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Iowa’s PBM Reform Breakthrough: Inside Senate File 383 | PBM Reform with APCI · Pharmacy Podcast Network

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Speaker 1: You are listening to the global network of podcasters dedicated
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Speaker 1: to the pharmacy profession.
0:10
Speaker 2: Welcome to the Pharmacy Podcast Network.
0:33
Speaker 3: Welcome to the PBM Reform Podcast, where we dive deep
0:37
Speaker 3: into the world of pharmaceutical benefit management, cutting through the
0:41
Speaker 3: noise to uncover the truth. Since 2019, we've been your
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Speaker 3: go-to source for the latest on how PBMs impact patient care,
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Speaker 3: drug pricing, and the very future of pharmacy. Here, we
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Speaker 3: champion the role of pharmacists, the most knowledgeable advocates for
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Speaker 3: medication safety and expertise. Join us as we expose and
1:03
Speaker 3: generate discussions that are reshaping healthcare and explore how we
1:07
Speaker 3: build a better payment system, which focuses on advancing pharmacy care.
1:19
Speaker 1: Hey, welcome back to the PBM Reform Podcast. I get
1:22
Speaker 1: to take the mic over today from our regular host,
1:27
Speaker 1: I don't want to say normal host because Greg Reibold's
1:30
Speaker 1: about as normal as I am, and I'm not sure
1:32
Speaker 1: if that's normal or not.
1:34
Speaker 2: So who knows? You'll have to be the judge of
1:35
Speaker 2: that as the listeners.
1:36
Speaker 1: But my name is Todd Urey, founder of the Pharmacy
1:39
Speaker 1: Podcast Network, and I get to host our PBM Reform Podcast.
1:44
Speaker 1: We are featuring, and I said to Dr. Barker, Brett Barker, PharmD,
1:49
Speaker 1: that he was on my bucket list of podcasts. I've
1:52
Speaker 1: been after him since he ran for state representative. in
1:58
Speaker 1: the Iowa legislature. I can never say legislature. It kind
2:02
Speaker 1: of pours out of my mouth like lasagna is in
2:05
Speaker 1: my mouth or something.
2:06
Speaker 2: Brett, welcome to the show.
2:07
Speaker 4: Yeah, happy to be here.
2:08
Speaker 5: I've been a listener for quite some time, so it's
2:10
Speaker 5: good to actually get to be on the show with you.
2:12
Speaker 2: Absolutely.
2:13
Speaker 1: I'm very excited, very proud of you as a pharmacist
2:18
Speaker 1: making waves within your own state, but I think those
2:22
Speaker 1: waves crash out into... all of what is pharmacy and
2:27
Speaker 1: people paying attention to that pharmacists understand things in ways
2:31
Speaker 1: that other legislatures, legislators might not understand. And there's some
2:38
Speaker 1: brilliant ones out there. Jake Auchincloss out of Connecticut is
2:41
Speaker 1: one of my favorites. He's been on our show two
2:44
Speaker 1: or three times. However, he's not a pharmacist. So as
2:48
Speaker 1: intelligent as he is, and he really knows his stuff,
2:51
Speaker 1: there's things that you understand of the dominoes that fall
2:57
Speaker 1: on your constituents and on your communities that do come
3:00
Speaker 1: from inside of healthcare. And you got to see it
3:02
Speaker 1: before you became a state representative. So you got to
3:05
Speaker 1: see it as a pharmacist and how it was impacting
3:08
Speaker 1: people that were standing right in front of you, you know,
3:11
Speaker 1: throughout your time as a pharmacist. So let's take a
3:14
Speaker 1: pause for a second for the listener's sake. Tell us
3:17
Speaker 1: about yourself. What pharmacy school did you go to and
3:21
Speaker 1: why did you want to become a pharmacist in the
3:22
Speaker 1: first place?
3:23
Speaker 5: Yeah, I went to the University of Iowa for pharmacy school,
3:26
Speaker 5: which is ultimately what led me here. I went to
3:28
Speaker 5: Iowa to go to school and now I've stayed in
3:31
Speaker 5: the state. And I wanted to be a pharmacist because
3:34
Speaker 5: I wanted to do something healthcare in general, wanted to
3:37
Speaker 5: help patients. And at the time, my grandparents were aging
3:40
Speaker 5: and I was watching how their lives were impacted through
3:44
Speaker 5: pharmacists and started to really look at it. And then
3:47
Speaker 5: also was trying to do something that was health care
3:50
Speaker 5: without the blood and guts. And what's funny, I just
3:52
Speaker 5: told my kids this. My daughter's a senior in high school.
3:55
Speaker 5: They were giving me a hard time. They're like, you
3:56
Speaker 5: don't like blood and needles, but you're a pharmacist and
3:58
Speaker 5: you do vaccines all the time. And I'm like, well,
3:59
Speaker 5: when I was accepted into the program, I didn't know that.
4:02
Speaker 5: And I learned it the first day of orientation. So
4:05
Speaker 5: we were on the forefront of the vaccine efforts back
4:08
Speaker 5: in those days.
