Ever wonder why prescription drugs cost so much? In this episode of Health Care Rounds, Alison Lum (VP of Pharmacy Services, Blue Shield of California) joins John to peel back the layers of the complex world of pharmaceutical pricing and sheds light on the misleading list prices, opaque rebates, and tangled web of stakeholders that contribute to skyrocketing medication costs.
Topics:
(11:00) Pharmacy benefit management basics
(15:28) Rebates and pricing benchmarks
(18:34) Blue Shield of California’s pharmacy care reimagined initiative
(21:25) Capturing real-world evidence to asses new medications
(23:52) Transforming the pharmacy benefits industry with partnerships and alliances
(29:32) Baseline drug prices and innovative contracting approaches
(33:52) Shifting to a value-based model to make drug pricing more cost-effective
(37:13) The need for systemic change and holistic health in the pharmacy benefit industry
About Health Care Rounds
Health Care Rounds is a podcast developed for health care leaders who are at the forefront of health care delivery and payment reform. Join Darwin Research Group founder and CEO John Marchica as he discusses the latest advancements in health care business news and policy developments.
About Alison Lum
As Blue Shield Vice President, Pharmacy Services, Alison Lum leads the team that is transforming the Blue Shield pharmacy benefit into one that is worthy of our family and friends and sustainably affordable. At Blue Shield, she has taken an active role in employee engagement, management training, and leadership development. Prior to joining Blue Shield, Alison was the Director of Clinical Services at a managed Medicaid plan,
San Francisco Health Plan, where she was responsible for pharmacy benefits, utilization/case management, and provider relations.
Alison also has experience in Medicare Part D, PACE programs, and account management. She holds a doctorate of pharmacy degree from the University of California, San Francisco, and completed the California Healthcare Foundation Leadership Fellowship. Alison participated on the California Pharmacist Association state-wide task force for SB493 payment models and was a keynote speaker on the topic at the 2015 West Coast Pharmacy Exchange. She was honored with the Blue Shield Team Mission and Values in Action awards for 2016 and 2013 and the inaugural San Francisco Health Plan’s first Here For You award in 2008.
About John Marchica, Host of Health Care Rounds
John Marchica is a veteran healthcare strategist and CEO of Darwin Research Group, a strategic consulting and market intelligence firm focused on hospitals, health systems, physician groups, and the evolving healthcare ecosystem. John has a degree in economics from Knox College, an MBA and M.A. in public policy from the University of Chicago, and completed his Ph.D. coursework at The Dartmouth Institute. He is an active member of the American College of Healthcare Executives and is pursuing certification as a Fellow.
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You know, what we described in
terms of rebates, that is what I
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would say is like a core pharmacy
benefit management function.
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A lot of the organizations these
days have that function, but they
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also own the dispensing pharmacy.
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You have this vertically integrated chain
where that list price that we talked
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about, the MSRP, every single component
of that vertically integrated supply chain
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has an incentive for that list price to
be higher because all of the contracting
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is based off of that list price.
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Welcome to Healthcare Rounds.
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I'm John Marchica, CEO
of Darwin Research Group.
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I'm really psyched today.
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I have a very, very special guest, Allison
Lum, who is, I'm going to get this title
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wrong, I'm sure, but VP Pharmacy Services.
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Can you nod?
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Is that right?
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Yeah.
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Good.
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All right, got it.
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Um, and somebody I've been wanting to
talk to for some time, and you'll see why
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as we get into our conversation today.
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So welcome, Allison.
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Thanks for taking the time to talk today.
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Great to
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see you today, Don.
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Thanks for having me.
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Um, now, usually we'll read in a short
little bio, but if there's anything that
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you'd like to say to kind of orient our
audience, just really quickly on your
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background, then we'll dive into it.
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Well, I am a pharmacist by training.
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Um, I've been the Vice President
of Pharmacy Services here at
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Blue Shield of California for
the last five, almost five years.
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And I've spent most of my career
in managed care, health plans.
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Um, and I also spent my early days
working in community pharmacy, so I've
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seen it up front, close and personal.
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You've,
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you've, you've been in the trenches,
and now you're sort of in that, in that
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corporate view and trying to make a
difference, uh, in, in this role, um,
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and so, You know, you probably thought
last time we talked just in preparing
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for this, that I was a nice person, but
I'm not very nice because I'm going to
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ask you your very first question, um,
a very hard question and a Herculean
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task, I might add, or it could be,
maybe you'll just make it easy for all
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of us, but I want to talk about, um,
pharmaceutical pricing and if you do
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a Google on how does pharma pricing
work, And if you go into the images,
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you're going to see some crazy stuff.
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I mean, we do actually for new researchers
here, we do a training, a dedicated
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training just on this and they walk
out of there and they're just like, you
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know, kind of scratching their heads.
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So I don't know how good of a job we do.
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Um, but I wanted, um, without the
benefit of or confusion of diagrams
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for you to, to kind of walk us through
how pharmaceutical pricing works.
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And I think I think a good place
to start would be the acronyms and
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then you can take it from there.
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So AWP, WAC, all these things that,
that are out there that I guess
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contracts or other things are based
on, but maybe give just a sense.
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Cause I think most.
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Lay people would think,
Oh, pharma pricing.
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That's like what I pay at the drugstore.
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Right.
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That's obviously not it.
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So, um, maybe start there and
then, and then walk us through.
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And I might interrupt with a question here
or there, because I think this is going
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to require a little bit of explanation.
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Well,
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John, I would say this is the
easiest, hard question for us
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to start with, because it, the
answers will just reinforce for
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everybody how complex the system is.
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How complex pharmaceutical pricing
actually is and um when you think You
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talked about googling the image And we
like to say that if you had to map it all
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out, it is a spaghetti diagram As in most
in most industries you have the product
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and it goes from the manufacturer Usually
to some type of wholesale distributor
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to the retailer, to the patient or
to the consumer, I should say, right.
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The supply chain, um, and the money
flow typically follows that same supply
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chain, the consumer pays the retailer
who pays the wholesaler who pays the
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manufacturer in the pharmaceutical world,
the money flow does not match the flow
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of the product and those four sets.
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Or so that we describe of manufacturer
wholesaler retailer consumer is actually
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complicated by a whole bunch of different
stakeholders along the way who actually
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handle the money for that pharmaceutical
product and and there are a whole bunch
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of acronyms out there for pricing a W.
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P.
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Average wholesale price W.
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A.
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C.
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R.
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Wax wholesale acquisition costs
maximum allowable cost max.
