1 00:00:00,240 --> 00:00:02,720 Imagine this. You're at the Swiss Hotel in 2 00:00:02,720 --> 00:00:06,399 Chicago surrounded by top executives from leading insurance 3 00:00:06,399 --> 00:00:08,099 companies and health systems. 4 00:00:08,480 --> 00:00:12,160 Welcome to Becker's Fall Pair Issues Roundtable, November 5 00:00:12,160 --> 00:00:13,859 4th through 6, 2024. 6 00:00:14,625 --> 00:00:17,345 Picture the excitement as you gather business cards 7 00:00:17,345 --> 00:00:20,005 from over 500 executive level attendees, 8 00:00:20,545 --> 00:00:22,164 building invaluable connections. 9 00:00:22,704 --> 00:00:25,345 Feel the energy as you participate in over 10 00:00:25,345 --> 00:00:29,285 26 educational sessions led by 90 elite speakers. 11 00:00:29,769 --> 00:00:32,969 Envision yourself engaging in lively discussions about new 12 00:00:32,969 --> 00:00:36,409 health plans, hospital at home models, behavioral health, 13 00:00:36,409 --> 00:00:37,549 and price transparency. 14 00:00:38,170 --> 00:00:41,690 Now imagine being inspired by keynotes from boxing 15 00:00:41,690 --> 00:00:45,045 legend, Sugar Ray Leonard, and 4 time NBA 16 00:00:45,184 --> 00:00:47,744 All Star, Chris Webber. Their stories will leave 17 00:00:47,744 --> 00:00:50,004 you motivated and ready to innovate. 18 00:00:50,384 --> 00:00:53,024 Don't miss out on this unique opportunity. Get 19 00:00:53,024 --> 00:00:55,204 registered today. Visit beckershospital 20 00:01:03,759 --> 00:01:05,700 events page. See you in Chicago. 21 00:01:06,319 --> 00:01:08,560 Hello, everyone. This is Jacob Emerson with the 22 00:01:08,560 --> 00:01:10,259 Becker's Payer Issues podcast. 23 00:01:10,754 --> 00:01:13,075 Thrilled today to be joined by a special 24 00:01:13,075 --> 00:01:16,834 guest. Cronos Manolis is the chief pharmacy officer 25 00:01:16,834 --> 00:01:19,634 at UPMC Health Plan. Cronos, thank you so 26 00:01:19,634 --> 00:01:21,394 much for taking the time to sit down 27 00:01:21,394 --> 00:01:22,774 with us on the podcast today. 28 00:01:23,120 --> 00:01:23,700 Thanks, Jacob. 29 00:01:24,480 --> 00:01:26,560 So, Cronos, before we dive into everything that 30 00:01:26,560 --> 00:01:28,079 we wanna talk with you about, can you 31 00:01:28,079 --> 00:01:29,939 tell us a little bit more about yourself, 32 00:01:30,079 --> 00:01:32,159 your background in health care, and what it 33 00:01:32,159 --> 00:01:34,239 is that you're doing today at UPMC Health 34 00:01:34,239 --> 00:01:34,739 Plan? 35 00:01:35,584 --> 00:01:36,225 Yeah. So, 36 00:01:36,704 --> 00:01:39,125 pharmacist by education, been in the business, 37 00:01:39,584 --> 00:01:42,245 for lots lots of years, really within, 38 00:01:42,704 --> 00:01:44,864 all the pharmacy channels. So I've worked in 39 00:01:44,864 --> 00:01:46,004 specialty pharmacy, 40 00:01:46,385 --> 00:01:47,844 worked in retail pharmacy, 41 00:01:48,704 --> 00:01:49,765 worked at a PBM, 42 00:01:50,819 --> 00:01:52,200 and, for the past, 43 00:01:52,579 --> 00:01:54,040 almost 19 years, 44 00:01:54,340 --> 00:01:55,400 worked here at UPMC, 45 00:01:56,260 --> 00:01:59,140 where I, am the chief pharmacy officer of 46 00:01:59,299 --> 00:02:01,400 been really responsible for all things, 47 00:02:01,859 --> 00:02:03,719 on the pharmacy service line. 48 00:02:04,555 --> 00:02:07,194 Fantastic. So a long career in in health 49 00:02:07,194 --> 00:02:09,134 care and and a long one at UPMC 50 00:02:09,514 --> 00:02:10,014 specifically. 51 00:02:11,354 --> 00:02:13,834 In that vein, Kronos, can you hoping to 52 00:02:13,834 --> 00:02:15,194 talk with you a little bit about your 53 00:02:15,194 --> 00:02:16,259 perspective on 54 00:02:16,659 --> 00:02:19,319 the pharmacy and drug access landscape 55 00:02:19,780 --> 00:02:21,459 right now. There's obviously there's so much we 56 00:02:21,459 --> 00:02:24,599 could talk about from the federal level and 57 00:02:24,659 --> 00:02:27,000 things like Medicare negotiation powers, 58 00:02:28,180 --> 00:02:30,875 and access issues to on the private side 59 00:02:30,875 --> 00:02:32,954 in terms of GLP ones right now. It's 60 00:02:32,954 --> 00:02:35,514 obviously a hot topic within the pharmacy space 61 00:02:35,514 --> 00:02:37,694 and the costs and access issues there. 62 00:02:38,074 --> 00:02:40,715 So from your role as as chief pharmacy 63 00:02:40,715 --> 00:02:43,034 officer, can you give us a 30,000 foot 64 00:02:43,034 --> 00:02:45,930 level view of where you view pharmacy 65 00:02:46,390 --> 00:02:48,250 and drug access issues 66 00:02:48,629 --> 00:02:49,129 today? 