4:09
Speaker 2: That's hilarious. Yeah, I would be the exact same way.
4:13
Speaker 1: I always thought, you know, I'm not a pharmacist. I
4:16
Speaker 1: pretend to be one on the podcast mics every once
4:19
Speaker 1: in a while. And no, heck, no way, no way,
4:24
Speaker 1: no way, no way do I want to see people
4:27
Speaker 1: bleeding or in, you know, in pain. Although you might
4:31
Speaker 1: see people in pain as a pharmacist, but not the
4:33
Speaker 1: way that you're Not like a surgery, an open heart surgery.
4:36
Speaker 1: So I would faint. I would not be able to
4:38
Speaker 1: put up with that. All right, let's get into this
4:40
Speaker 1: because I'm excited you're here. Congratulations on Iowa Senate File 383.
4:46
Speaker 1: It was a major PBM reform law. It was aimed
4:50
Speaker 1: at protecting independent pharmacies. And I think that's more important
4:54
Speaker 1: than what the general public understands. They might think, hey,
4:59
Speaker 1: I got my chain pharmacy over here and I got
5:02
Speaker 1: another pharmacy over here. They don't understand that there's more
5:07
Speaker 1: impact to that specific area and specific town or city
5:13
Speaker 1: that it's in when an independent community pharmacy closes down
5:16
Speaker 1: because of the control that the owners have over where
5:19
Speaker 1: those dollars are spent as an organization supporting the actual
5:25
Speaker 1: area that it's serving. And it was strengthening patient choice
5:30
Speaker 1: as well, which I think is absolutely necessary. It was
5:33
Speaker 1: signed by Governor Kim Reynolds on June 11th, 2025. We
5:38
Speaker 1: just celebrated the first year anniversary of it, and it
5:41
Speaker 1: took effect in July of 2025. Can you tell us
5:46
Speaker 1: kind of like what the biggest points of that win is?
5:49
Speaker 1: I kind of give an overview, but let's dig into that.
5:52
Speaker 1: What did that do to help strengthen health care within
5:55
Speaker 1: the state of Iowa?
5:57
Speaker 5: Yeah, and it's probably the biggest dogfight of my life
6:00
Speaker 5: to get that through, as you can imagine. And the
6:02
Speaker 5: governor signed it the very last day she was able
6:05
Speaker 5: to sign bills because it was the most contentious thing.
6:09
Speaker 5: There were two that were really contentious that she waited
6:11
Speaker 5: to the last minute to sign. And that was one
6:13
Speaker 5: of them and it's because it actually does move the needle.
6:17
Speaker 5: I worked from the Iowa Pharmacy Association side as a
6:20
Speaker 5: senior policy advisor previous to being elected and was able
6:23
Speaker 5: to pass the PBM reform bill in 2022 from the
6:26
Speaker 5: lobby side.
6:27
Speaker 4: And which was a good bill.
6:28
Speaker 5: It kind of followed on the changes we needed after
6:30
Speaker 5: the Rutledge decision got us in a better place from
6:33
Speaker 5: an enforcement standpoint.
6:34
Speaker 4: But there was a lot more that needed to be done.
6:36
Speaker 5: So there were a lot of things left on the
6:37
Speaker 5: cutting floor after that process that we learned from and
6:40
Speaker 5: we brought those back.
6:42
Speaker 4: In 2025.
6:43
Speaker 5: So I showed up as a newly elected legislator, luckily
6:46
Speaker 5: was appointed to our commerce committee, which oversees insurance issues.
6:50
Speaker 5: And our commerce chair said at the time, hey, I've
6:53
Speaker 5: got a lot of big issues in front of the
6:54
Speaker 5: committee that she was gonna have to deal with this chair.
6:56
Speaker 5: And she asked me if I would be interested in
6:58
Speaker 5: floor managing our PBM reform bill. So of course, I
7:01
Speaker 5: said yes, and kind of ran from there. And we
7:04
Speaker 5: got the best bill I could have ever hoped for
7:07
Speaker 5: through the process. Quite interesting how it played out because
7:10
Speaker 5: our Senate had always been our issue, getting good PBM
7:14
Speaker 5: reforms to the governor's desk. Well, the Senate went first
7:17
Speaker 5: and they passed a super great bill over to the House.
7:20
Speaker 5: And so then the House members face the pressure from
7:23
Speaker 5: the industry that they had never faced before because everybody
7:26
Speaker 5: just put their pressure on the Senate, assuming that was
7:28
Speaker 5: their firewall and the House is gonna pass what the
7:30
Speaker 5: House is gonna pass. So then my colleagues in the
7:32
Speaker 5: House started getting the pressure and their eyes were like,
7:35
Speaker 5: what is happening?
7:36
Speaker 4: What is going on? Here's what they're telling me.
