Latest / Making Medicine / Can We Fix Healthcare? A Look Inside Our System

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Can We Fix Healthcare? A Look Inside Our System · Making Medicine

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  Speaker 1: You're listening to Making Medicine Stories from the Early stage
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  Speaker 1: life Sciences Ecosystem, a podcast that explores the people and
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  Speaker 1: deals that have led to the medicines, devices, and technologies
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  Speaker 1: that keep us healthy. Let's get into the show.
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  Speaker 2: Hello and welcome to the Making Medicine Podcast. I'm your host,
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  Speaker 2: John Stanford and joined today by a known quantity in
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  Speaker 2: the healthcare policy realm, Brian Reid, principle at Read Strategic
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  Speaker 2: and the author of the must Read Cost Curve newsletter. Brian,
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  Speaker 2: Welcome to the podcast.
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  Speaker 3: Hey, thanks so much for having me. What a kick
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  Speaker 3: to ticket to talk to someone who's again talked about
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  Speaker 3: must Read. You all are really generating a lot of
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  Speaker 3: the data we need to dissect some of the topics
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  Speaker 3: that we'll get into.
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  Speaker 2: Well, and we have lots to talk about because, as
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  Speaker 2: you've pointed out many times, there's just a lot going on.
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  Speaker 2: And I don't think it's going to be a quiet
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  Speaker 2: fall either. I think this will be the first of
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  Speaker 2: many episodes where you come on and share your wisdom
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  Speaker 2: and thoughts. But I always like to begin with what
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  Speaker 2: our listeners want to hear, and that's how did people
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  Speaker 2: get to where they are? What's their background and your
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  Speaker 2: personal mantra of we can't build a better healthcare system
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  Speaker 2: until everyone understands the system today. How's that sort of
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  Speaker 2: a guiding light and how did that take you on
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  Speaker 2: your path to creating read Strategic.
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  Speaker 3: Yeah, I've been in communications my entire career. The first
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  Speaker 3: ten years or so, I was on the journalism side.
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  Speaker 3: So I've always worked in health and medicine because I
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  Speaker 3: find it really interesting and I find that's a place
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  Speaker 3: where that communications is really important. Explaining this to the
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  Speaker 3: people who need to understand, whether that's the health and
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  Speaker 3: medicine side of it, whether that's the public policy side
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  Speaker 3: of it, becomes really really important because it turns out,
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  Speaker 3: if you don't understand the basics of how your body works,
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  Speaker 3: if you don't understand the basics of how health policy works,
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  Speaker 3: you end up getting really bad advice and really bad solutions.
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  Speaker 3: And in the same way lows the advice from your
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  Speaker 3: doctor makes your diseases worse. I think getting lowsy advice
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  Speaker 3: about health policy makes our health system worse. And so
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  Speaker 3: the goal has always been what can we do to
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  Speaker 3: make this better? Smarter? So a couple of years ago
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  Speaker 3: I launched read Strategic in part to really zero in
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  Speaker 3: on that question of can we talk about the system
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  Speaker 3: in ways that are better because I got really interested
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  Speaker 3: in the health policy bit in twenty fourteen, twenty fifteen,
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  Speaker 3: twenty sixteen, where you had, in rapid succession the introduction
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  Speaker 3: of hepatitis C drugs in Martin Shcrelly and the EpiPen debacle,
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  Speaker 3: and what tied all of that together was that we
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  Speaker 3: weren't having a particularly smart discussion about value and where
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  Speaker 3: the money was following and why things were the way
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  Speaker 3: they were. And that's when it first became clear that
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  Speaker 3: there were these big reputational hazards being created that didn't
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  Speaker 3: necessarily link up with sound public policy.