67 00:02:50,230 --> 00:02:52,310 Yeah. So, you know, you framed it right, 68 00:02:52,310 --> 00:02:55,849 Jacob. There is tons of complexity in pharmacy 69 00:02:55,909 --> 00:02:57,689 today, and we could we could do, 70 00:02:58,310 --> 00:02:59,849 a number of these. Right? 71 00:03:00,504 --> 00:03:02,044 And, you know, from my perspective, 72 00:03:02,344 --> 00:03:04,185 you've said it. Right? I've had a long 73 00:03:04,185 --> 00:03:06,185 career, and I have never seen the kind 74 00:03:06,185 --> 00:03:07,004 of complexity 75 00:03:07,305 --> 00:03:09,705 and attention that pharmacy is getting. I really 76 00:03:09,705 --> 00:03:11,405 believe it's reached its apex. 77 00:03:11,944 --> 00:03:13,784 If you think about it, I have seen 78 00:03:13,784 --> 00:03:14,284 more 79 00:03:14,900 --> 00:03:16,280 headlines about health, 80 00:03:16,819 --> 00:03:18,040 insurers struggling 81 00:03:18,819 --> 00:03:20,120 with their costs, 82 00:03:20,580 --> 00:03:22,740 but drug being one of the top three 83 00:03:22,740 --> 00:03:24,979 reasons that really has never happened in the 84 00:03:24,979 --> 00:03:26,919 past, and it's almost, like, repetitive. 85 00:03:27,780 --> 00:03:29,319 But if you think about it, 86 00:03:29,844 --> 00:03:31,064 we've got a pipeline 87 00:03:31,525 --> 00:03:34,164 that is gonna hold promise for drugs that 88 00:03:34,164 --> 00:03:35,944 we've we've never seen before, 89 00:03:36,245 --> 00:03:37,944 onetime cures, etcetera. 90 00:03:38,564 --> 00:03:41,224 That is only gonna get enhanced by AI, 91 00:03:42,004 --> 00:03:44,004 and other tools. And then you've got a 92 00:03:44,004 --> 00:03:44,504 Fed 93 00:03:45,099 --> 00:03:45,599 that 94 00:03:46,219 --> 00:03:49,180 has accelerated approval programs, things like that. So, 95 00:03:49,180 --> 00:03:50,879 you know, really, the track is 96 00:03:51,180 --> 00:03:53,599 is slick and and drugs are gonna come. 97 00:03:54,139 --> 00:03:56,060 And then you've got, you know, drug pricing, 98 00:03:56,060 --> 00:03:57,759 which never seems to end. 99 00:03:58,139 --> 00:03:59,199 And then the IRA. 100 00:03:59,844 --> 00:04:01,305 You know, I I think the IRA, 101 00:04:01,765 --> 00:04:04,025 what's been done for the benefit 102 00:04:04,885 --> 00:04:07,865 is just tremendous for patients, for providers. 103 00:04:08,325 --> 00:04:11,125 We're finally gonna close the donut hole. We're 104 00:04:11,125 --> 00:04:14,269 gonna cap, you know, patients' cost at $2,000 105 00:04:15,050 --> 00:04:17,790 on drug. I mean, that's literally a 150 106 00:04:18,089 --> 00:04:19,230 plus a month, 107 00:04:19,610 --> 00:04:21,290 and you get all the drugs you want. 108 00:04:21,290 --> 00:04:23,629 And and so, and then we fundamentally 109 00:04:24,009 --> 00:04:25,229 changed the math 110 00:04:25,644 --> 00:04:28,685 in the equation. So who's responsible for what? 111 00:04:28,685 --> 00:04:30,284 So you're gonna see, you know, you're gonna 112 00:04:30,284 --> 00:04:32,204 see some growing pains as we get through 113 00:04:32,204 --> 00:04:34,685 that. And then, of course, we have drug 114 00:04:34,685 --> 00:04:36,625 negotiation, which will kick in, 115 00:04:37,564 --> 00:04:39,485 a little while, and anyone that tells you 116 00:04:39,485 --> 00:04:41,009 they they understand the 117 00:04:41,410 --> 00:04:41,910 of 118 00:04:42,290 --> 00:04:44,310 that, we're only just speculating 119 00:04:44,610 --> 00:04:45,509 at this point. 120 00:04:46,129 --> 00:04:47,910 And and you've got PBM reform. 121 00:04:48,610 --> 00:04:51,110 And and PBM reform is gaining attention. 122 00:04:51,650 --> 00:04:53,810 You see all the activity. You see a 123 00:04:53,810 --> 00:04:56,074 lot of the rhetoric coming out of the 124 00:04:56,074 --> 00:04:56,735 the FTC, 125 00:04:57,915 --> 00:04:59,855 and who knows where that lands. 126 00:05:00,795 --> 00:05:02,235 But at the end of the day, we 127 00:05:02,235 --> 00:05:04,735 we can't let any of this distract us. 128 00:05:05,514 --> 00:05:06,254 We have 129 00:05:06,634 --> 00:05:09,490 we have we have got to get the 130 00:05:09,490 --> 00:05:11,889 value of drug. And so, you know, at 131 00:05:11,889 --> 00:05:13,189 at my plan, 132 00:05:13,490 --> 00:05:16,230 we're really trying to engage all the stakeholders, 133 00:05:16,449 --> 00:05:17,189 our members, 134 00:05:17,569 --> 00:05:18,550 our providers, 135 00:05:19,490 --> 00:05:20,629 pharmaceutical manufacturers, 136 00:05:21,415 --> 00:05:22,394 retail pharmacists, 137 00:05:22,694 --> 00:05:24,854 anybody who touches the patient because I think 138 00:05:24,854 --> 00:05:26,074 that's the way we're 139 00:05:26,454 --> 00:05:27,995 gonna get to better care, 140 00:05:28,535 --> 00:05:30,475 better member education, etcetera. 