7:39
Speaker 5: And so I was very thankful to be in the
7:41
Speaker 5: House at that point, because before that I was going,
7:43
Speaker 5: you know, may have been better for me to be
7:44
Speaker 5: in the Senate because maybe that's where the PBM battle
7:47
Speaker 5: is going to be fought. Well, it actually ended up
7:48
Speaker 5: being the House this time. And so some of the
7:51
Speaker 5: things it does, you know, obviously the patients seem to
7:54
Speaker 5: be the focus. We say in Iowa all the time,
7:56
Speaker 5: it's our mantra, if it's right for the patient, it's
7:57
Speaker 5: right for the profession. So really, we led with patient
8:00
Speaker 5: access pieces. They get to choose their pharmacy, the steering issues,
8:06
Speaker 5: the disparities in co-pays, those types of things. The coupon cards,
8:11
Speaker 5: those were things that were all built into it from
8:15
Speaker 5: an access, a patient choice, empowering patient standpoint.
8:18
Speaker 4: Obviously, then we.
8:19
Speaker 5: We get into transparency pieces and reimbursement pieces on the
8:22
Speaker 5: pharmacy and to keep them whole. So we have a
8:24
Speaker 5: cost plus methodology for reimbursement, kind of a NADAC plus
8:28
Speaker 5: dispensing fee model. We have an appeals process of the
8:33
Speaker 5: pharmacies getting paid below their acquisition costs. They're able to
8:36
Speaker 5: appeal that and at least be made whole on the
8:38
Speaker 5: product cost because as we all know, especially from an
8:42
Speaker 5: independent standpoint. I mean, you see all those transactions all
8:45
Speaker 5: day long, and it used to drive me crazy. It
8:47
Speaker 5: would be negative, negative, negative, then a few pennies here
8:50
Speaker 5: and there, and then you have a couple of big winners.
8:52
Speaker 5: And so we really told that story, honestly, on the
8:55
Speaker 5: cost plus. I, at the time, was working for a
8:58
Speaker 5: small regional chain and was able to actually give them
9:00
Speaker 5: real data from a pharmacy. Here's what our day looks like,
9:04
Speaker 5: and I graphed it. here's all the losers, here's all
9:07
Speaker 5: the ones right at the break even mark. Here's the
9:09
Speaker 5: cost of dispensing line and here's the few things above it.
9:12
Speaker 5: And that kind of opened legislators eyes a little bit
9:14
Speaker 5: of what we're dealing with every day. Because like I
9:17
Speaker 5: told them, we really have a couple of choices in pharmacy.
9:19
Speaker 5: You either don't take the contract and that's just a blow,
9:23
Speaker 5: you're done, right? You don't have access to patients. Or
9:25
Speaker 5: you take the contract and it's death by a thousand
9:27
Speaker 5: cuts and eventually you bleed out. So it's really neither
9:31
Speaker 5: option is good. And you take the best of the
9:32
Speaker 5: bad options and kind of fight, try to live to
9:34
Speaker 5: fight another day. But those were some of the big
9:38
Speaker 5: areas we tried to tackle with a piece of legislation.
9:42
Speaker 2: It's very robust.
9:45
Speaker 1: I think the listeners that have been following the PBM
9:49
Speaker 1: Reform podcast, when we talk, we usually focus on one
9:52
Speaker 1: or two specific issues within a bill that's driven.
9:57
Speaker 2: But this is huge. And I don't want to underplay this.
10:01
Speaker 1: So PBMs cannot steer patients towards a preferred affiliated network
10:08
Speaker 1: or mail order pharmacy by using different co-pays or reimbursement terms.
10:14
Speaker 1: PBMs cannot require patients to obtain pharmacy services exclusively through
10:21
Speaker 1: nor can they make using a community pharmacy more expensive
10:25
Speaker 1: or restricting them. A PBM cannot deny network participation to
10:29
Speaker 1: a pharmacy that meets the plan's requirement and accepts the
10:33
Speaker 1: reimbursement terms applicable to similar classified pharmacies.
10:37
Speaker 2: That's huge.
10:39
Speaker 1: PBMs cannot improperly classify drugs as specialty drugs simply to
10:45
Speaker 1: restrict patient access through a particular pharmacy.
10:49
Speaker 2: That's also huge.
10:51
Speaker 1: And then it says retail pharmacy reimbursements generally cannot fall below,
10:56
Speaker 1: like you were saying, Brett, the national average drug acquisition
10:59
Speaker 1: cost or NADAC.
11:01
Speaker 4: I don't know.
11:02
Speaker 2: I might be, I don't know.
11:05
Speaker 1: I don't know of a pharmacy bill that has hit
11:07
Speaker 1: that many things that are, as soon as it goes
11:10
Speaker 1: into law of how that would impact patient choice and
11:14
Speaker 1: patient health, Because all of the PBRM Reform Board bills
11:18
Speaker 1: that we've been following, they've been great and they've really helped, obviously,
11:22
Speaker 1: the state. But I don't know if they've hit all
11:24
Speaker 1: of those things. And I've only mentioned five of the,
11:27
Speaker 1: I think there's 10 possible lists of how this could
11:33
Speaker 1: impact patient health and patient access to pharmacy care.
11:37
Speaker 2: So, Brett, this is huge.
11:39
Speaker 5: And it's the beauty of the laboratory of democracy, right?