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Um, One could spend a lot of time, and we
were talking about learning instruments.
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When I got into managed care pharmacy and
Learning about pharmaceutical pricing.
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It's like learning a whole new language,
like learning how to read sheet music.
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It can, it can be difficult
and take, take, take some time.
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Well, but one of the things that we
talked about pre, uh, you know, again,
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in our, our previous conversation was
back in the day, back when I was at
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Abbott, because it was so complicated.
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The whole pricing element at that time,
and we're going back quite a few years,
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was really managed by one person who
could understand some of the complexities.
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And of course he had a team, but
it was really one guy because of
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exactly what you said, because
there's all of this complexity.
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But anyway, I didn't mean to interrupt.
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I just, I was thinking
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of that.
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We had a couple of experts
in my first job, um, working
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at a small pharmacy benefits.
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Management company and that expert
who who was very familiar at the time
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with pricing and this was 20 years ago
asked me, um Joking jokingly allison,
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uh, because I was a pharmacy resident.
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He said allison What what does awp
stand for and I said, oh, I know
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the answers average wholesale price
and he looked at me He said wrong.
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It ain't what paid Because because
Everybody thinks that average wholesale
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price is actually what the drug costs.
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That's kind
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of, it's kind of like MSRP if you're
buying a car or something like that,
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it's a list price.
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It's like, like you're saying
the suggested retail price, but
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at the end of the day, we hide
that, we hide that from everybody.
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Like the consumer, the patient does
not pay the average wholesale price.
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They're paying a cost sharing,
a copay, um, based on what
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their insurance plan covers.
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Um, the pharmacies do not pay average
wholesale price, um, to the wholesalers.
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There's usually some type of
discounts that are built in, um,
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or some type of, uh, fees that
are exchanged alongside with that.
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So that's not, at the end of the day, what
the pharmacy is paying the wholesaler, um,
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and the wholesaler certainly is not paying
average wholesale price for that drug when
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they purchase it from the manufacturer.
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And so we've, as an industry, to create
some consistency, have established
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pricing benchmarks, but at the end of
the day, that's not what anybody pays.
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Right.
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Right.
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And I think there's a corollary.
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We don't need to go down this rabbit
hole because we'll be here forever.
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There's a corollary in that people just
don't pay for health care services, right?
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You go to the doctor and
maybe, maybe it's free.
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Depending on your insurance plan, maybe
it's 10 bucks, 20 bucks, whatever it is
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for your copay and or if you go to the
hospital and you have some procedures
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done that the consumer never really
faces that, but I think what you're
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probably going to at least my my feeling
on it is, is that even though there
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is that corollary, the pharma side of
things is is yet even more complex.
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Absolutely.
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When we counted our on our spaghetti
slide of all the different stakeholders
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who touched the money, but not
necessarily the drug product itself,
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there could be upwards of eight different
entities that are exchanging money
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for any one drug product that is sold.
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Yeah, that's.
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Why do we have that amount of
extra overhead and contracting?
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Why does it exist?
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Well,
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um, a cynic might say everybody
wants to get a piece of the pie.
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There's dollars for everybody to
get their little, their little bit.
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Um, but you might have
something different to say about
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that.
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Well, every piece of the pie, every
little bit of margin that's being
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added on top of the cost to manufacture
that drug is creating a system
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that is not sustainably affordable.
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And one of the things that you and I
talked about last time is quadruple
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Affordability is now in the spotlight.
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You know, there's the toxicity and
side effects from medications, but
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there's also financial toxicity.
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Um, there are multiple reasons why
somebody might not take their medication
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and we know that cost is, is one of those
drivers that's preventing people from
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either getting the prescription filled
in the first place or continuing to take
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medications if they need to stay healthy.
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That's a real
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problem.
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Well, and if you think about
it from, I mean, even from the
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manufacturers perspective, right?
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I mean, they want people to take
their medicines, not just because
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it's more money or feeling more, but
if the drug, the drug's not going
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to work if you're not taking it.
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Or if you're, you know, taking half of
what you would norm or would be prescribed
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to take because you can't afford it.
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So, so I get that.
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Um, one of the things, let's just peel
out then one part of the pricing, which
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again, I think most people have heard
this term, but might not understand
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the concept, the pharmacy benefit.
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In any given health plan is usually
managed by a third party, or it could
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be the insurance company that has an
entity that manages that, but it's
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typically carved out just like your
glasses or just like your dental care.
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As part of your overall
health plan, you have that.
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How does maybe talk a little bit about the
pharmacy benefit management and treatment.
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Yeah.
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I don't know if we call it
the PBM industry, but that
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slice of health care and how
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that works.
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Pharmacy benefits and pharmacy
outpatient pharmacy drugs, the drugs
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that somebody takes on their own,
self administered once a doctor You
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know, issues of prescription have
really changed over the last 20 years.
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Um, I actually worked with a pharmacist
early, early in my career, where she
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said, Oh, when I first started working
and this is more than 20 years ago,
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we didn't have national drug codes.
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Nbc's those are the the codes that are
on the prescription bottle So, you know
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exactly which drug it is that you're
dispensing And so we've come a long way
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and and it's it's actually been really
great in the course of my career alone
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We've had so many breakthrough innovations
new medications for conditions that
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didn't exist before and so the managed
care or pharmacy benefit management
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industry evolved to Keep help keep track
of all that because we've had this like
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enormous growth of innovation and But also
price increases and so pharmacy benefit
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management is a pretty unique area where
it's focused on managing prescription
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drugs, primarily those that are taken
self administered that, you know, a
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patient will either take tablet, capsule,
you know, cream or something like that.
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And we have health plans that
design pharmacy benefits.
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And we also have entities that, as you're
mentioning, pharmacy benefit managers that
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might offer a standalone pharmacy benefit.
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And that's usually part of an
overall health plan benefit, right?
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You've got your medical benefit
side where you have doctor visit,
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hospital visit, and then you have the
pharmacy benefit to pair with that.
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So it, it could be an outside entity or
it could just be a carve out from the
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health plan.
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Right?
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It could be part of what
a health plan offers.
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Like at Blue Shield of California,
we offer an integrated benefit
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where it's the medical benefit
plus the pharmacy benefit together.
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And what what's great about that is
it's all in the spirit of holistic
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health holistic integrated health
where the health plan blue shield
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Covers all of those medical services
including drugs that you might get
213
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administered from a clinician under
the medical benefit as well as
214
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treatment Under the pharmacy benefit
those self administered medication.