141 00:05:31,975 --> 00:05:34,055 Absolutely. It's such a great message that there 142 00:05:34,055 --> 00:05:37,210 is a lot of swirling conversations and messages 143 00:05:37,270 --> 00:05:38,870 going on right now all over the country 144 00:05:38,870 --> 00:05:40,490 and certainly in Washington around 145 00:05:40,870 --> 00:05:43,430 drug costs. You mentioned the PBM conversations that 146 00:05:43,430 --> 00:05:44,949 are going on in the headlines that we 147 00:05:44,949 --> 00:05:48,009 see almost daily, Cronus, around this this topic, 148 00:05:48,245 --> 00:05:49,845 but a but a great message that you're 149 00:05:49,845 --> 00:05:52,324 focused on on drug costs and access for 150 00:05:52,324 --> 00:05:54,504 your members at UPMC Health Plan. 151 00:05:55,045 --> 00:05:57,045 And fascinating to hear you talk about how 152 00:05:57,045 --> 00:05:59,205 you think we're at the apex of of 153 00:05:59,205 --> 00:05:59,705 pharmacy, 154 00:06:00,959 --> 00:06:03,439 interest right now across across the media and 155 00:06:03,439 --> 00:06:04,500 the general public. 156 00:06:04,959 --> 00:06:07,600 But you mentioned something earlier in terms of 157 00:06:07,600 --> 00:06:08,980 drug costs and 158 00:06:09,360 --> 00:06:12,000 one drug class that we've seen mentioned over 159 00:06:12,000 --> 00:06:13,779 and over again this year, 160 00:06:14,480 --> 00:06:16,339 by health plans like you, 161 00:06:17,514 --> 00:06:18,814 by self insured employers, 162 00:06:19,194 --> 00:06:21,754 by public health plans like state governments all 163 00:06:21,754 --> 00:06:23,694 over the country. They're talking about GLP-1s. 164 00:06:24,395 --> 00:06:27,035 So and the cost, some some payers have 165 00:06:27,035 --> 00:06:29,275 even completely dropped coverage of these drugs because 166 00:06:29,275 --> 00:06:30,814 of because of the high costs. 167 00:06:31,194 --> 00:06:33,209 So how are you dealing with this? Some 168 00:06:33,209 --> 00:06:35,470 have some have called this GLP one insanity, 169 00:06:36,329 --> 00:06:38,970 dominating the pharmacy space. Where do you view 170 00:06:38,970 --> 00:06:41,449 this from from the perspective of UPMC Health 171 00:06:41,449 --> 00:06:41,949 Plan? 172 00:06:42,810 --> 00:06:44,649 Well, you know, let let me take a 173 00:06:44,649 --> 00:06:46,810 step back first because, you know, when we 174 00:06:46,810 --> 00:06:49,435 talk about Apex and and what that means, 175 00:06:49,895 --> 00:06:51,835 I I judge it very simply. 176 00:06:52,295 --> 00:06:55,095 What what drug names does my CFO know? 177 00:06:55,095 --> 00:06:55,595 Right? 178 00:06:55,895 --> 00:06:59,254 Everybody knows the GLPs. Right? The the my 179 00:06:59,254 --> 00:07:02,169 neighbors know about GLPs, and it really and 180 00:07:02,169 --> 00:07:04,430 I I think January of 23, 181 00:07:05,129 --> 00:07:07,069 the combination of the pandemic, 182 00:07:08,410 --> 00:07:10,810 and, you know, really the world getting back 183 00:07:10,810 --> 00:07:11,310 together, 184 00:07:11,689 --> 00:07:14,810 there was just this really social media craze 185 00:07:14,810 --> 00:07:17,495 about what these drugs could do. We've had 186 00:07:17,495 --> 00:07:20,235 GLPs for diabetes for a long time. 187 00:07:21,014 --> 00:07:23,514 And but there was just a whole different, 188 00:07:25,014 --> 00:07:26,235 accelerant there. 189 00:07:26,935 --> 00:07:28,615 But I I think, you know, the way 190 00:07:28,615 --> 00:07:30,314 I look at it is we have to 191 00:07:31,259 --> 00:07:33,980 really separate the 2 types of GLPs. There 192 00:07:33,980 --> 00:07:35,680 there are GLPs for diabetes, 193 00:07:36,379 --> 00:07:39,259 and those are Ozempic and and Monjaro and 194 00:07:39,259 --> 00:07:41,740 Trulicity, and then there are the GLPs for 195 00:07:41,740 --> 00:07:42,480 weight loss. 196 00:07:42,875 --> 00:07:45,115 And, you know, the the and we tend, 197 00:07:45,115 --> 00:07:47,675 as a population, we just blend them all 198 00:07:47,675 --> 00:07:48,175 together. 199 00:07:49,194 --> 00:07:49,694 And, 200 00:07:50,235 --> 00:07:52,254 and and it's because of the shortages. 201 00:07:52,875 --> 00:07:54,634 You know, people were trying to use one 202 00:07:54,634 --> 00:07:56,639 instead of the other, and and, you know, 203 00:07:56,639 --> 00:07:59,439 we we've got shortages that are impacting diabetics. 204 00:07:59,439 --> 00:08:01,439 And sometimes the shortages are for the weight 205 00:08:01,439 --> 00:08:03,839 loss drugs that impact other you know, interrupt 206 00:08:03,839 --> 00:08:04,819 people's treatment. 207 00:08:05,279 --> 00:08:06,879 But at the end of the day, the 208 00:08:06,879 --> 00:08:08,100 demand is incredible. 