11:42
Speaker 5: We've got 50 states and our state capitals have been
11:45
Speaker 5: really active in PBM. Unfortunately, as we all know, DC
11:48
Speaker 5: hasn't been as active as we would like them to be.
11:50
Speaker 5: And so a lot of this battle is being fought
11:53
Speaker 5: in our state capitals. And what we were able to
11:55
Speaker 5: do was really look around at what language had been
11:57
Speaker 5: passed and stood up To the courts across the country,
12:01
Speaker 5: particularly the Eighth Circuit, we have to look at even closer.
12:04
Speaker 5: And really, we ran with everything that at the time
12:07
Speaker 5: had been passed and had been successful, and we were
12:10
Speaker 5: able to get it all done. Now, since as we
12:12
Speaker 5: were working on ours, and I call it the full Arkansas,
12:14
Speaker 5: I mean, they're as aggressive as anybody. They went even
12:17
Speaker 5: farther with with some of their provisions in Tennessee as followed.
12:20
Speaker 5: But that was new at the time. And, you know,
12:22
Speaker 5: we did have some conversations like, should we add this in?
12:24
Speaker 5: And at that point, we're like, okay, we've got enough
12:26
Speaker 5: fish to fry to get this to the governor's desk.
12:28
Speaker 5: Let's not add some more chaos here at the 11th hour.
12:32
Speaker 5: But yeah, as of that session, that was as aggressive
12:35
Speaker 5: of a PBM bill as we could have run with.
12:38
Speaker 1: So you've learned a lot being a state representative. What
12:43
Speaker 1: ancillary things happening in the realm of health care kind
12:47
Speaker 1: of butt up against the realm of of pharmacy care
12:51
Speaker 1: are there other things happening in the state that you've
12:54
Speaker 1: got to be a part of or understand where it's
12:57
Speaker 1: like wow if we could get this aligned or change
12:59
Speaker 1: this a little bit it's going to help in the
13:01
Speaker 1: realm of total health care rather than just pharmacy care.
13:05
Speaker 5: Yeah, obviously there's a lot that we get to deal with.
13:07
Speaker 5: And I just had the opportunity to zoom into the
13:10
Speaker 5: University of Florida and talk to their pharmacy students the
13:12
Speaker 5: other day. And we talked a lot about these types
13:14
Speaker 5: of issues and what legislatures are doing that impact pharmacy.
13:18
Speaker 5: And as we know, healthcare is heavily regulated and we're
13:22
Speaker 5: very much impacted by decisions at our capital. So if
13:24
Speaker 5: we're not making our voice heard there, other people are
13:27
Speaker 5: that can impact us. And pharmacists, have a huge opportunity
13:31
Speaker 5: to advocate. We are located in every legislative district. Legislators
13:35
Speaker 5: trust what pharmacists say. And despite our, we're going to
13:39
Speaker 5: get outspent, we're going to get out lobbied. But our advocacy,
13:43
Speaker 5: we can often offset that. And that's how we were
13:45
Speaker 5: able to pass the PBM bill in Iowa. What's beautiful
13:48
Speaker 5: about our state is we have one unified profession. So
13:50
Speaker 5: when pharmacy speaks at the Capitol, it speaks for everyone.
13:53
Speaker 5: And so the other side tried to play the chain
13:56
Speaker 5: pharmacy versus the the independent pharmacy versus rural versus urban.
14:00
Speaker 5: And we all stood together and we said, no, this
14:02
Speaker 5: is across the profession. This impacts every pharmacy setting, every
14:06
Speaker 5: patient in our state and we're not gonna be divided here.
14:09
Speaker 5: But some of the other things we get into and
14:11
Speaker 5: one thing I'm really proud of is our pharmacy practice act.
14:13
Speaker 5: It would have been written in 1984 when I was
14:16
Speaker 5: still in the lobby, I got a chance to redline
14:18
Speaker 5: the word document that became our rewritten pharmacy practice act.
14:21
Speaker 5: And we went from the old school bright line where
14:24
Speaker 5: every time something changes in pharmacy education or practice, we
14:27
Speaker 5: had to go back to the legislature to ask for approval.
14:30
Speaker 5: And then it would be stuck in concrete again until
14:32
Speaker 5: the next time we used our political capital to update that.
14:35
Speaker 4: So we went full standard of care here in Iowa.
14:38
Speaker 5: We're regulated just like every other health profession now from
14:40
Speaker 5: the clinical standpoint. We have full prescriptive authority just like
14:44
Speaker 5: the other prescribers in our state. And that's really going
14:46
Speaker 5: to open up the clinical opportunities going forward. So I'm
14:49
Speaker 5: really excited because one, we've protected through the PBM reform effort,
14:54
Speaker 5: the bread and butter of traditional community pharmacy of the dispensing. Well,
14:58
Speaker 5: we've also opened up doors for us to diversify our
15:01
Speaker 5: offerings on the clinical side. So I think those two
15:03
Speaker 5: things together are going to set up well in our
15:05
Speaker 5: state for a long time. And I'm excited for the
15:08
Speaker 5: students that are going through, they're going to be able
15:09
Speaker 5: to practice in that environment.