215
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So it's really that holistic
piece some employers Opt to assign
216
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that pharmacy benefit management
to a pharmacy benefit manager
217
00:13:37,000 --> 00:13:41,580
So how does thinking of the
pharmacy benefit manager nine,
218
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that's a little different from
the way that you're doing things.
219
00:13:44,330 --> 00:13:49,149
Why is it that these companies are
being hauled in front of Congress?
220
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That's the issue.
221
00:13:52,814 --> 00:13:55,645
Yeah, they're one of the stakeholders
who never, never touch a product.
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They don't actually
touch the drug product.
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And there has been a lot of
consolidation over the years.
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And while pharmacy benefit managers,
the great things that they do include
225
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contract pharmacy networks, they
might help establish lists of drugs.
226
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They also contract with
drug manufacturers.
227
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And we've created this contracting
system where what is paid for the
228
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drug when a patient receives it.
229
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We call that at point of sale that
price isn't necessarily the price that
230
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is Due at the end of the day by these
pharmacy benefit managers or even the
231
00:14:34,104 --> 00:14:41,564
health plans We have this system Usually
for branded drugs and they're called
232
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rebates And so in exchange for for
putting a branded drug on a formulary
233
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Or a drug list of which drugs might be
covered by that pharmacy benefit manager.
234
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The offset or the incentive is to
receive a rebate at a later date.
235
00:14:59,230 --> 00:15:03,780
And so what happens is that patient
oftentimes will be charged based on
236
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that point of sale price and pretty
complicated, maybe it's a hundred
237
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dollars, we'll pretend it's a hundred
dollars, your cost sharing will be
238
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based off of that a hundred dollars.
239
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But at the end of the day, the
net cost or the final cost, So the
240
00:15:20,670 --> 00:15:25,209
PBM or the health plan, if they're
able to pass that through, is maybe
241
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closer to 40 because of rebidding.
242
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Right.
243
00:15:29,140 --> 00:15:32,969
So the system that is created well,
well intended to do more like group
244
00:15:32,969 --> 00:15:37,160
purchasing or both purchasing both
contracting has really resulted in a
245
00:15:37,230 --> 00:15:41,649
system where we have these inflated
prices that are really driven by that
246
00:15:41,730 --> 00:15:47,250
ain't what's paid, the AWP, basing
their contracting and their transactions
247
00:15:47,279 --> 00:15:50,199
off of that really inflated price.
248
00:15:50,510 --> 00:15:50,860
Right.
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00:15:50,890 --> 00:15:55,359
And so I think the way to think
about it is he, you still have.
250
00:15:55,865 --> 00:16:01,055
The manufacturer will ship to some
sort of distributor and a Kessin,
251
00:16:01,065 --> 00:16:05,345
a Cardinal, one of these, and then
ultimately it goes to the pharmacy,
252
00:16:05,625 --> 00:16:09,615
could be a hospital pharmacy, could be
a retail pharmacy, could be mail order.
253
00:16:09,684 --> 00:16:14,534
And I think what gets people, and it
is sort of like an SAT question, right?
254
00:16:14,534 --> 00:16:19,554
What gets people concerned is that if
it's, if all we're talking about is
255
00:16:19,554 --> 00:16:25,660
rebates, and let's say, Let's say the
drug cost or the, I guess this would
256
00:16:25,670 --> 00:16:29,609
be the WAC or maybe the AWP, 1, 000.
257
00:16:29,689 --> 00:16:37,530
If there's a 50 percent rebate on 1,
000 and say, well, that's 500, right?
258
00:16:38,239 --> 00:16:42,039
If you increase the, well, for
lack of a better term, again, MSRP.
259
00:16:43,605 --> 00:16:50,375
To 10, 000 now they're getting a
5, 000 rebate, assuming that that
260
00:16:50,375 --> 00:16:52,045
rebate percentage is constant.
261
00:16:52,064 --> 00:16:56,714
And so the criticism is if we're just
looking at rebates, there would be an
262
00:16:56,714 --> 00:17:01,144
incentive, an incentive sort of for
the pharmacy benefit manager for a
263
00:17:01,144 --> 00:17:05,125
manufacturer to increase prices because
they just say, well, if I have a
264
00:17:05,125 --> 00:17:10,035
percentage of this amount and the amount
goes up that I'm getting a percentage
265
00:17:10,035 --> 00:17:11,964
against, then I make more money.
266
00:17:12,125 --> 00:17:12,315
Right.
267
00:17:12,315 --> 00:17:15,045
Is that, I mean, I've kind of simplified
it, but that's, does that make sense?
268
00:17:15,695 --> 00:17:17,015
Yes, absolutely.
269
00:17:17,015 --> 00:17:17,735
And.
270
00:17:18,040 --> 00:17:22,060
What I would add to that is, you know,
what we described it in terms of rebates.
271
00:17:22,329 --> 00:17:26,790
That is what I would say is like a core
pharmacy benefit management function.
272
00:17:27,030 --> 00:17:31,620
A lot of the organizations these days
have that function, plus they also
273
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own the dispensing pharmacies, right?
274
00:17:35,539 --> 00:17:42,889
And so you have this vertically integrated
chain where every, that list price
275
00:17:42,889 --> 00:17:45,000
that we talked about, the MSRP, right.
276
00:17:45,080 --> 00:17:46,529
Um, that we're talking about.
277
00:17:47,150 --> 00:17:51,100
Every single component of that
vertically integrated supply chain has
278
00:17:51,100 --> 00:17:55,620
an incentive for that list price to be
higher because all of the contracting
279
00:17:55,620 --> 00:17:57,030
is based off of that list price.
280
00:17:57,300 --> 00:17:57,690
That's
281
00:17:57,690 --> 00:17:58,280
crazy.
282
00:17:59,639 --> 00:18:00,610
That's the way we do
283
00:18:00,610 --> 00:18:00,990
things.
284
00:18:01,460 --> 00:18:03,409
That is the way we do things.
285
00:18:04,050 --> 00:18:05,670
And it's not sustainable.
286
00:18:06,589 --> 00:18:07,949
Absolutely not sustainable.
287
00:18:09,670 --> 00:18:09,880
I
288
00:18:09,880 --> 00:18:10,480
agree.
289
00:18:10,520 --> 00:18:13,020
So now we're going to get to the
reason why I wanted to talk to
290
00:18:13,020 --> 00:18:17,580
you in the first place, which is
what are you doing differently?
291
00:18:17,950 --> 00:18:21,739
What are what are on the on
the pharmacy benefit side?
292
00:18:22,100 --> 00:18:25,349
What are what have you
created and are creating?