209 00:08:08,639 --> 00:08:09,860 We've had shortages, 210 00:08:11,095 --> 00:08:11,595 and 211 00:08:12,134 --> 00:08:13,995 these shortages are being mitigated. 212 00:08:14,535 --> 00:08:17,415 It makes us really nervous to see what 213 00:08:17,415 --> 00:08:20,535 is gonna happen to this category. We've had 214 00:08:20,535 --> 00:08:21,035 sequential 215 00:08:21,894 --> 00:08:23,834 quarter over quarter growth 216 00:08:24,134 --> 00:08:25,194 in double digits, 217 00:08:25,860 --> 00:08:28,279 And I can't remember a drug category 218 00:08:29,060 --> 00:08:32,279 that's had that kind of action to it. 219 00:08:32,980 --> 00:08:35,220 And, you know, I and think about it. 220 00:08:35,220 --> 00:08:36,839 For weight loss drugs, 221 00:08:37,539 --> 00:08:40,084 most people don't cover them. Right? So you 222 00:08:40,245 --> 00:08:42,024 Medicare, it's a it's an exclusion, 223 00:08:42,485 --> 00:08:43,784 and I guarantee you 224 00:08:44,164 --> 00:08:45,704 it won't be that way for long. 225 00:08:46,725 --> 00:08:48,424 We will start to see, 226 00:08:48,884 --> 00:08:49,625 the pressure 227 00:08:50,164 --> 00:08:52,964 from all sides to to cover these drugs 228 00:08:52,964 --> 00:08:53,625 in Medicare. 229 00:08:54,200 --> 00:08:56,919 And in commercial, you know, we it's a 230 00:08:56,919 --> 00:08:59,960 buy up generally. And commercial plans like ours 231 00:08:59,960 --> 00:09:02,200 that have large fully insured books, we're on 232 00:09:02,200 --> 00:09:03,179 the same pressure. 233 00:09:03,639 --> 00:09:05,240 You you can't have it both ways. You 234 00:09:05,240 --> 00:09:06,299 can't blame obesity, 235 00:09:07,894 --> 00:09:09,674 on everything that ails us downstream 236 00:09:10,375 --> 00:09:12,934 and then, you know, not cover the drugs 237 00:09:12,934 --> 00:09:14,855 because these are effective drugs. It was different 238 00:09:14,855 --> 00:09:17,334 when we didn't have effective drugs. These drugs 239 00:09:17,334 --> 00:09:18,314 were 15%, 240 00:09:18,694 --> 00:09:20,154 you know, body weight potential. 241 00:09:21,230 --> 00:09:23,809 So but it's such a massive population. 242 00:09:24,350 --> 00:09:27,230 And the data, the early data is just 243 00:09:27,230 --> 00:09:28,529 really early discontinuing 244 00:09:28,909 --> 00:09:31,409 rates. Right? So what did we really accomplish? 245 00:09:31,470 --> 00:09:32,610 And the other thing, 246 00:09:33,125 --> 00:09:35,044 the elephant in the room is people gain 247 00:09:35,044 --> 00:09:37,044 the weight back. Not everybody. You know, if 248 00:09:37,044 --> 00:09:39,204 you if you adopt the right lifestyle, who 249 00:09:39,204 --> 00:09:41,044 knows? But that's where a lot of the 250 00:09:41,044 --> 00:09:43,704 manufacturers are going next. How do we find 251 00:09:44,084 --> 00:09:46,159 drugs that where you don't gain the weight 252 00:09:46,159 --> 00:09:49,519 back as easily when you return return normal 253 00:09:49,519 --> 00:09:51,839 life? So and, additionally, you know, you we 254 00:09:51,839 --> 00:09:54,639 had all these compounding shops that are popping 255 00:09:54,639 --> 00:09:56,100 up all over the place, 256 00:09:56,799 --> 00:09:58,579 and and then we've got the manufacturers 257 00:09:59,039 --> 00:10:01,059 themselves going direct to consumer. 258 00:10:01,815 --> 00:10:03,915 You don't see a lot of that certainly. 259 00:10:04,535 --> 00:10:07,274 So here's where I just have a real 260 00:10:07,335 --> 00:10:07,835 challenge, 261 00:10:09,175 --> 00:10:10,855 and I get it, but these are really 262 00:10:10,855 --> 00:10:12,075 good diabetes drugs. 263 00:10:12,455 --> 00:10:14,455 We went from a period of time for 264 00:10:14,455 --> 00:10:16,695 type 2 diabetes that we didn't have great 265 00:10:16,695 --> 00:10:19,389 drugs. These are good drugs. You know, they're 266 00:10:19,389 --> 00:10:22,669 cardio protective. They you lose weight, which helps 267 00:10:22,669 --> 00:10:23,570 in type 2. 268 00:10:23,950 --> 00:10:25,730 You have a one c reduction. 269 00:10:26,669 --> 00:10:27,809 And yet 270 00:10:28,269 --> 00:10:29,330 the explosion 271 00:10:29,870 --> 00:10:32,669 of cost and demand has caused a lot 272 00:10:32,669 --> 00:10:34,615 of our stakeholders to say, 273 00:10:35,075 --> 00:10:37,955 you know, manage these drugs. Put more prior 274 00:10:37,955 --> 00:10:40,455 auth on. Put, you know, more management. 275 00:10:40,995 --> 00:10:43,894 We can't afford the costs anymore. 276 00:10:44,514 --> 00:10:46,035 And I I you know, again, I've been 277 00:10:46,035 --> 00:10:48,600 I've been at UPMC for for 18 plus, 278 00:10:48,600 --> 00:10:49,419 and I've been, 279 00:10:49,879 --> 00:10:51,959 in the industry in managed care for a 280 00:10:51,959 --> 00:10:53,980 long time. I I don't ever remember 281 00:10:54,519 --> 00:10:57,259 that we put barriers on diabetes drugs, 282 00:10:58,039 --> 00:11:01,000 and that is really something to think about. 