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  Speaker 2: One of the constant threads I think is where you
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  Speaker 2: touched on there this disconnect between what policymakers believe here
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  Speaker 2: maybe see in the media, and the reality of our
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  Speaker 2: very in my view, broken healthcare system or certainly broken
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  Speaker 2: health payer system. Do you point to that disconnect? What's
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  Speaker 2: the rink cause that this is just so complex and
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  Speaker 2: the complaint it's that there's not really bias one way
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  Speaker 2: or the other, and it's just by the time you
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  Speaker 2: pull it, all the threads of the healthcare system they're tangled,
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  Speaker 2: they're nodded, and they're mixed incentives, and we just can't
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  Speaker 2: get to the bottom of why things are the way
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  Speaker 2: they are, or is there more Is there something else
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  Speaker 2: at play? Why do we have such a disconnect From
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  Speaker 2: a professional communicator standpoint, So.
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  Speaker 3: I think there are two ways of looking at it,
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  Speaker 3: you know. I think one is the benign way, which
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  Speaker 3: you kind of laid out, which is say, there's just
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  Speaker 3: a lot of moving pieces, this is hard stuff. We
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  Speaker 3: have a complicated system. That's the American way, and we
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  Speaker 3: all have an obligation to try to not this this
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  Speaker 3: incredible system. I think the more cynical way of looking
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  Speaker 3: at it is there are huge parts of the healthcare
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  Speaker 3: system that benefit specifically from complexity, and so when you
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  Speaker 3: look at how things are set up contractually, how regulations
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  Speaker 3: are written and implemented, those who benefit from things being
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  Speaker 3: more opaque, less transparent, more complicated. So in part, we
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  Speaker 3: have an obligation to do our best to explain what's
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  Speaker 3: really going on. But I also think there's probably from
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  Speaker 3: a crusading standpoint, and I have no desire to spend
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  Speaker 3: the time with you pointing fingers. But if we're going
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  Speaker 3: to point fingers. Let's point at those who weaponize complexity,
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  Speaker 3: regardless of where they come in the healthcare system, because
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  Speaker 3: that just makes a bad problem even worse.
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  Speaker 2: And I think it truly has become weaponized. And we
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  Speaker 2: very rarely actually get round to talking about the patients.
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  Speaker 2: We all spend so much time pointing thing and you
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  Speaker 2: look at how we've in Congress holds, hearings or the
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  Speaker 2: administration talks about healthcare, we're usually blaming someone and not
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  Speaker 2: necessarily putting patients first. We're in this moment of dynamism,
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  Speaker 2: to be sure, particularly in the space you and I
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  Speaker 2: pay a lot of attention to the pharmaceutical landscape and
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  Speaker 2: life sciences, and the show is called Making Medicine in
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  Speaker 2: a lot. We're two years in from the Inflation Reduction Act,
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  Speaker 2: where we've gotten a host of some data, not all
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  Speaker 2: the data that I think you and I would like,
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  Speaker 2: in terms of some of the rationale around drug prices.
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  Speaker 2: What's standing out to you? What and there are a
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  Speaker 2: few lenses to this question, what stands out to you
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  Speaker 2: in terms of what's going to have impact to patients?
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  Speaker 2: And then what stands out to you that we're not
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  Speaker 2: talking about or we're talking about in the wrong way.
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  Speaker 3: Boy, there's lots unpacked there. So let's start with one
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  Speaker 3: of the questions that really permeates all of this is,
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  Speaker 3: and I know this is something you think about every day,
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  Speaker 3: So what's the impact going to be on innovation? And
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  Speaker 3: I don't think we're having a particularly smart dialogue about
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  Speaker 3: that because I think there are two ways of looking
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  Speaker 3: at it. The first is the basic economics. Will we
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  Speaker 3: get less R and D? Will we get fewer new drugs?
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  Speaker 3: And that's one where the answer seems pretty clear. You
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  Speaker 3: can argue about the degree, but it's a two part process.
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  Speaker 3: One is will there be less revenue available to the
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  Speaker 3: biopharmaceutical industry? And again the answer there seems clearly yes.