293
00:18:25,900 --> 00:18:28,390
At Blue Shield of
California, that's different.
294
00:18:28,410 --> 00:18:31,620
That's addressing this
problem among other problems.
295
00:18:31,620 --> 00:18:33,840
I should say, I know it's
not just this one, but among
296
00:18:34,180 --> 00:18:38,240
other pharmacy benefit, we're actually
looking at all prescription drugs,
297
00:18:38,269 --> 00:18:41,990
whether they be on the medical benefit
side or the pharmacy benefit side.
298
00:18:42,430 --> 00:18:46,689
Um, but we did make an announcement
last year, John, around our pharmacy
299
00:18:46,689 --> 00:18:48,199
care, re imagined initiative.
300
00:18:48,259 --> 00:18:52,319
And that is our long term
strategic initiative with the
301
00:18:52,329 --> 00:18:53,879
aim that every person has safe.
302
00:18:54,590 --> 00:19:00,529
Equitable access to sustainably affordable
prescription drugs and we have three main
303
00:19:00,570 --> 00:19:05,969
strategies that we're employing to get
there And it's very similar to to um and
304
00:19:05,970 --> 00:19:10,549
addresses a lot of the quadruple aim that
we talked about a couple days ago um,
305
00:19:11,050 --> 00:19:17,860
we're We're addressing affordability um by
looking at the supply chain, so Working to
306
00:19:18,250 --> 00:19:23,120
take the spaghetti out of that spaghetti
diagram making it less complex working
307
00:19:23,189 --> 00:19:28,165
to bring value Um, as, as a, as a part
of the payment equation, rather than just
308
00:19:28,465 --> 00:19:30,505
relying off of these high list prices.
309
00:19:31,535 --> 00:19:34,324
The other thing that we're working
on in this part of our strategy is
310
00:19:34,325 --> 00:19:36,125
what we call elevate pharmacy care.
311
00:19:36,635 --> 00:19:39,605
Um, which is near and dear to
my heart as being a pharmacist,
312
00:19:39,645 --> 00:19:41,025
but also being a patient.
313
00:19:41,455 --> 00:19:46,495
Um, because it's our, our aim to improve
clinical quality, um, improve the member
314
00:19:46,495 --> 00:19:51,485
experiences, elevate pharmacy care,
meaning elevate pharmacists to the top
315
00:19:51,525 --> 00:19:55,205
of their license, and elevating their
experiences as well as physicians.
316
00:19:55,950 --> 00:19:58,240
Um, and prescribers more generally.
317
00:19:58,720 --> 00:20:01,340
Um, so, so that's really
exciting there as well.
318
00:20:01,670 --> 00:20:07,210
And then, um, you know, we know that in
this day and age, and certainly pharmacy
319
00:20:07,250 --> 00:20:11,219
and pharmacy claims data, all the data
capture that we have is so powerful.
320
00:20:12,059 --> 00:20:15,000
And so, leveraging data and technology.
321
00:20:15,635 --> 00:20:20,695
To really power all of that, um,
leveraging real world outcomes,
322
00:20:20,915 --> 00:20:25,955
longitudinal patient record to really
inform and again, reinforce this idea of
323
00:20:25,955 --> 00:20:30,715
paying for value rather than paying based
off of these list prices that really don't
324
00:20:30,724 --> 00:20:32,705
mean anything and just drive up margin.
325
00:20:33,254 --> 00:20:37,145
So how do you, I know you've got
more to say on this, but how do you
326
00:20:37,145 --> 00:20:40,135
assess, you know, some of these new.
327
00:20:40,675 --> 00:20:44,595
And there's a whole category of these new
diabetes drugs that are very popular for
328
00:20:44,595 --> 00:20:48,395
weight loss and they're marketed under
different names by different companies.
329
00:20:48,945 --> 00:20:54,265
Um, when you're talking about value
and of course affordability, uh, these
330
00:20:54,265 --> 00:21:00,545
three areas here, how do you assess
something, something like this, which
331
00:21:00,545 --> 00:21:05,239
is, Not extraordinarily expensive, like
a cancer drug or something like that can
332
00:21:05,239 --> 00:21:10,820
be in the tens of thousands of dollars or
more, but all of the potential ancillary
333
00:21:10,820 --> 00:21:16,679
health benefits beyond, you know, sort
of that, um, you know, hemoglobin a one
334
00:21:16,679 --> 00:21:19,800
c control or maybe shedding a few pounds.
335
00:21:19,810 --> 00:21:21,600
How do you assess something like that?
336
00:21:21,830 --> 00:21:24,760
In the framework that
you've you've built here?
337
00:21:25,190 --> 00:21:25,600
Well,
338
00:21:25,620 --> 00:21:28,550
it definitely involves capturing
the real world evidence.
339
00:21:29,090 --> 00:21:32,970
So that's not only the pharmacy claims,
the medical claims, but also to the
340
00:21:32,970 --> 00:21:37,350
extent that we can capture the clinical
data and we are building a digital
341
00:21:37,360 --> 00:21:40,849
health record to integrate all of
that data together, which could even
342
00:21:40,849 --> 00:21:42,770
include some patient reporting data.
343
00:21:42,920 --> 00:21:46,850
It's definitely, and this is where
I need help from my actuary team,
344
00:21:46,850 --> 00:21:50,110
but it's tracking those outcomes
over, over a period of time.
345
00:21:50,899 --> 00:21:55,419
Um, and it's like with any kind of
newer drugs to market, because some
346
00:21:55,419 --> 00:21:59,360
of the diabetes and obesity drugs
that you're mentioning recently came
347
00:21:59,360 --> 00:22:03,609
out, it takes time for the industry
to understand their place in therapy.
348
00:22:04,100 --> 00:22:08,919
Um, and so, right, you know, one of
the things that we firmly believe at
349
00:22:08,920 --> 00:22:13,050
Blue Shield is that, You know, it's not
all just about drugs, you know, and I
350
00:22:13,060 --> 00:22:16,690
think that's one of the challenges that
we have here with, with these newer
351
00:22:16,790 --> 00:22:19,159
treatments, the drugs, it seems easy.
352
00:22:19,429 --> 00:22:22,739
I mean, and I know it's not for everybody
because they're self injectables.
353
00:22:22,869 --> 00:22:29,699
And what we do know is that any type
of changes, particularly around losing
354
00:22:29,710 --> 00:22:32,990
weight, whether you need to lose weight
because you have diabetes or you need
355
00:22:32,990 --> 00:22:36,904
to lose weight because of your obesity
and risk factors, requires changes.