15:12
Speaker 2: That's rich.
15:12
Speaker 1: I just got back from visiting It's my fourth time,
15:17
Speaker 1: four years in a row, of visiting WVU School of
15:20
Speaker 1: Pharmacy's P3s. And I choose the P3s on purpose because
15:25
Speaker 1: they're not going out of their minds, getting ready for NAPLEX,
15:28
Speaker 1: but they're kind of at the stage of their pharmacy
15:32
Speaker 1: education career to start making decisions in their heads. Hey,
15:36
Speaker 1: what sector of pharmacy do I want to go to?
15:39
Speaker 1: And while I was talking to them, I talked to
15:41
Speaker 1: them about the importance of PBM reform. I think there
15:44
Speaker 1: were about 35 students in that class. And when I
15:50
Speaker 1: asked about who understands what a PBM is, there were
15:54
Speaker 1: only about 10 of them that put their hands up.
15:57
Speaker 1: So for students to understand not only what a PBM is,
16:01
Speaker 1: but the fact that PBMs are extremely important there, it's
16:06
Speaker 1: not like we're always playing down PBMs at all. What
16:09
Speaker 1: we're asking for is a fair playing field and, and
16:13
Speaker 1: and factors in the field of play of healthcare. It
16:17
Speaker 1: comes back to patient choice, transparency of the medication cost
16:23
Speaker 1: and stop playing shell games and also stop taking money
16:26
Speaker 1: away from independent community pharmacies, you know, three months, six
16:30
Speaker 1: months down the road because of some new shift in
16:34
Speaker 1: how the contract works or whatever. And it's just, it's
16:39
Speaker 1: nice to have an opportunity to talk with the future
16:42
Speaker 1: pharmacists out there so that right from the get-go, they
16:45
Speaker 1: have a base understanding of what a PBM can be,
16:51
Speaker 1: which I think there's a good side of it. And
16:53
Speaker 1: then of course, what we're pulling out of, out of
16:55
Speaker 1: the three big ones that, you know, hey, we have
16:58
Speaker 1: to make some shifts and we have to make some
17:00
Speaker 1: changes because the way that it was designed was only
17:05
Speaker 1: allowing these three big entities, vertically integrated entities, to do
17:11
Speaker 1: pretty much anything that they wanted. So state by state,
17:15
Speaker 1: we're really starting to see changes that is meaningful changes.
17:19
Speaker 1: I've been in the industry, been in pharmacy since 2004.
17:23
Speaker 1: I've never seen so much PBM reform action rather than
17:28
Speaker 1: just talk within the last five years. It just seems
17:31
Speaker 1: like there's finally the fire's been lit. And like I say,
17:35
Speaker 1: I don't want to see CVS Health or Optum or
17:39
Speaker 1: Express Grips I don't want to see them go out
17:42
Speaker 1: of business. I don't want to see them, you know,
17:45
Speaker 1: their business is suffering. I want them to play on
17:48
Speaker 1: an even playing field and make things, once again, accessibility for.
17:52
Speaker 2: The patient's choice.
17:54
Speaker 1: And with their reimbursing their pharmacies that they own, as
17:58
Speaker 1: a matter of fact, they shouldn't own pharmacies, but that's
18:00
Speaker 1: another PBM reform podcast. But it's like, hey, if you're
18:04
Speaker 1: getting a certain reimbursement, you got to pass the exact
18:07
Speaker 1: same reimbursement. to another pharmacy and you have to open
18:10
Speaker 1: up the network so that patients have a choice. And
18:14
Speaker 1: you know better than I do because your constituents and
18:16
Speaker 1: the people that you're serving in the state of Iowa
18:19
Speaker 1: are suffering from other things than just PBM stuff or
18:22
Speaker 1: pharmacy issues.
18:24
Speaker 2: But there are sections of.
18:27
Speaker 1: The areas that you're serving, Brett, that you won't have
18:31
Speaker 1: healthcare services for miles and miles away. And the independent
18:35
Speaker 1: community pharmacy, that's it. Like that's the only health care
18:38
Speaker 1: provided forever. So what do you think the next steps
18:41
Speaker 1: are in getting this legislation or some kind of bill
18:46
Speaker 1: passed that we can finally see some, I don't know,
18:50
Speaker 1: some groundwork or some leveling of PBMs being reined in
18:56
Speaker 1: at the national level?
18:58
Speaker 5: Yeah, and you hit on a lot of good things there. One,
19:00
Speaker 5: I think the student engagement is critical. We need to
19:03
Speaker 5: have students really taught on how to advocate because they're
19:06
Speaker 5: going to be the future of the profession. And so
19:08
Speaker 5: I honestly may not be where I am had I
19:10
Speaker 5: not gone to the day on the hill as a
19:11
Speaker 5: student that really set that interest and pharmacy policy from
19:16
Speaker 5: that experience. And so I highly encourage students to take
19:19
Speaker 5: those opportunities. But as far as the national level, we
19:22
Speaker 5: just have to keep telling our story. When I first
19:24
Speaker 5: started going to DC, I had to define what PBMs
19:28
Speaker 5: were for our legislators. We don't have to do that anymore.