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  Speaker 3: Maybe it's the six billion that the Biden administration has promised.
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  Speaker 3: Maybe that number will go up, maybe that will go down.
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  Speaker 3: There's clearly an impact. And then the second question is great,
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  Speaker 3: what's the connection between a decrease in revenue and a
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  Speaker 3: decrease in R and D and a grit. There's a
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  Speaker 3: great economics literature that makes very clear that there is
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  Speaker 3: a connection there. More money means more R and D,
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  Speaker 3: Less money means less R and D. This ought not
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  Speaker 3: be a particularly controversial take, and yet there is this
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  Speaker 3: undercurrent of skepticism about whether or not there will be
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  Speaker 3: any impact whatsoever on industry. So I just want to
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  Speaker 3: kind of set that framework of saying there will be
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  Speaker 3: an impact, and we can argue about the degree, but
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  Speaker 3: it's really hard to have a smart conversation that doesn't
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  Speaker 3: start with the acknowledgment that, yes, we're going to get
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  Speaker 3: less of this thing we want because we've implemented price controls.
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  Speaker 3: So that's one way of looking at it. The second
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  Speaker 3: way of looking at it is to say what kind
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  Speaker 3: of R and D are we incentivizing? And again, you
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  Speaker 3: spend a lot of time thinking about this right Like
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  Speaker 3: you know, there's the small molecules get four years less
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  Speaker 3: of protection than biologics. There's a huge discouragement to continue
• 7:35
  Speaker 3: researching a drug after it's been approved because the moment
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  Speaker 3: of drug has been approved, you're on this IRA clock.
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  Speaker 3: The IRA applies to medicare, so there's probably a disincentive
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  Speaker 3: to work on drugs that affect predominantly an older audience.
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  Speaker 3: If you want to have more than one orphan indication,
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  Speaker 3: you're no longer protected from the IRA. You have all
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  Speaker 3: of these things, and so if you add them up,
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  Speaker 3: you know, what's an example of a small molecule affecting
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  Speaker 3: mostly seniors where there's traditionally been a lot of post
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  Speaker 3: marketing development. I mean, what's the classic case here, or
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  Speaker 3: al oncology. So we've created the system that very explicitly
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  Speaker 3: discourages the creation of cancer pills. And I don't think
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  Speaker 3: anyone in Congress passes law saying we want to pick
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  Speaker 3: winners in losers, and we really want oral oncology drugs
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  Speaker 3: to be in the loser column. You know. I think
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  Speaker 3: that really gets at the weird incentives here, and part
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  Speaker 3: of the reason why industry is not necessarily trying to
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  Speaker 3: scuttle the whole thing. They're just trying to fix some
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  Speaker 3: of these broken incentives so that if you are an
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  Speaker 3: early stage company, if you are a researcher with a
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  Speaker 3: great idea about a cancer pill, no one's ever going
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  Speaker 3: to come to you and say, well, remember the government
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  Speaker 3: really doesn't want you to develop this kind of drug.