356
00:22:37,415 --> 00:22:43,095
Behavioral modification and lifestyle
changes for it to be long, long lasting.
357
00:22:43,165 --> 00:22:46,135
And so those are definitely some
things that we, that we're looking
358
00:22:46,295 --> 00:22:50,215
into and pairing with some of our,
our blue shield revolution programs
359
00:22:50,255 --> 00:22:54,164
and making sure that our patients, our
members get not just the drugs that
360
00:22:54,165 --> 00:22:59,285
they need, but the ongoing support,
lifestyle modification, behavioral
361
00:22:59,295 --> 00:23:03,375
health support that's needed to, to
really, um, get the outcomes intended.
362
00:23:03,885 --> 00:23:05,925
But it takes time to track those outcomes.
363
00:23:06,485 --> 00:23:11,095
Sure, and anybody, I'm raising my hand
now, anybody who's tried to shed a
364
00:23:11,095 --> 00:23:17,024
few pounds along the way, at multiple
times in my lifetime I've done that,
365
00:23:17,475 --> 00:23:21,550
knows that if you don't have You
know, whatever diet that you're on or
366
00:23:21,550 --> 00:23:26,160
whatever, you know, I haven't tried any
of the new medications, but it's got
367
00:23:26,160 --> 00:23:27,960
to be accompanied by more than that.
368
00:23:28,000 --> 00:23:29,620
Otherwise, it's not sustainable.
369
00:23:30,050 --> 00:23:33,970
And if you're not making those
lifestyle changes, I get that.
370
00:23:34,360 --> 00:23:39,110
So into I guess a little bit more
into the nitty gritty and you
371
00:23:39,110 --> 00:23:42,570
talked about the spaghetti and you
talked about the three different
372
00:23:42,590 --> 00:23:45,150
areas and pharmacy care reimagined.
373
00:23:46,060 --> 00:23:47,730
What does that really look like?
374
00:23:47,730 --> 00:23:50,170
Like what kinds of
partnerships are you forming?
375
00:23:50,529 --> 00:23:53,820
What kinds of alliances do you because
obviously you can't do this alone.
376
00:23:54,310 --> 00:23:58,760
So what does that practically
look like from the standpoint
377
00:23:58,760 --> 00:24:00,150
from execution standpoint?
378
00:24:00,920 --> 00:24:05,410
Yeah, last year we announced some
partnerships and I alluded to this
379
00:24:05,420 --> 00:24:12,909
vertically integrated supply chain
um, and and how Every, every entity
380
00:24:12,909 --> 00:24:17,710
within that supply chain, whether it
be a pharmacy benefit manager, they're,
381
00:24:17,870 --> 00:24:22,330
they're owned and affiliated specialty
pharmacies or retail pharmacies or home
382
00:24:22,420 --> 00:24:26,890
mail service pharmacies, wholesalers,
even some of them on wholesalers and
383
00:24:26,940 --> 00:24:28,610
and group purchasing organizations.
384
00:24:30,100 --> 00:24:34,960
We took a hard look at that, and we did
a request for proposal, um, the year
385
00:24:34,960 --> 00:24:39,800
before last, and what we did was we went
out with a request for very different
386
00:24:39,850 --> 00:24:46,060
contracting so that we could get to the
transparency around what really drives
387
00:24:46,900 --> 00:24:48,739
revenue and margin in those areas.
388
00:24:49,545 --> 00:24:53,545
And so we announced partnerships
with different entities, and
389
00:24:53,555 --> 00:24:55,175
I'll go ahead and list them now.
390
00:24:55,495 --> 00:24:59,455
So we are partnering with Abarca
for pharmacy claims processing.
391
00:24:59,645 --> 00:25:03,305
We have for our retail
network contracting, we have
392
00:25:03,305 --> 00:25:04,684
Navitas Health Solutions.
393
00:25:04,754 --> 00:25:07,905
For our home delivery pharmacy,
we have Amazon Pharmacy.
394
00:25:08,399 --> 00:25:13,689
And for our specialty pharmacy, we are
working with CVS specialty pharmacy
395
00:25:13,969 --> 00:25:17,699
and for pharmaceutical manufacturer
contracting, we have Prime Therapeutics.
396
00:25:17,849 --> 00:25:22,370
And we're also partnering with Mark
Cuban Cox plus drug company for
397
00:25:22,429 --> 00:25:24,100
developing some new pricing models.
398
00:25:24,580 --> 00:25:24,750
It's a
399
00:25:24,750 --> 00:25:25,200
lot.
400
00:25:25,219 --> 00:25:32,500
How do you pull all the,
how do you https: otter.
401
00:25:33,050 --> 00:25:36,990
ai Right.
402
00:25:37,240 --> 00:25:43,580
How do you align the incentives for
these different players to have the
403
00:25:43,580 --> 00:25:48,560
same goal and, you know, to ensure
that you're all working together?
404
00:25:49,570 --> 00:25:49,919
Yeah.
405
00:25:50,290 --> 00:25:53,460
Well, some of it's in the
contracting, um, and having those,
406
00:25:53,740 --> 00:25:57,560
those very clear contract terms
about roles and responsibilities.
407
00:25:58,304 --> 00:26:03,895
And I would say it's a large part
of that is also having started with
408
00:26:03,995 --> 00:26:09,385
the intent, the intention, um, and
keeping our shared goal, front and
409
00:26:09,385 --> 00:26:13,985
center, which is very closely aligned
to the pharmacy care reimagined goal.
410
00:26:14,205 --> 00:26:18,145
And like you said, manufacturers want
to make sure that patients have access.
411
00:26:18,855 --> 00:26:21,555
All of the people that we're
working with have that.
412
00:26:22,145 --> 00:26:26,455
Baseline guiding principle of keeping
the, keeping the supply chain,
413
00:26:26,455 --> 00:26:30,865
keeping the system itself simple,
getting to transparency, making sure.
414
00:26:30,865 --> 00:26:33,475
And, and, you know, I think
some people would say, Oh, I
415
00:26:33,475 --> 00:26:34,605
don't know that that's the case.
416
00:26:34,605 --> 00:26:37,494
I haven't seen that from all
those entities, but, um, you
417
00:26:37,494 --> 00:26:41,554
haven't seen my contract, so you
don't know exactly what we have.
418
00:26:41,555 --> 00:26:47,195
Um, and I will say that those contracts
definitely are, you know, reinforcing
419
00:26:47,195 --> 00:26:50,394
that, that transparency that has
not existed today in the market.
