these brothers that are heavily
• 21:42
  - into the business world or have been. It's
• 21:44
  - when you're doing business with other people's money,
• 21:47
  - somebody else is paying for it, you're not
• 21:49
  - nearly as true a consumer.
• 21:51
  - So so, you know, it just it's the
• 21:52
  - old I know I I'm a lawyer by
• 21:54
  - background. The last thing we want is an
• 21:55
  - individual client. We want clients that are from
• 21:57
  - big companies where it's not coming out of
• 21:59
  - their pocket when they pay the bills. Not,
• 22:00
  - you know, not good or bad, but, you
• 22:02
  - know, any business. You wanna be in the
• 22:03
  - other people's money business because people don't watch
• 22:05
  - the cost.
• 22:06
  - So clearly. If we get drugs to be
• 22:09
  - where people are paying for them directly,
• 22:11
  - the cost go down because people won't tolerate
• 22:13
  - the thousand dollars a month. They won't tolerate
• 22:15
  - the $600 a month. And and you're just
• 22:17
  - like, you know, we're we're in we're periodically
• 22:19
  - we were at an event, a conference in
• 22:22
  - in in Mexico,
• 22:24
  - and it's amazing the amount of stuff you
• 22:25
  - could buy for almost nothing.
• 22:27
  - That is the same stuff that we have
• 22:29
  - here that cost a fortune here. I mean,
• 22:31
  - it's literally it's it's ludicrous, and it's all
• 22:34
  - locked up and going through payers, going through
• 22:36
  - PPMs, going in other ways. Zeke, let me
• 22:38
  - turn it to you. What are some of
• 22:39
  - the answers here? What can we do?
• 22:42
  - Well, look. We have to recognize that, whatever,
• 22:45
  - 90%
• 22:46
  - of prescriptions are generic drugs.
• 22:48
  - And as Miriam has made clear, we've added
• 22:52
  - all sorts of administrative,
• 22:54
  - add ons to drugs that
• 22:56
  - to produce are, you know, pennies per pill,
• 23:00
  - if and, you know, the administrative costs are
• 23:03
  - way in excess of the production
• 23:05
  - and supply and,
• 23:07
  - sales cost. And we need to I believe
• 23:10
  - look.
• 23:11
  - I'm an oncologist.
• 23:13
  - Right? What we want is our patients to
• 23:15
  - take the medication.
• 23:16
  - Yes. When a doctor prescribes a pill, we
• 23:19
  - want them to take the medication.
• 23:21
  - What does a deductible and co pay do
• 23:23
  - or a high drug price do?
• 23:25
  - It impedes patients taking medications that are gonna
• 23:28
  - make them healthy, and that is not the
• 23:30
  - place we need to be in our health
• 23:31
  - care system. So our proposal,
• 23:33
  - get rid of the co pay and deductible
• 23:36
  - on generic drugs,
• 23:38
  - seems to be very straightforward.
• 23:41
  - As Miriam says, there are a whole handful
• 23:43
  - of drugs, thirty, forty,
• 23:45
  - you can you know, depends on, as you
• 23:47
  - pointed out, your risk tolerance,
• 23:49
  - that are safe. We know they're safe. We've
• 23:51
  - been using them for sixty, seventy years. They're
• 23:53
  - safer than Tylenol
• 23:54
  - and Aspirin. Let's just put it that way.
• 23:56
  - And we should have them over the counter.
• 24:00
  - That doesn't get to the brand name drugs
• 24:03
  - that are, you know, 10,000,
• 24:05
  - 20,000
• 24:06
  - a month. And for those drugs, we're gonna
• 24:08
  - need federal government drug price regulation.
• 24:11
  - No patient
• 24:12
  - is gonna have the,
• 24:14
  - shopping power
• 24:16
  - to Right. Actually Right. Change those pricing. So
• 24:19
  - we need to deal with these two different
• 24:20
  - segments of the market differently.
• 24:23
  - One, the generics. I think we can get,
• 24:26
  - patients
• 24:27
  - to actually
• 24:28
  - change the market, and the prices should be
• 24:31
  - low,
• 24:32
  - by,
• 24:33
  - getting rid of those co pay and deductibles.
• 24:35
  - The other, I think, the brand names,
• 24:38
  - we you know, we're one of the only
• 24:40
  - countries that had that gives
• 24:43
  - drug companies patents, and then says, set the
• 24:46
  - price. And we know, you know, basic economics
• 24:49
  - tells you what happens. We need drug price
• 24:51
  - regulation there, and we also need, as Miriam
• 24:54
  - has,
• 24:55
  - eloquently pointed out, we need to clean up
• 24:58
  - the whole mess.
• 24:59
  - Everyone's taking a piece of this pie and
• 25:01
  - adding
• 25:02
  - not much value or even no value, and
• 25:06
  - that has to stop.
• 25:08
  - The rebates and all of the other,
• 25:12
  - elements. You know, we just need to have
• 25:14
  - uniform pricing. My own
• 25:17
  - favorite idea, it really comes out of German
• 25:20
  - Australia, I mean, which is you get a
• 25:22
  - price for a new class of drugs.
• 25:25
  - Every new drug that comes on gets that
• 25:27
  - same price unless it's got some big advantage,
• 25:29
  - like fewer side effects or more efficacy,
• 25:32
  - and the price drops. Once you have a
• 25:34
  - me too drug, the price should drop, and
• 25:36
  - the price should drop again. And
• 25:39
  - we need to have some
• 25:40
  - system
• 25:41
  - like that so that we don't have, as
• 25:44
  - Miriam nicely points out, you know, hundreds of
• 25:46
  - prices for the same damn drug.
• 25:49
  - We should Right.