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  Speaker 2: What you just laid there. I think we're going to
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  Speaker 2: freeze frame repeat because I've tried to explain to a
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  Speaker 2: lot of policy makers it's not death by a thousand cuts,
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  Speaker 2: but it's not death by one cut either, and there
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  Speaker 2: could be easily mapped patient populations. Or maybe you feel
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  Speaker 2: like you have the manufacturing setup and the pair negotiations
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  Speaker 2: and you can get a drug to market quickly, and
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  Speaker 2: maybe nine years is going to be enough if everything
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  Speaker 2: is perfect and set up. But I love what you
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  Speaker 2: just did there. It's about layering on top. Maybe it's
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  Speaker 2: the small molecule limitation in addition to the ability to
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  Speaker 2: seek a further indication, which we see a ton in
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  Speaker 2: the oncology space, and then layer on top of that
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  Speaker 2: that you don't want to deal with price controls, stay
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  Speaker 2: out of the medicare population, and when you add those
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  Speaker 2: on top of each other, I just think what you
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  Speaker 2: laid out there, and this is the kind of brilliant
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  Speaker 2: to all the listeners. This is the kind of concise
• 9:49
  Speaker 2: and clear reading you get from cost Curve newsletter. So
• 9:52
  Speaker 2: I encourage you to sign up and make sure you
• 9:55
  Speaker 2: read it like we do religiously. It's the accumulated effect
• 9:59
  Speaker 2: there that I think is so powerful, and you said
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  Speaker 2: it very well. I want to also come back to
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  Speaker 2: use that word skepticism because one of the reasons I
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  Speaker 2: was so keen to have you on the show. Is
• 10:10
  Speaker 2: some recent writing you did. The moment these price controls
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  Speaker 2: came out, the announced prices, so much media was devoted to, well,
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  Speaker 2: the CEOs are saying on their earnings calls that they're
• 10:23
  Speaker 2: going to be okay, and therefore we're not losing any innovation.
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  Speaker 2: There was that skepticism. I think you and I share
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  Speaker 2: the sort of econ one oh one point of you
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  Speaker 2: take money out of the system. Some of it was
• 10:35
  Speaker 2: at least going to R and D who knows how much,
• 10:37
  Speaker 2: but some of it was can you expound a little
• 10:40
  Speaker 2: bit further. I don't want to put words in your mouth,
• 10:43
  Speaker 2: so I won't say they have it wrong. But when
• 10:45
  Speaker 2: you hear someone saying, well, the CEO on the earnings
• 10:50
  Speaker 2: call said will be okay, therefore innovation is okay? Does
• 10:54
  Speaker 2: that argument hold water for you?
• 10:57
  Speaker 3: I mean, so, let me express some sympathy to the journal.
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  Speaker 3: You know, this at one point was my tribe. You know,
• 11:03
  Speaker 3: they are trying to answer a legitimate and important question,
• 11:07
  Speaker 3: which is how badly is this law hurting pharmaceutical companies?
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  Speaker 3: And the nice thing about the stock market is you
• 11:13
  Speaker 3: have this updated every moment of every but in the
• 11:16
  Speaker 3: trading hour is this scorecard, and so it's very tempting
• 11:20
  Speaker 3: to say, when event X happens, what's the impact, you
• 11:24
  Speaker 3: know why over here on the stock market, And if
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  Speaker 3: there's not a direct one to one correlation, it becomes
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  Speaker 3: very tempting to say, ah, there's been no impact. But
• 11:33
  Speaker 3: the reality is that there has been an impact. It's
• 11:36
  Speaker 3: just been anticipated by the market. So Wall Street is
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  Speaker 3: a prediction machine, and over the last two years, analysts
• 11:42
  Speaker 3: and executives have really looked at the law, looked at
• 11:45
  Speaker 3: how it's been implemented, and made a series of guesses
• 11:48
  Speaker 3: about how these price controls were going to finally manifest
• 11:53
  Speaker 3: when they were announced. And it turns out that the
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  Speaker 3: executives and analysts and investors got it right that there
• 12:00
  Speaker 3: is going to be an absolute impact. And if you
• 12:02
  Speaker 3: look at as to sales estimates for twenty twenty six,
• 12:05
  Speaker 3: two years ago versus today for those ten drugs, invariably
• 12:09
  Speaker 3: they're all lower. The reality is, though the market had
• 12:13
  Speaker 3: eighteen months to come to terms with this, and when
• 12:16
  Speaker 3: the actual event happened, it just wasn't you know, it
• 12:20
  Speaker 3: didn't defy expectations. So it's not that there wasn't an impact.
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  Speaker 3: It's just that the impact wasn't different than it was expected.
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  Speaker 3: So again it's not the wrong question to ask, it
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  Speaker 3: was just the wrong metric to use. And I think
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  Speaker 3: the other interesting question that is, Okay, what are some
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  Speaker 3: metrics you could use to say is this law impacting industry?