19:31
Speaker 5: We've come a tremendous way.
19:36
Speaker 4: From there.
19:37
Speaker 5: Now we're to the point that one of our congresswoman
19:40
Speaker 5: who is running for the Senate has asked me, who
19:43
Speaker 5: are people I can talk to in the state that
19:45
Speaker 5: are really fired up about PBM reform? Because she wants
19:47
Speaker 5: to focus on that in the campaign and if elected.
19:50
Speaker 5: We're blessed, our senior Senator Chuck Grassley, I'm sure most
19:53
Speaker 5: of your listeners probably have have heard of his efforts
19:56
Speaker 5: in DC. He's like a dog with a bone. He's
19:59
Speaker 5: very tenacious. It's one of his big things as PBM
20:01
Speaker 5: reform at the federal level. Congresswoman Miller Meeks from Iowa,
20:05
Speaker 5: she's a physician. She's been very tenacious in the House
20:07
Speaker 5: and has been one of those that's been trying to
20:09
Speaker 5: lead the conversation in the House. And we've been lucky
20:11
Speaker 5: that whether Republican or Democrat from Iowa, they've all been
20:14
Speaker 5: bought in on the need for PBM reform. So I
20:17
Speaker 5: think we just as states need to keep telling our story.
20:19
Speaker 5: And more and more of our delegations are going to
20:22
Speaker 5: see what's going on. I know that they've tried to
20:24
Speaker 5: do some things from the executive side. The Federal Trade
20:29
Speaker 5: Commission's been trying to go at it from a regulatory side.
20:33
Speaker 5: And so I do think it's going to take all
20:35
Speaker 5: the above. We're just going to have to be tenacious.
20:37
Speaker 5: This has all been about And that's where I've also
20:39
Speaker 5: told people too, when they get into this, is this
20:42
Speaker 5: is not about being discouraged because we didn't get all
20:45
Speaker 5: we wanted right away. This takes a long, long, long time.
20:49
Speaker 5: My first time trying to lobby, and it was actually
20:51
Speaker 5: for PBM reform. As a brand new first time as
20:54
Speaker 5: an official lobbyist, quote at the Capitol, all the big
20:57
Speaker 5: money from community firms, you're gonna get to do that job,
21:00
Speaker 5: which is mostly just because I enjoyed it, wanted to
21:02
Speaker 5: do it. But my state senator at the time, I
21:06
Speaker 5: always remember him telling me, nobody gets what they want
21:08
Speaker 5: on their first ask. A lot of times it's true.
21:11
Speaker 5: You have to build the coalitions. You have to tell
21:13
Speaker 5: your story. You have to build momentum. And we have
21:15
Speaker 5: momentum now. We have momentum in the states. We've been
21:19
Speaker 5: able to expose a lot of the bad practices that
21:21
Speaker 5: PBMs are doing. We've got a lot of good data
21:24
Speaker 5: that shows that the horror stories the other side will
21:27
Speaker 5: say about the health care system falling apart and costs
21:29
Speaker 5: going through the roof actually doesn't happen in places that
21:31
Speaker 5: have done this. That was one of the things that
21:33
Speaker 5: we were able to share is here's all the states
21:36
Speaker 5: that have these provisions. Here's what their health care premiums
21:39
Speaker 5: have done. Here's what their experience actually is in states
21:42
Speaker 5: that have gone before us. So as more and more
21:43
Speaker 5: of us states move forward, you know, you'll be able
21:46
Speaker 5: to look at Iowa in a couple of years and
21:47
Speaker 5: look at our health care premiums and what happens after
21:50
Speaker 5: he passes. this legislation goes into effect and show that
21:52
Speaker 5: it actually didn't have the sky is falling at the
21:55
Speaker 5: other side.
21:55
Speaker 4: I'll tell you it has.
21:56
Speaker 5: So we're just gonna have to keep building that story
21:59
Speaker 5: and hopefully federally get something done. I mean, I think
22:01
Speaker 5: it's nice that again, it's bipartisan out there. Both parties
22:04
Speaker 5: are telling the story on PBMs. And I've talked to
22:07
Speaker 5: John Thune myself about PBMs. I've talked to our leader
22:12
Speaker 5: in the House myself about PBMs.
22:15
Speaker 4: They both understand the importance.
22:17
Speaker 5: And so hopefully we'll be able to get something done.
22:22
Speaker 5: I know that the president's talked about it from time
22:24
Speaker 5: to time. So they're all aware, which is a much
22:26
Speaker 5: better place than we've ever been. But as we all know,
22:29
Speaker 5: The opposition we face on this issue, it's David and Goliath.
22:33
Speaker 5: I mean, the resources, I joked around about the private
22:36
Speaker 5: jets that start flying into state capitals as soon as
22:38
Speaker 5: the PBM bill drops, cuz they're gonna bring in all
22:41
Speaker 5: the high powered folks to try to get ahead of this.