283 00:11:01,000 --> 00:11:02,919 What what are we gonna do tomorrow when 284 00:11:02,919 --> 00:11:03,659 the innovation 285 00:11:04,654 --> 00:11:06,355 is gonna be even greater? 286 00:11:06,815 --> 00:11:08,674 I I I think that is 287 00:11:09,695 --> 00:11:10,514 our challenge. 288 00:11:11,535 --> 00:11:13,075 But look. You know, I I also, 289 00:11:14,095 --> 00:11:15,475 I came from the 290 00:11:16,095 --> 00:11:18,174 the you know, a world where, you know, 291 00:11:18,174 --> 00:11:20,539 there's been lots of these kinds of blips, 292 00:11:21,000 --> 00:11:23,559 and we'll manage through them. But, anyway, I 293 00:11:23,559 --> 00:11:25,320 think that's what we're trying to hold on 294 00:11:25,320 --> 00:11:25,820 to. 295 00:11:26,919 --> 00:11:28,919 Wow. I I mean, just so interesting to 296 00:11:28,919 --> 00:11:30,360 hear you talk about this. So many different 297 00:11:30,360 --> 00:11:32,360 angles and nuances that we could attack this 298 00:11:32,360 --> 00:11:34,665 conversation from, but so interesting to hear that 299 00:11:34,665 --> 00:11:36,904 this is the the most explosive drug growth 300 00:11:36,904 --> 00:11:38,684 you've seen in your career, 301 00:11:38,985 --> 00:11:41,225 Cronus. And and, you know, to your point 302 00:11:41,225 --> 00:11:42,985 is well heard in terms of people often 303 00:11:42,985 --> 00:11:44,504 do gain the weight back on these drugs. 304 00:11:44,504 --> 00:11:46,285 And we saw the largest study 305 00:11:46,639 --> 00:11:48,799 to date on on that topic from Blue 306 00:11:48,799 --> 00:11:50,639 Cross Blue Shield come out earlier this year, 307 00:11:50,639 --> 00:11:53,360 finding almost 60% of the people prescribed these 308 00:11:53,360 --> 00:11:53,860 medications 309 00:11:54,320 --> 00:11:56,820 don't actually reach a meaningful health benefit. So 310 00:11:57,200 --> 00:11:59,039 to your point, it is fascinating to see 311 00:11:59,039 --> 00:12:00,960 the research and and the data points that 312 00:12:00,960 --> 00:12:02,115 are coming out about this. 313 00:12:02,674 --> 00:12:04,115 You you had said earlier too that it's 314 00:12:04,115 --> 00:12:06,514 not it's not necessarily just GLP ones, you 315 00:12:06,514 --> 00:12:08,914 know, driving up these costs. It's specialty drugs 316 00:12:08,914 --> 00:12:11,414 in general. And we've also been hearing employers 317 00:12:11,554 --> 00:12:13,794 self insured this year talk about the the 318 00:12:13,794 --> 00:12:16,534 rising cost of cardiac and cancer drugs. 319 00:12:16,910 --> 00:12:19,090 So I think the broader question here, Cronos, 320 00:12:19,149 --> 00:12:20,830 is what's keeping you up at night from 321 00:12:20,830 --> 00:12:24,210 a broader drug access and affordability perspective 322 00:12:24,750 --> 00:12:25,730 for your members? 323 00:12:27,309 --> 00:12:29,549 Well, I think the biggest change that I've 324 00:12:29,549 --> 00:12:31,784 seen over my career is we just were 325 00:12:31,784 --> 00:12:33,725 running out of levers in pharmacy 326 00:12:34,105 --> 00:12:36,584 to manage cost. If you whether you like 327 00:12:36,584 --> 00:12:39,725 them or not, our traditional levers were really, 328 00:12:40,105 --> 00:12:41,245 you know, pay 329 00:12:41,625 --> 00:12:42,684 squeeze pharmacies 330 00:12:43,065 --> 00:12:43,565 more, 331 00:12:44,279 --> 00:12:46,699 drive try to squeeze pharma 332 00:12:47,480 --> 00:12:49,559 more, in the in the sense of more 333 00:12:49,559 --> 00:12:50,059 rebating. 334 00:12:50,440 --> 00:12:52,620 It was really a volume play. 335 00:12:53,079 --> 00:12:55,240 And if if you if you kinda look 336 00:12:55,240 --> 00:12:58,065 at it and and utilization management, prior auth. 337 00:12:58,065 --> 00:13:00,144 Right? And if you look at those levers 338 00:13:00,384 --> 00:13:02,404 and and so we would live off of 339 00:13:03,105 --> 00:13:04,485 really just driving, 340 00:13:05,184 --> 00:13:06,964 the supply chain down 341 00:13:07,424 --> 00:13:08,245 and squeezing 342 00:13:08,625 --> 00:13:10,945 cost out of it. And and now you 343 00:13:10,945 --> 00:13:11,764 look at it. 344 00:13:12,309 --> 00:13:13,129 Prior authorizations 345 00:13:13,509 --> 00:13:15,430 is is out of favor. You know, there's 346 00:13:15,430 --> 00:13:17,210 lots of enemies out there. 