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  Speaker 3: And I think this is a place where you all
• 12:40
  Speaker 3: have done some really interesting work here starting to unpack
• 12:44
  Speaker 3: that question. Look, the stock ticker of MIRK may not
• 12:48
  Speaker 3: be a great metric here, but there are other metrics
• 12:51
  Speaker 3: we can look at, at least for circumstantial evidence.
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  Speaker 2: I think you are right, and I think as an
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  Speaker 2: industry and as observers of industry and as advocates in
• 13:01
  Speaker 2: my case, at least for the early stage part of
• 13:03
  Speaker 2: the ecosystem, we do have to do better. We have
• 13:07
  Speaker 2: to constantly be educating about why the stock ticker isn't
• 13:13
  Speaker 2: the adequate representation. And then another one that I've kind
• 13:18
  Speaker 2: of tussled with some research that's come out lately that
• 13:21
  Speaker 2: I think you've seen as well, pointing to well, small
• 13:25
  Speaker 2: biotechs do so much of the innovation, and all grant that,
• 13:28
  Speaker 2: and I think even some of the large companies will
• 13:31
  Speaker 2: absolutely grant that. I feel like some of the antagonists
• 13:35
  Speaker 2: in this space point to that as a flaw in
• 13:38
  Speaker 2: the system. Small biotechs do early stage up through phase two,
• 13:43
  Speaker 2: maybe phase three, and then the large companies come in
• 13:46
  Speaker 2: and acquire I'd say from our perspective as investors, that's
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  Speaker 2: a sign the system's working. But I don't know how
• 13:53
  Speaker 2: you react to that.
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  Speaker 3: This.
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  Speaker 2: I feel like we're pushed to feel like it's small
• 13:58
  Speaker 2: versus big, but we see it very much as small
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  Speaker 2: and big are what make the US system work so
• 14:06
  Speaker 2: well from a development standpoint.
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  Speaker 3: Well, and I think you know better than I that
• 14:10
  Speaker 3: when we talk about biotechnology, or when we talk about
• 14:13
  Speaker 3: small companies, that's not remotely a homogenous group. And there's
• 14:17
  Speaker 3: a big difference between a researcher with a good idea
• 14:20
  Speaker 3: going out there seeking venture funding, seeking Series A funding,
• 14:25
  Speaker 3: and a company maybe they got proof of concept, maybe
• 14:27
  Speaker 3: they're in phase two, they're looking to they're looking to
• 14:31
  Speaker 3: be acquired by a company that can commercialize and help
• 14:34
  Speaker 3: patients in a way that they don't have the resources
• 14:36
  Speaker 3: to do. Those two kinds of companies are not their
• 14:40
  Speaker 3: different species. They exist along the spectrum. And so I
• 14:44
  Speaker 3: think there's been a lot of analyzes that have just
• 14:46
  Speaker 3: kind of said small companies or small companies and big
• 14:48
  Speaker 3: companies are big companies, and they're not really looking at
• 14:52
  Speaker 3: the disparate impacts here at how the whole system fits together.
• 14:56
  Speaker 3: And again, unless you've been in it, you know sometimes
• 14:59
  Speaker 3: that's hard to explain or make clear. But the reality
• 15:02
  Speaker 3: is for every one of these little subcategories, their impacts.
• 15:05
  Speaker 3: But let's be clear, no one is getting a tailwind
• 15:08
  Speaker 3: from the current policy environment. The only question is how
• 15:12
  Speaker 3: much harder is it than it was? And for some
• 15:15
  Speaker 3: companies it's a lot harder. And you've seen that in
• 15:18
  Speaker 3: the venture funding numbers. You've seen that in the companies
• 15:20
  Speaker 3: that are pulling programs. You're beginning to see the anecdotal
• 15:24
  Speaker 3: evidence of where these phenomenon are having the biggest effect.