420
00:26:50,759 --> 00:26:53,469
So let's hypothetical situation.
421
00:26:54,189 --> 00:26:57,209
Um, I have a new drug,
I'm manufacturer ABC.
422
00:26:57,209 --> 00:26:59,070
I just have this new ABC drug company.
423
00:26:59,220 --> 00:27:03,120
I have a new drug for hypertension,
something common, right?
424
00:27:03,389 --> 00:27:10,100
And it's a different novel mechanism
works better, whatever their selling
425
00:27:10,100 --> 00:27:13,600
points are, whatever the true benefits
of that are, but let's just say it's
426
00:27:13,600 --> 00:27:19,239
different, but it's to treat something
that a lot of people have, how does.
427
00:27:19,630 --> 00:27:23,190
This pharmacy care reimagined with
all of these different players.
428
00:27:23,190 --> 00:27:25,430
I know we could probably spend
an hour on this, but just in the
429
00:27:25,430 --> 00:27:27,790
shortest possible terms and time.
430
00:27:28,380 --> 00:27:33,900
Um, how does Blue Cross of Calif or
Blue Shields gives me of California.
431
00:27:33,910 --> 00:27:42,834
How do you Blue Address that what's the
process like in pricing or in contracting,
432
00:27:42,834 --> 00:27:45,034
like what is that in practical terms?
433
00:27:45,034 --> 00:27:47,695
And I know we're getting into the
weeds a little bit here, but I'm just,
434
00:27:47,995 --> 00:27:51,095
you know, we've been talking about
how drugs are priced and the PBMs and
435
00:27:51,095 --> 00:27:52,405
how you're doing things differently.
436
00:27:52,764 --> 00:27:54,434
And now here's a real world example.
437
00:27:54,434 --> 00:27:55,234
Like what would happen?
438
00:27:56,105 --> 00:27:56,435
Yeah.
439
00:27:56,645 --> 00:28:00,905
Well, it all starts with, with the work
that, uh, and the, the responsibilities
440
00:28:00,905 --> 00:28:02,395
that Blue Shield has retained.
441
00:28:02,505 --> 00:28:05,845
So I listed a lot of partners, but
there's also still a full team of
442
00:28:05,855 --> 00:28:10,595
pharmacists and experts within Blue
Shield that manage our pharmacy benefit.
443
00:28:10,715 --> 00:28:13,974
So we set the strategy around
pharmacy, the pharmacy benefit
444
00:28:13,974 --> 00:28:18,855
itself, our formulary, all of our
medication policy and all of that.
445
00:28:18,895 --> 00:28:21,915
We even have our own pharmacy and
therapeutics committee, which are
446
00:28:22,265 --> 00:28:24,555
external physicians and pharmacists that.
447
00:28:24,989 --> 00:28:27,459
Help us to evaluate when
new drugs come to market.
448
00:28:27,539 --> 00:28:33,010
So it starts there We do the clinical
evaluation and we determine where it falls
449
00:28:33,010 --> 00:28:37,729
in terms of place in therapy Is it as
effective as what's on the market today?
450
00:28:38,189 --> 00:28:42,879
Um, are there new different benefits or
indications or populations that maybe
451
00:28:43,110 --> 00:28:48,650
maybe it should be covered in so it starts
there Then, when, after we've, you know,
452
00:28:48,800 --> 00:28:52,780
done that review, then we would turn
to all of, to these different partners
453
00:28:52,810 --> 00:28:54,720
to get the contracted rates set up.
454
00:28:55,300 --> 00:28:59,889
Some of them are already in place, um,
and so they would just flow into the,
455
00:28:59,989 --> 00:29:03,419
the contracting and how the claims are,
are set up and everything like that.
456
00:29:03,979 --> 00:29:09,500
But we would, we would likely go to
our, um, partner at Prime, partners
457
00:29:09,500 --> 00:29:12,439
at Prime Therapeutics and say,
what type of pricing deals can we
458
00:29:12,439 --> 00:29:13,879
get for when this drug is covered?
459
00:29:13,879 --> 00:29:16,524
Thanks Here's how we're
treating it benefits design.
460
00:29:16,865 --> 00:29:17,995
How, how does this look?
461
00:29:18,014 --> 00:29:20,145
What type of innovative
contract can we get?
462
00:29:20,875 --> 00:29:24,544
I also want to mention depending on, you
know, for drugs that are in the medical
463
00:29:24,544 --> 00:29:28,134
benefit We actually have a company
that we started a couple of years ago
464
00:29:28,134 --> 00:29:32,525
with four other blue slams That's Evio
Health, uh, Evio Pharmacy Solutions.
465
00:29:32,525 --> 00:29:36,725
And so we might go to them and
say, Hey, we have this new drug
466
00:29:36,725 --> 00:29:38,265
that's on the medical benefit side.
467
00:29:38,865 --> 00:29:42,014
Help us understand what are some of the,
you know, if we're going to cover this
468
00:29:42,015 --> 00:29:47,304
drug as, as reviewed by our pharmacy
and therapeutic committee, what type of
469
00:29:47,354 --> 00:29:49,034
innovative deals could we get out there?
470
00:29:49,235 --> 00:29:53,425
How can we pay you for value instead
of, you know, basing it off of average
471
00:29:53,425 --> 00:29:55,685
wholesale price or the list price?
472
00:29:57,274 --> 00:29:57,915
So I.
473
00:29:58,575 --> 00:30:03,275
Everything up until Prime
sounded pretty familiar to me.
474
00:30:03,785 --> 00:30:04,045
Right.
475
00:30:04,365 --> 00:30:09,825
You know, P and T evaluation, um,
efficacy, safety costs, all those things.
476
00:30:10,265 --> 00:30:18,725
Um, how are you going to avoid the trap
that other, that like the typical PBM,
477
00:30:18,735 --> 00:30:23,755
gets a cut and also how do you, how
do you avoid that trap with this new
478
00:30:23,775 --> 00:30:25,905
model and all of these new partners?
479
00:30:26,635 --> 00:30:27,135
Understood.
480
00:30:27,395 --> 00:30:29,975
So that, that comes in with
the innovative contracting.
481
00:30:30,285 --> 00:30:33,585
We're looking at ways
to either change that.
482
00:30:34,385 --> 00:30:36,095
Baseline price for the drug.
483
00:30:37,105 --> 00:30:42,075
Are we able to avoid rebates
and get upfront discounts?
484
00:30:42,695 --> 00:30:46,855
So that the cost of the drug at point
of sale when the patient's picking it
485
00:30:46,855 --> 00:30:52,114
up Is actually lower so that their cost
sharing can be based on that lower amount.