347 00:13:17,590 --> 00:13:19,029 I don't know that I agree with it. 348 00:13:19,029 --> 00:13:20,649 I think it's it's right, 349 00:13:21,190 --> 00:13:23,830 but there is there is it's become table 350 00:13:23,830 --> 00:13:25,290 stakes. It's not really 351 00:13:25,654 --> 00:13:27,495 a lever the way we used to think 352 00:13:27,495 --> 00:13:28,235 about it. 353 00:13:28,695 --> 00:13:32,215 Network pharmacies have become really noisy, and and 354 00:13:32,215 --> 00:13:33,115 rightly so. 355 00:13:33,654 --> 00:13:36,154 And that's what's driving all the PBM consternation. 356 00:13:37,415 --> 00:13:40,159 So anyone who's thinks they're gonna live on 357 00:13:40,159 --> 00:13:41,779 reduced pharmacy reimbursement, 358 00:13:43,360 --> 00:13:44,579 it's not gonna happen. 359 00:13:44,959 --> 00:13:46,820 I see it as like hospitals. 360 00:13:47,200 --> 00:13:48,100 We give hospitals 361 00:13:48,720 --> 00:13:52,079 cost of living increases. That's never happened in 362 00:13:52,079 --> 00:13:52,579 pharmacy. 363 00:13:52,959 --> 00:13:53,715 But I think 364 00:13:54,115 --> 00:13:56,695 network pharmacies have really reached the bottom. 365 00:13:57,235 --> 00:13:59,315 You know, in one sense, PBMs did their 366 00:13:59,315 --> 00:14:01,254 job. We went out and charged them 367 00:14:01,795 --> 00:14:04,035 to reduce costs, but, you know, we've kinda 368 00:14:04,035 --> 00:14:06,055 tilted too far to the other side. 369 00:14:06,514 --> 00:14:08,434 So I I think that's a lever that's 370 00:14:08,434 --> 00:14:10,559 not gonna happen. Rebate uncertainty 371 00:14:11,100 --> 00:14:13,580 is is really what's out there. Right? So 372 00:14:13,580 --> 00:14:13,980 there's been 373 00:14:14,700 --> 00:14:17,120 you know, we've we've rode that wave. 374 00:14:17,980 --> 00:14:19,440 Now with drug negotiation 375 00:14:19,899 --> 00:14:21,360 on the Medicare side, 376 00:14:21,740 --> 00:14:24,000 what will pharma do on the 377 00:14:24,464 --> 00:14:26,625 on the rebate side? What will they do 378 00:14:26,625 --> 00:14:29,365 crossover into commercial? Will there be unintended 379 00:14:29,824 --> 00:14:31,044 consequences there? 380 00:14:31,424 --> 00:14:32,725 And, you know, biosimilars, 381 00:14:34,384 --> 00:14:36,164 sure, we've saved some money, 382 00:14:36,779 --> 00:14:39,440 but, you know, not like I think everyone 383 00:14:39,579 --> 00:14:41,360 thought. It's it's it's opaque. 384 00:14:41,820 --> 00:14:44,399 It's hard to explain. The brand name companies 385 00:14:44,459 --> 00:14:45,199 are are 386 00:14:45,500 --> 00:14:46,559 all involved. 387 00:14:47,179 --> 00:14:48,940 And and so I I think, you know, 388 00:14:48,940 --> 00:14:50,959 you you you you have these levers. 389 00:14:51,534 --> 00:14:53,634 You have the demand for, 390 00:14:54,575 --> 00:14:56,034 these innovative therapies, 391 00:14:56,414 --> 00:14:56,914 like, 392 00:14:57,534 --> 00:15:00,254 the gene therapies and rare therapies. They just 393 00:15:00,254 --> 00:15:03,774 come to market faster and faster, aided by 394 00:15:03,774 --> 00:15:04,434 the FDA, 395 00:15:04,815 --> 00:15:06,034 aided by technology, 396 00:15:07,500 --> 00:15:08,800 and then you layer on 397 00:15:09,259 --> 00:15:11,120 inequities and health disparities. 398 00:15:11,660 --> 00:15:14,059 Even when we give drugs away, people don't 399 00:15:14,059 --> 00:15:16,860 understand them. They don't take them, and that's 400 00:15:16,860 --> 00:15:18,000 not gonna be, 401 00:15:18,540 --> 00:15:19,034 something. 402 00:15:19,595 --> 00:15:21,034 So at the end of the day, you 403 00:15:21,034 --> 00:15:23,674 know, we have been through this before. So 404 00:15:23,674 --> 00:15:25,294 in the in the early 2000, 405 00:15:26,554 --> 00:15:27,615 5 drug categories 406 00:15:28,235 --> 00:15:28,735 drove 407 00:15:29,115 --> 00:15:30,095 a significant 408 00:15:30,475 --> 00:15:30,975 cost. 409 00:15:31,649 --> 00:15:32,389 Those categories 410 00:15:32,690 --> 00:15:33,669 were statins, 411 00:15:34,449 --> 00:15:34,949 PPIs, 412 00:15:35,490 --> 00:15:36,949 non sedating antihistamines, 413 00:15:37,970 --> 00:15:38,470 SSRIs, 414 00:15:40,610 --> 00:15:41,110 and, 415 00:15:42,209 --> 00:15:44,529 ACEs and ARBs. And if you look at 416 00:15:44,529 --> 00:15:47,704 it, those 5 categories, they're still the standard 417 00:15:47,704 --> 00:15:50,664 of care. They're all just generics and pretty 418 00:15:50,664 --> 00:15:53,384 much give them away. But managed care had 419 00:15:53,384 --> 00:15:54,924 to work their way through it. 420 00:15:55,704 --> 00:15:58,039 I find ourselves in a similar spot. We're 421 00:15:58,039 --> 00:15:59,879 gonna have to work our way through it. 422 00:15:59,879 --> 00:16:01,960 The pressure will be there. The demand will 423 00:16:01,960 --> 00:16:02,620 be there. 