22:46
Speaker 5: I honestly don't think that we would have gotten the
22:48
Speaker 5: bill to the governor's desk had I not been in
22:50
Speaker 5: the House Majority Caucus when we were having that battle.
22:53
Speaker 4: Being able to.
22:54
Speaker 5: Actually rebut with real world insight in our caucus room
22:58
Speaker 5: to try to get that to the floor. We had
23:01
Speaker 5: a rally at the Capitol. We had hundreds of pharmacists there.
23:04
Speaker 5: It was an incredible, incredible day. They're all out in
23:06
Speaker 5: the hallway and I get to be in that room
23:08
Speaker 5: trying to tell the story about what's actually true. And
23:11
Speaker 5: people would bring up a word being told this and
23:12
Speaker 5: I got to respond with what was real. So we
23:15
Speaker 5: need more pharmacists to be in these type of roles
23:17
Speaker 5: because that's also going to help us. I mean, we've
23:19
Speaker 5: talked about Buddy Carter in DC, other folks like that.
23:21
Speaker 5: I mean, having the actual experienced pharmacists that know the
23:25
Speaker 5: issue help because their colleagues trust them. The only capital
23:32
Speaker 5: I have at the Capitol is my own word and trust.
23:34
Speaker 5: And so Uh, once, once people, your colleagues learn, they
23:37
Speaker 5: can trust you. That goes a long way when they learn,
23:39
Speaker 5: they can't trust you. You're not going to get anything done.
23:41
Speaker 5: So your word is all you have, but, um, having
23:43
Speaker 5: pharmacists that led that other colleagues trust also makes a difference.
23:49
Speaker 1: So let's talk about resources for a second, $ 44 million
23:54
Speaker 1: in PBM reform, lobbying spend from PCMA, from, um, from, um, OptumRx,
24:03
Speaker 1: from CVS, Caremark, from Express Scripts. If you add up
24:07
Speaker 1: all four of those organizations, it equals $ 43. 7 million in
24:13
Speaker 1: lobbying dollars that are put towards keeping PBM reform from happening.
24:23
Speaker 1: I think that's very telling of the kind of money
24:26
Speaker 1: that they can shell out so that PBM reform doesn't
24:29
Speaker 1: take place and that they can keep things in the
24:32
Speaker 1: status quo. And then a comment back to the need
24:38
Speaker 1: for pharmacists. Before we started recording, I said this, pharmacists
24:43
Speaker 1: understand things, physicians understand things differently than the lay person
24:47
Speaker 1: or differently than the lawyer or someone that's in legislation
24:53
Speaker 1: or legislators throughout the country, either Senate or or the House.
24:58
Speaker 1: And when I start counting this up, you know, it's
25:02
Speaker 1: like there's 39 pharmacist office holders, two pharmacists, members of Congress,
25:09
Speaker 1: and thinking of approximately 37 pharmacists serve in the state
25:14
Speaker 1: houses and state senates nationwide. I mean, it's a little
25:20
Speaker 1: bit more than I thought, but it's still not really
25:22
Speaker 1: enough because there's still pockets of the country that that
25:26
Speaker 1: will have zero providers in the House or the Senate
25:30
Speaker 1: that I think is a lacking of real information of
25:36
Speaker 1: what's really happening rather than some of this big speak
25:40
Speaker 1: or these confusing terms. Or like you said, Brett, before
25:44
Speaker 1: five years ago, if you went to any state representative
25:48
Speaker 1: that wasn't a physician or a pharmacist and you said,
25:51
Speaker 1: can you tell me what a PBM is? They'd be like,
25:54
Speaker 1: a PB what? A PB & J?
25:56
Speaker 2: What are you talking about? What is that?
25:58
Speaker 1: And I think that now you can say to most
26:02
Speaker 1: House of Representatives or even state senators, do you understand
26:06
Speaker 1: what PBMs do, what pharmacy benefit managers do? And they're
26:10
Speaker 1: going to say, oh, that's insurance. At least they know
26:13
Speaker 1: the beginnings of what that really means. And I think
26:17
Speaker 1: it finally has gotten to a point where we don't
26:20
Speaker 1: have to, it kind of reminds me of when I
26:22
Speaker 1: started podcasting in 2009, I used to have to tell
26:25
Speaker 1: a person what a podcast was. I would be like, hey,
26:28
Speaker 1: do you ever want to listen to my podcast? They'd
26:29
Speaker 1: be like, what's a podcast?
26:31
Speaker 2: Now we don't have to say that anymore.
26:35
Speaker 5: And I think one of the things I would recommend
26:36
Speaker 5: to other states is find those champions in your state
26:40
Speaker 5: that are willing to dig in and own the issue.
26:42
Speaker 5: Oftentimes it may be a healthcare provider, but it also
26:45
Speaker 5: may not. One advantage we had in 2022 in Iowa
26:49
Speaker 5: when I was in the lobby side, they assigned it
26:50
Speaker 5: to Senator Mike Clements. She was fairly new at the time.