486
00:30:52,985 --> 00:30:54,885
How do we also factor in?
487
00:30:55,214 --> 00:31:01,525
Tracking outcomes and tying that To how
the drug is working so that influences
488
00:31:01,695 --> 00:31:06,255
the price at the end of the day Those
are usually referred to as value based
489
00:31:06,345 --> 00:31:11,525
agreements because you're tracking
outcomes into like a later point in time.
490
00:31:11,535 --> 00:31:15,124
Those typically act like rebates
because you're tracking the
491
00:31:15,124 --> 00:31:16,374
outcome to see what happens.
492
00:31:17,084 --> 00:31:20,735
But there are opportunities
and ways that you can move the
493
00:31:21,185 --> 00:31:23,295
discounts, if you will, up front.
494
00:31:24,035 --> 00:31:25,895
And we actually have a
proven example of that.
495
00:31:26,465 --> 00:31:30,835
We did that With Civica Script, are
you familiar with Civica script?
496
00:31:31,345 --> 00:31:31,735
Uh, I
497
00:31:31,735 --> 00:31:34,790
am, but you should probably
tell the, um, our listeners.
498
00:31:34,790 --> 00:31:35,030
Yeah.
499
00:31:35,610 --> 00:31:40,585
So, um, Civica was a company that
was founded, um, to address, address
500
00:31:40,975 --> 00:31:43,495
infused drug shortages in hospitals.
501
00:31:44,295 --> 00:31:47,655
And, oh boy, I've probably been
now like five or six years,
502
00:31:48,105 --> 00:31:49,545
blues plans came together.
503
00:31:50,085 --> 00:31:53,115
Um, blue, blue Plans from the Blue
Cross Blue Shield Association.
504
00:31:53,115 --> 00:31:53,175
It.
505
00:31:54,440 --> 00:31:59,530
Boy, wouldn't it be cool if we, um,
stood up an outpatient generic drug,
506
00:31:59,700 --> 00:32:06,230
drug, um, company that could address the
market failures of generic drug pricing.
507
00:32:07,290 --> 00:32:12,510
And so CivicaScript launched their
first generic drug last year.
508
00:32:13,069 --> 00:32:15,970
Um, it is a cancer drug
used for prostate cancer.
509
00:32:16,380 --> 00:32:23,910
And in some cases, I believe the cost was
upwards of, um, a few thousand per month.
510
00:32:24,310 --> 00:32:29,830
For a prescription to be filled and we
were able to get it lowered down to 200.
511
00:32:30,570 --> 00:32:31,070
Wow.
512
00:32:32,150 --> 00:32:32,300
Wow.
513
00:32:32,670 --> 00:32:32,960
That's amazing.
514
00:32:33,530 --> 00:32:33,900
Yeah.
515
00:32:33,900 --> 00:32:38,350
And so in that example, to get
it less expensive, we actually
516
00:32:38,360 --> 00:32:41,930
had ended up working with a
different specialty pharmacy.
517
00:32:42,849 --> 00:32:48,990
Um, and they are receiving the,
the drug supply directly from, you
518
00:32:48,990 --> 00:32:53,470
know, through Civica script and
dispensing only that Civica script,
519
00:32:54,290 --> 00:32:56,590
um, abiraterone to our patients.
520
00:32:57,705 --> 00:33:02,975
So it was really great to be able to get
the feedback from our members that they
521
00:33:02,975 --> 00:33:08,965
went from like, quote, banging their head
against the wall around their copay to,
522
00:33:09,375 --> 00:33:11,574
wow, now I can actually afford my copay.
523
00:33:13,055 --> 00:33:14,185
That that makes sense.
524
00:33:14,225 --> 00:33:18,205
You, um, you mentioned sort
of that the value based model.
525
00:33:18,215 --> 00:33:20,725
One of my just back up a little bit.
526
00:33:20,755 --> 00:33:26,145
My sense is from doing some of the
research that we do, um, is that often
527
00:33:26,154 --> 00:33:32,505
those models don't get implemented Or,
you know, maybe you try it in fits and
528
00:33:32,505 --> 00:33:37,035
starts and then abandon it because the
cost and the complexity of tracking
529
00:33:37,045 --> 00:33:43,155
outcomes and other things associated
with that drug or that treatment are
530
00:33:43,155 --> 00:33:48,065
prohibitive and a comment that I've
actually heard multiple times in
531
00:33:48,074 --> 00:33:52,054
interviews around this topic are just
lower the price and we'll all be happier.
532
00:33:52,074 --> 00:33:52,434
Right?
533
00:33:52,884 --> 00:33:54,265
So is that something?
534
00:33:54,910 --> 00:33:59,940
That through this, maybe through what you
have today and through this pharmacy care,
535
00:33:59,940 --> 00:34:02,120
re imagine that you're able to address.
536
00:34:02,130 --> 00:34:07,250
In other words, being more cost
effective in how you approach
537
00:34:07,250 --> 00:34:08,490
these kinds of agreements.
538
00:34:09,400 --> 00:34:10,220
Absolutely.
539
00:34:10,590 --> 00:34:16,160
So one of the things that we're trying
to do is around getting to that new value
540
00:34:16,160 --> 00:34:18,910
base, what we've been calling net price.
541
00:34:19,690 --> 00:34:20,100
So like.
542
00:34:20,530 --> 00:34:25,150
Take instead of having this high list
price and not knowing what it stands
543
00:34:25,150 --> 00:34:30,110
for or what where it came from We are
thinking and I know that other people
544
00:34:30,110 --> 00:34:33,429
have been thinking about this And in fact
several states have passed legislation
545
00:34:33,429 --> 00:34:38,140
or are trying to pass legislation around
establishing some type of board that looks
546
00:34:38,140 --> 00:34:46,530
at um having a third party evaluator to
establish kind of a neutral value Pricing
547
00:34:47,290 --> 00:34:48,990
for different, different therapies.
548
00:34:49,180 --> 00:34:54,530
And so I, I think that's worth pursuing
because we've had this inflated
549
00:34:54,530 --> 00:34:58,090
list benchmark prices for years
now, and it's not serving us well.
550
00:34:58,090 --> 00:35:01,740
It's created the spaghetti
slide where it's confusing.
551
00:35:01,740 --> 00:35:03,270
It's raising the prices for.
552
00:35:04,775 --> 00:35:07,305
And so that's definitely something
that, that we're looking at.