• 15:28
  Speaker 2: Once again, so well put, I know we only have
• 15:31
  Speaker 2: a little time left. You also recently put out some
• 15:35
  Speaker 2: great commentary of what you're watching this fall, and I
• 15:38
  Speaker 2: would love to have you back on as some of
• 15:40
  Speaker 2: these things play out. We've talked a lot about IRA implementation.
• 15:45
  Speaker 2: What else is on your mind as the election years,
• 15:48
  Speaker 2: as the year wraps up, what's catching your attention in
• 15:51
  Speaker 2: this space?
• 15:54
  Speaker 3: You know, It's one of those deals where it's like
• 15:56
  Speaker 3: watching for sharks, you're never quite sure which one is
• 15:58
  Speaker 3: going to surface. But the Biden administration still has a
• 16:02
  Speaker 3: pending rule that would really undermine the intellectual property regime.
• 16:07
  Speaker 3: There is a marchin thing that needs to take action
• 16:10
  Speaker 3: at some point. PBM reform has been talked about as
• 16:14
  Speaker 3: a candidate for occurring in the lame Duck, and that's
• 16:17
  Speaker 3: clearly something that's going to be important in shaping that
• 16:20
  Speaker 3: broader environment. Dit O with three point forty B. I
• 16:23
  Speaker 3: think there's a lot of IRA pieces here that are
• 16:26
  Speaker 3: still how is this going to get operationalized? That are
• 16:29
  Speaker 3: still not completely clear, how the money is going to
• 16:32
  Speaker 3: flow through the system, what role the government is going
• 16:35
  Speaker 3: to take in protecting patients from efforts that may be
• 16:38
  Speaker 3: steering patients away from better options options their doctors want
• 16:43
  Speaker 3: lower cost options. I think just a number of lines
• 16:46
  Speaker 3: in the water here, and it's not really clear you
• 16:49
  Speaker 3: know which ones are going to be dramatic, but I
• 16:51
  Speaker 3: think we can say in totality there's a lot of
• 16:54
  Speaker 3: uncertainty now around the system, and I think there's a lot,
• 16:56
  Speaker 3: quite frankly, to get to where we started. That's going
• 16:59
  Speaker 3: to I'll be confusing to the general public if there's
• 17:02
  Speaker 3: not a real concerted effort to make these things clear.
• 17:05
  Speaker 2: I can't stress enough what a body of information you
• 17:09
  Speaker 2: are and timely in distilling that in your newsletter? Can
• 17:14
  Speaker 2: you tell listeners if they did want to sign up subscribe,
• 17:19
  Speaker 2: where can they do that? How can they get the
• 17:21
  Speaker 2: kind of insights that you provide on a regular basis?
• 17:25
  Speaker 3: Sure? So you can set it for my newsletter at
• 17:27
  Speaker 3: my consultancy's website, which is read Strategic dot com. And
• 17:31
  Speaker 3: I am on LinkedIn all the time. I may not
• 17:35
  Speaker 3: be the most famous Brian Read, but since you're LinkedIn
• 17:37
  Speaker 3: to me, I should be a second degree connection to
• 17:39
  Speaker 3: all of your listeners. So those are probably the two
• 17:42
  Speaker 3: best places to track me down.
• 17:44
  Speaker 2: Well, he is certainly the most famous Brian read in
• 17:47
  Speaker 2: life sciences, policy and the LinkedIn and absolute expert LinkedIn
• 17:52
  Speaker 2: follow especially because he engages with some members of Congress
• 17:56
  Speaker 2: and you can see policy sharpen in real time if
• 18:00
  Speaker 2: you follow Brian, So do that. Thank you again for
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  Speaker 2: joining me, although we hope to have you back on
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  Speaker 2: very soon again. I do encourage people to subscribe to
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  Speaker 2: in making today's podcast, and as always, keep innovating.
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