424 00:16:03,000 --> 00:16:05,159 But I do get I do get, 425 00:16:05,799 --> 00:16:07,580 concerned that the lever's 426 00:16:07,960 --> 00:16:10,519 not sure where the affordability is gonna come 427 00:16:10,519 --> 00:16:11,019 from. 428 00:16:12,024 --> 00:16:15,404 Absolutely. So so health plans, your employer customers, 429 00:16:15,544 --> 00:16:17,625 you're running out of the levers to manage 430 00:16:17,625 --> 00:16:19,865 these pharmacy costs. I think the natural question 431 00:16:19,865 --> 00:16:21,884 to that, Cronos, is if you you personally 432 00:16:21,945 --> 00:16:24,024 could wave a magic wand, what are the 433 00:16:24,024 --> 00:16:25,804 some of the things that you would change 434 00:16:26,100 --> 00:16:27,000 policy wise 435 00:16:27,379 --> 00:16:30,360 in in the private market to ensure preservation 436 00:16:30,659 --> 00:16:32,120 of the pharmacy benefit? 437 00:16:33,139 --> 00:16:35,220 Well, I mean, I I I'm gonna make 438 00:16:35,220 --> 00:16:36,039 this simple, 439 00:16:36,579 --> 00:16:38,279 and it's not. But, 440 00:16:39,444 --> 00:16:41,924 you know, we need value in pharmacy. There 441 00:16:42,004 --> 00:16:44,424 there's very little value based 442 00:16:45,444 --> 00:16:45,944 construct 443 00:16:46,245 --> 00:16:48,584 in pharmacy. And what I mean by that, 444 00:16:49,444 --> 00:16:51,629 we still pay you know, I I I 445 00:16:51,629 --> 00:16:53,170 worked at a retail pharmacy, 446 00:16:53,549 --> 00:16:56,029 you know, many, many, many years ago. It's 447 00:16:56,029 --> 00:16:57,950 it's not a whole lot different. You have 448 00:16:57,950 --> 00:16:59,330 automation. You have technology, 449 00:17:00,190 --> 00:17:02,670 but you're still making margin on on drug. 450 00:17:02,670 --> 00:17:05,089 You're still make you're all of the clinical 451 00:17:05,230 --> 00:17:05,730 services 452 00:17:06,255 --> 00:17:07,634 we get out of pharmacies 453 00:17:08,335 --> 00:17:10,035 are funded by drug margin. 454 00:17:10,494 --> 00:17:12,734 It it doesn't make any sense. Right? It's 455 00:17:12,734 --> 00:17:13,055 certainly 456 00:17:13,535 --> 00:17:16,015 you know, it flies it's the direct opposite 457 00:17:16,015 --> 00:17:17,695 of what we do on the medical side 458 00:17:17,695 --> 00:17:19,259 of the house where we, you know, we 459 00:17:19,259 --> 00:17:21,840 have the ACO model. We have more physicians 460 00:17:21,900 --> 00:17:22,640 at risk. 461 00:17:23,019 --> 00:17:25,259 You're you have alignment. We don't have any 462 00:17:25,259 --> 00:17:26,720 of that pharmacy today. 463 00:17:27,019 --> 00:17:29,580 And I think, that's just one aspect of 464 00:17:29,580 --> 00:17:32,160 it. When you think about these rare therapies 465 00:17:32,220 --> 00:17:33,519 that are coming to market, 466 00:17:34,095 --> 00:17:36,494 The structure we've had over the last 20 467 00:17:36,494 --> 00:17:37,554 years has been, 468 00:17:38,095 --> 00:17:39,855 let me get my drug on formulary, and 469 00:17:39,855 --> 00:17:42,255 I'll pay you a discount. How about let's 470 00:17:42,255 --> 00:17:43,634 see if your drug works, 471 00:17:44,095 --> 00:17:45,869 and then we'll see what the price is 472 00:17:45,950 --> 00:17:49,390 gonna be. So outcomes based contracts, value based 473 00:17:49,390 --> 00:17:52,130 contracts, we need those in pharmacy as well. 474 00:17:52,910 --> 00:17:55,710 Those are coming, but they're I think we're 475 00:17:55,710 --> 00:17:58,450 kicking and screaming and dragging everybody with us. 476 00:17:58,829 --> 00:18:01,150 And then physician risk models as well. We 477 00:18:01,150 --> 00:18:03,525 we we talk all the time with 478 00:18:03,985 --> 00:18:06,384 docs are frustrated because the drugs are so 479 00:18:06,384 --> 00:18:08,485 expensive. They don't always have the tools. 480 00:18:08,865 --> 00:18:10,144 But at the end of the day, they 481 00:18:10,144 --> 00:18:12,785 control the scripts, so we have to have 482 00:18:12,785 --> 00:18:14,805 them involved. So in my opinion, 483 00:18:15,599 --> 00:18:16,819 in order to, 484 00:18:17,759 --> 00:18:21,759 really get everybody aligned, including the PBMs who, 485 00:18:21,759 --> 00:18:24,420 you know, started out as the greatest concept, 486 00:18:24,559 --> 00:18:27,299 you know, you can real time alert people 487 00:18:28,115 --> 00:18:30,275 before the drugs go over the wall. All 488 00:18:30,275 --> 00:18:32,835 that great technology, but they've, you know, they've 489 00:18:32,835 --> 00:18:33,735 been able to 490 00:18:34,674 --> 00:18:37,875 vertically integrate and and really find themselves in 491 00:18:37,875 --> 00:18:40,455 lots of different businesses with lots of different 492 00:18:40,515 --> 00:18:41,015 conflicts. 493 00:18:41,599 --> 00:18:42,740 We need to get value. 