553
00:35:08,365 --> 00:35:13,225
So, um, final question around the
implementation that we should probably
554
00:35:13,225 --> 00:35:16,884
wrap up soon, I could talk to you
for another half hour, another hour
555
00:35:16,885 --> 00:35:20,404
on this topic, but I know there's
a certain point when people say in
556
00:35:20,404 --> 00:35:22,064
these podcasts, so I'm done listening.
557
00:35:22,295 --> 00:35:24,135
This is so interesting.
558
00:35:24,135 --> 00:35:25,025
I could just keep going.
559
00:35:25,455 --> 00:35:32,415
Um, and that is, you know, We work with,
um, or certainly study a lot of these, um,
560
00:35:32,425 --> 00:35:37,344
large health systems, you know, staying in
California, the Sutters, the, the Sharps,
561
00:35:37,385 --> 00:35:39,005
the Scripps and so on and so forth.
562
00:35:39,615 --> 00:35:40,115
Um.
563
00:35:40,770 --> 00:35:44,540
I imagine that they have a key
interest or a keen interest in the
564
00:35:44,540 --> 00:35:46,580
kinds of work that you're doing.
565
00:35:46,840 --> 00:35:50,450
And so what I'm thinking about and
just in terms of implementation,
566
00:35:50,969 --> 00:35:52,750
what are some of the roadblocks?
567
00:35:52,770 --> 00:35:58,369
What are some of the things that, you
know, if, if I'm the CMO or the chief
568
00:35:58,380 --> 00:36:03,980
pharmacy officer for scripts, let's say,
or for, for Sharp, what are some of the
569
00:36:03,980 --> 00:36:06,250
things that I need to be thinking about?
570
00:36:06,625 --> 00:36:10,255
If I'm going to be working with Blue
Shield, we're going to forge a partnership
571
00:36:10,255 --> 00:36:14,455
and with all of these other partners,
what are some of the roadblocks and
572
00:36:14,465 --> 00:36:19,375
considerations that as a health system
executive that I need to be thinking
573
00:36:19,375 --> 00:36:22,195
about in this, in this sort of new model?
574
00:36:22,584 --> 00:36:28,034
I would say, first of all, overall change
and admitting that we are all part of
575
00:36:28,034 --> 00:36:32,705
this, that we all have to be, for us to be
part of the solution, we all have to admit
576
00:36:32,705 --> 00:36:34,879
that we are part of that spaghetti slide.
577
00:36:35,500 --> 00:36:38,000
Because we are we are
part of that spaghetti.
578
00:36:38,030 --> 00:36:43,980
I call it the slides the spaghetti diagram
Um, and so really kind of understanding
579
00:36:44,030 --> 00:36:50,680
how you and your organization have a
role to play in all of this Um means that
580
00:36:50,799 --> 00:36:54,579
we are all going to have to change our
business models in order to solve this
581
00:36:54,650 --> 00:37:01,130
together And I think one barrier that
i've certainly encountered is readiness
582
00:37:01,130 --> 00:37:07,110
and willingness to change Is not always
there and we have to think beyond that
583
00:37:07,120 --> 00:37:09,690
drug product That doesn't always happen.
584
00:37:09,690 --> 00:37:15,305
I think people get very narrowly
focused on the drug And what we all
585
00:37:15,305 --> 00:37:21,985
have to remember is about holistic
health and really keeping the
586
00:37:21,985 --> 00:37:23,635
patient at the center of everything.
587
00:37:23,635 --> 00:37:24,555
I think people
588
00:37:24,555 --> 00:37:27,895
say that, but I get what
you're saying about change.
589
00:37:27,895 --> 00:37:33,115
We have 25 people in this small
company of ours here at Darwin and
590
00:37:33,115 --> 00:37:37,975
trying to get people to change in an
organization this size is hard enough.
591
00:37:38,475 --> 00:37:43,075
And so you're talking about systemic
change and you're talking about, you
592
00:37:43,075 --> 00:37:47,845
know, across the, across the, even if
we just limit it to California, all of
593
00:37:47,845 --> 00:37:53,375
the different players involved, um, I
can see how that would be challenging.
594
00:37:53,545 --> 00:37:57,324
Well, if I'm going to pretend like
I'm, I'm that, uh, chief medical
595
00:37:57,324 --> 00:38:01,605
officer for sharp as we wrap this
up, what are, what, what should I be
596
00:38:01,605 --> 00:38:04,915
thinking about and, and why do I want
to have a meeting with you, Alison?
597
00:38:07,695 --> 00:38:11,705
Well, we should be thinking about the
fact that if we don't do something
598
00:38:11,725 --> 00:38:17,895
now, none of us are going to be able
to afford prescription drug treatment
599
00:38:18,085 --> 00:38:19,665
and health care in the long term.
600
00:38:20,645 --> 00:38:25,464
And we should be thinking about our family
and friends and whether or not we want
601
00:38:25,464 --> 00:38:31,265
to be here 20 years from now, or even
10 years from now, maybe even five years
602
00:38:31,265 --> 00:38:32,975
from now saying we can't afford this.
603
00:38:33,910 --> 00:38:37,580
I certainly want to be able to have
treatments available for my, my
604
00:38:37,580 --> 00:38:43,100
parents and my brother and we should
be doing it for them for ourselves.
605
00:38:45,260 --> 00:38:45,650
Yeah.
606
00:38:46,110 --> 00:38:50,299
Well, um, Allison, you're
very inspirational and I
607
00:38:50,299 --> 00:38:51,809
enjoyed our talk very much.
608
00:38:51,860 --> 00:38:55,590
As I said, and maybe, um, if you would be
so kind, I'm not going to put you on the
609
00:38:55,590 --> 00:39:00,129
spot, but at some point in the future, I'd
like to pick up this conversation again,
610
00:39:00,240 --> 00:39:03,840
maybe six months, a year down the road
and just see how this project is going.
611
00:39:03,840 --> 00:39:05,740
See what kind of progress
that you're making.
612
00:39:06,245 --> 00:39:09,625
Um, I think that, that people
will find this, our listeners
613
00:39:09,625 --> 00:39:11,485
will find this to be fascinating.
614
00:39:11,485 --> 00:39:14,835
So again, thank you for taking
the time to speak with me.
615
00:39:14,835 --> 00:39:17,454
I really, really appreciate it
and appreciate your being part of
616
00:39:17,455 --> 00:39:18,145
Healthcare Routes.
617
00:39:18,475 --> 00:39:19,205
Thank you, John.
618
00:39:19,235 --> 00:39:21,295
I would love to catch up in
another, in another few months.