• 25:50
  - One of the things I that that I
• 25:52
  - love that you said was this differentiation
• 25:54
  - between the generics or the lower priced drugs
• 25:57
  - and the high price specific therapeutical drugs that
• 26:00
  - are brand new and so forth. You know,
• 26:02
  - people talk a lot about,
• 26:04
  - you know, shopping for care,
• 26:07
  - but we know that for lots of regular
• 26:09
  - stuff, people will shop for care and price
• 26:11
  - shop. But you're not shopping for care, at
• 26:13
  - least price wise, on cancer, on cardiovascular
• 26:17
  - disease, on other things. And I think
• 26:20
  - the the this concept that somehow another patients
• 26:22
  - could be in the loop
• 26:23
  - on shopping for care for expensive drugs or
• 26:26
  - or that if price transparency would somehow or
• 26:28
  - another fix,
• 26:30
  - our our situation on,
• 26:32
  - you know,
• 26:33
  - cancer or, you know, or or cardiovascular
• 26:37
  - or any high sort of cost serious thing
• 26:39
  - is just is sort of, challenging and misguided
• 26:41
  - that that consumerism is not gonna fix that.
• 26:43
  - We need to find a way to ensure
• 26:45
  - that and do it the right way. But
• 26:47
  - let me ask you, should PPMs be out
• 26:49
  - of the game? Should there be no PPMs?
• 26:51
  - Have they do they not fill a a
• 26:52
  - need anymore?
• 26:54
  - I don't think they do. And if you
• 26:55
  - change the pricing system,
• 26:57
  - okay, so that all the drugs in a
• 26:59
  - class have the same price,
• 27:01
  - I don't think you would need a PBM.
• 27:03
  - I mean, what's the main fat fat, focus
• 27:05
  - of a PBM?
• 27:06
  - Putting together a formulary to get the better
• 27:08
  - pricing for,
• 27:10
  - the sponsor.
• 27:11
  - But if you don't need a formula because
• 27:13
  - all the drugs in that class are at
• 27:15
  - the same price,
• 27:16
  - seems to me, you know, you've gotten rid
• 27:18
  - of the formulary. You don't really need the
• 27:20
  - PBM function. You do need a distributor function,
• 27:23
  - but that's a whole different story.
• 27:25
  - I I know we're gonna run out of
• 27:27
  - time in a moment, so I'm gonna ask
• 27:28
  - each of you one more question.
• 27:31
  - Zeke, you may get a non serious question.
• 27:34
  - Miriam, you're gonna get a serious question. Okay?
• 27:36
  - Just so you're prepared. So so here's the
• 27:38
  - smart one is. So here's the well, yeah,
• 27:40
  - and I wouldn't say it like that, Zeke.
• 27:42
  - No. No. No. No. You're brilliant yourself. Getting
• 27:45
  - the obvious ways.
• 27:47
  - Zeke. But you're the famous one. Of the
• 27:50
  - two brothers,
• 27:51
  - Ari and Ram, who is more fun to
• 27:53
  - hang out with, who is more fun to
• 27:55
  - visit with, and who is more argumentative?
• 27:57
  - I've had the chance to argue with Ram,
• 28:00
  - and that's not an easy task. I don't
• 28:02
  - know Ari other than from TV and entourage
• 28:05
  - and so forth. But who is the more
• 28:07
  - fun brother to hang out with? Who is
• 28:09
  - more fun to argue with? And then, Mary,
• 28:10
  - I'm gonna ask you a much more serious
• 28:12
  - question. It all depends what you're doing. You
• 28:15
  - wanna go fly fishing? You go with Rob.
• 28:17
  - You wanna go and and,
• 28:20
  - hang out,
• 28:21
  - do surfing or, hang out at the beach
• 28:24
  - or, talk about, you know, the latest,
• 28:28
  - health,
• 28:29
  - activity, you hang out with Ari. But I
• 28:31
  - will say this, both of them are argumentative.
• 28:34
  - And, you know, when they're dealing with their
• 28:36
  - older brother, both of them are super critical.
• 28:39
  - So I always go to my,
• 28:42
  - gather
• 28:43
  - brothers wearing armor.
• 28:45
  - Sounds like it makes a lot of sense.
• 28:47
  - Oh my god. I I have a great
• 28:49
  - Ram story for another time, but fantastic.
• 28:52
  - Miriam,
• 28:53
  - tell us where we can learn more about
• 28:55
  - your work and what you do. It's you're
• 28:57
  - you're filling a critical need that's gotta be
• 29:00
  - solved. It's a debacle right now in our
• 29:02
  - country. How do we where can we learn
• 29:04
  - more about your work?
• 29:05
  - Well, you can follow me on LinkedIn, Miriam
• 29:08
  - Paramore,
• 29:09
  - or our company page, rxutility.com.
• 29:13
  - We are hoping to be the Expedia for
• 29:16
  - drug prices, Scott.
• 29:18
  - We wanna surface them all and let the
• 29:20
  - prices flow, democratize the prices
• 29:23
  - so they flow through all these workflows. And
• 29:25
  - then I'm gonna continue to work with Zeek
• 29:28
  - on the policy side to see if we
• 29:30
  - can't just get rid of some of the
• 29:32
  - nonsense,
• 29:33
  - that we have around,
• 29:36
  - access and affordability.
• 29:38
  - Well, we we we are so thankful for
• 29:40
  - the chance to visit with the two of
• 29:41
  - you today. Truly the highlight of my day.
• 29:44
  - I know our listeners will enjoy it tremendously.
• 29:46
  - Thank you, Trent, as well. But what a
• 29:48
  - pleasure to deal with doctor Emmanuel,
• 29:50
  - and Miriam Paramore. Just fantastic. Thank you folks
• 29:53
  - so much.
• 29:54
  - Thank you, Scott. Thank you so much.