26:53
Speaker 5: And they assigned it to him at the end of
26:54
Speaker 5: the week. He said, give me the week and I'm
26:56
Speaker 5: gonna read up on it. I wanna meet on Monday morning.
26:59
Speaker 5: So Monday we get back to the Capitol, I meet
27:00
Speaker 5: with him. And I swear, the guy, he studied over
27:04
Speaker 5: the weekend. I'm like, I feel like I'm talking to
27:05
Speaker 5: a pharmacist right now. He understood it at that deep
27:07
Speaker 5: of a level. Well, now he's a Senate majority leader.
27:10
Speaker 5: So you can imagine what that did for us in
27:12
Speaker 5: 2025 with him now as the majority leader. So maybe
27:18
Speaker 5: he wasn't yet, but he was in charge of, I think,
27:20
Speaker 5: the committee that it went through. But either way, he
27:22
Speaker 5: was a huge voice in leadership at the time. But
27:24
Speaker 5: having those champions make all the world, that can help
27:28
Speaker 5: move it forward. Because they're the ones on the inside
27:30
Speaker 5: that need to be tenacious, that need to build their
27:32
Speaker 5: internal coalitions.
27:34
Speaker 1: All right, so What's the next steps for something happening
27:38
Speaker 1: in the state of Iowa that you're like, okay, you
27:41
Speaker 1: got to come back to this and we got to
27:43
Speaker 1: kind of like tighten up? Or is there something else
27:46
Speaker 1: that you're that you're working on?
27:48
Speaker 5: Yeah, so as far as PBM reform goes, we knew
27:50
Speaker 5: at the time that it was gonna be litigated. The
27:53
Speaker 5: governor's office had some fear, are we gonna get sued?
27:56
Speaker 5: And I said, well, honestly, yes, because if we don't,
27:59
Speaker 5: we know we didn't pass something that's meaningful. Because we
28:02
Speaker 5: know every single meaningful PBM reform bill, and probably even
28:05
Speaker 5: a lot that aren't meaningful are gonna get litigated. And
28:07
Speaker 5: so ours is currently going through the Eighth Circuit process.
28:11
Speaker 5: It's being litigated. We do expect a decision. Now, we
28:15
Speaker 5: did attempt to fall very closely to current Eighth Circuit
28:20
Speaker 5: and Supreme Court precedents with the bill. And so hopefully
28:25
Speaker 5: most or all of it is upheld. But we do
28:28
Speaker 5: expect there to be some things we might have to
28:29
Speaker 5: go back and respond to. So when that happens, we're
28:33
Speaker 5: kind of in a waiting game. Once that happens, we'll
28:35
Speaker 5: go back. Our mantra is, what's the next right thing?
28:38
Speaker 5: So we'll respond once we know at that point what
28:41
Speaker 5: that is. So that's where we are there. We're working
28:43
Speaker 5: on other adjacent type payer issues like 340B contract pharmacy
28:47
Speaker 5: protections that also drive our access issues. and pharmacy deserts
28:51
Speaker 5: in rural Iowa. So those are some of the other things. Medicaid,
28:56
Speaker 5: we're working on some Medicaid payment issues too. So there's
28:59
Speaker 5: some other things we're working on kind of in adjacent areas.
29:02
Speaker 5: But as far as PBM reform goes, we're waiting for
29:04
Speaker 5: the courts to make their determination.
29:07
Speaker 2: Brett, this has been incredible.
29:09
Speaker 1: We're going to have to have you back on the
29:11
Speaker 1: PBM reform podcast in the future and just dig into
29:13
Speaker 1: other things that are happening. One, an update on 340B.
29:17
Speaker 1: There's lots of changes happening state to state and different
29:20
Speaker 1: things that are good and bad with 340B as a
29:24
Speaker 1: protected class of reimbursement for those entities that have the ability.
29:29
Speaker 1: They're like, hey, we're in an impoverished area. We know
29:32
Speaker 1: that these people don't have enough health care services. And
29:35
Speaker 1: by the way, we're pushing these medications through the system
29:38
Speaker 1: so they get better pricing. for these organizations and coverage.
29:41
Speaker 1: And we don't want that taken advantage of by organizations
29:45
Speaker 1: like some of the PBMs.
29:47
Speaker 4: That are.
29:48
Speaker 1: Not forthright. They're not doing it for the right reason
29:51
Speaker 1: to give that kind of coverage. So you've been a champion.
29:55
Speaker 1: Thank you so much for your work.
29:59
Speaker 2: Dr.
30:00
Speaker 1: Brett Barker, he is the state representative of the Iowa
30:04
Speaker 1: Legislature District 51. It seems like a good number because
30:09
Speaker 1: Bud Cook in the Pennsylvania state, he's our house of representative,
30:15
Speaker 1: District 51.
30:16
Speaker 2: That's my district. So coincidental.
30:19
Speaker 4: Here we go.
30:20
Speaker 2: So thank you very much, Brett, for being on the show.
30:23
Speaker 4: Yeah, happy to. Thanks for having me. Thank you.