494 00:18:43,119 --> 00:18:44,259 We need to get everybody, 495 00:18:45,119 --> 00:18:45,859 on board. 496 00:18:46,320 --> 00:18:48,320 And I think it's gonna be uncomfortable for 497 00:18:48,320 --> 00:18:50,320 a lot. And because we didn't get here 498 00:18:50,320 --> 00:18:50,820 overnight, 499 00:18:51,200 --> 00:18:53,940 if you want change, everyone's gonna give, 500 00:18:54,434 --> 00:18:56,355 and it's gonna be a you're gonna have 501 00:18:56,355 --> 00:18:59,075 to give to the uncomfortable point. But we 502 00:18:59,075 --> 00:19:00,215 gotta start somewhere. 503 00:19:01,555 --> 00:19:03,634 Kronos, what what do you make of, some 504 00:19:03,634 --> 00:19:04,775 of the large PBMs, 505 00:19:05,315 --> 00:19:05,815 Optum, 506 00:19:06,115 --> 00:19:06,615 Caremark, 507 00:19:07,075 --> 00:19:09,269 I believe Express Scripts has as well, launching 508 00:19:09,970 --> 00:19:11,109 with what they call, 509 00:19:11,730 --> 00:19:13,829 more more cost plus transparent 510 00:19:14,529 --> 00:19:15,029 models 511 00:19:15,650 --> 00:19:18,869 amid the rise of Mark Cuban's pharmacy company. 512 00:19:19,730 --> 00:19:21,289 Any any thoughts there in terms of, you 513 00:19:21,289 --> 00:19:23,329 know, you mentioned the value based outcomes based 514 00:19:23,329 --> 00:19:23,829 contracts. 515 00:19:24,255 --> 00:19:26,255 Are these new models examples of what you're 516 00:19:26,255 --> 00:19:27,954 talking about, or is this more 517 00:19:28,494 --> 00:19:30,974 public relations fluff? Where do you kind of 518 00:19:30,974 --> 00:19:32,115 fall on that? 519 00:19:33,295 --> 00:19:33,795 Well, 520 00:19:34,414 --> 00:19:38,095 TBD. Right? I mean, I've been advocating for 521 00:19:38,095 --> 00:19:39,875 a cost plus model, 522 00:19:40,950 --> 00:19:43,049 from the PBMs for a lot of years. 523 00:19:43,190 --> 00:19:43,589 And, 524 00:19:44,069 --> 00:19:46,390 we currently use Express Scripts, and we we 525 00:19:46,390 --> 00:19:47,609 talk about it a lot. 526 00:19:48,230 --> 00:19:49,130 But I think, 527 00:19:50,069 --> 00:19:52,970 cost plus needs to be associated with transparency, 528 00:19:53,829 --> 00:19:56,125 and I think what's happening is you're you're 529 00:19:56,125 --> 00:19:56,625 getting, 530 00:19:57,325 --> 00:19:59,325 you're getting the little guys to force the 531 00:19:59,325 --> 00:20:01,984 big guys to to get get in line. 532 00:20:02,765 --> 00:20:03,265 But 533 00:20:03,565 --> 00:20:06,525 I think I think the fundamental challenge we 534 00:20:06,525 --> 00:20:07,025 have 535 00:20:07,484 --> 00:20:08,305 is that 536 00:20:08,700 --> 00:20:09,200 government 537 00:20:09,740 --> 00:20:12,619 business is really tough, Medicare especially. I mean, 538 00:20:12,619 --> 00:20:14,720 think about the rocket science of 539 00:20:15,019 --> 00:20:16,079 having to calculate 540 00:20:16,460 --> 00:20:17,519 all those dollars 541 00:20:17,899 --> 00:20:20,539 in real time, and and, you know, a 542 00:20:20,539 --> 00:20:23,339 lot of smaller PBMs don't wanna invest in 543 00:20:23,339 --> 00:20:23,839 Medicare. 544 00:20:24,644 --> 00:20:26,424 So plans like ours 545 00:20:27,285 --> 00:20:28,105 that have, 546 00:20:28,484 --> 00:20:30,724 multiple lines of business, you know, there's a 547 00:20:30,724 --> 00:20:33,125 there's a limited field out there. But, you 548 00:20:33,125 --> 00:20:35,045 know, it's a start. It it's that's what 549 00:20:35,045 --> 00:20:37,625 competition does, so so that's great. 550 00:20:38,005 --> 00:20:39,045 You know, I I think, 551 00:20:39,859 --> 00:20:42,200 personally, though, I'll I'll I'll say this. 552 00:20:42,580 --> 00:20:45,059 The more we fragment the care, the more 553 00:20:45,059 --> 00:20:47,640 cost plus pharmacies that show up. 554 00:20:48,340 --> 00:20:51,220 It's gonna destroy the PBM model. I'm not 555 00:20:51,220 --> 00:20:54,099 shy about saying it, and I'll defend it 556 00:20:54,099 --> 00:20:55,080 all day long. 557 00:20:55,460 --> 00:20:58,714 The PBM model was built for all the 558 00:20:58,714 --> 00:21:00,335 claims to be in the pool. 559 00:21:00,714 --> 00:21:02,795 When the claims are in the pool, you 560 00:21:02,795 --> 00:21:05,355 can run all those safety checks. When the 561 00:21:05,355 --> 00:21:07,134 claims aren't in the pool anymore, 562 00:21:07,930 --> 00:21:10,029 Think about what a medication reconciliation. 563 00:21:10,570 --> 00:21:11,789 So we've got CMS 564 00:21:12,650 --> 00:21:15,049 paying us to do med rec in our 565 00:21:15,049 --> 00:21:15,950 stars programs. 566 00:21:16,330 --> 00:21:18,410 And yet, you know, 3 of the 12 567 00:21:18,410 --> 00:21:19,470 claims are missing. 568 00:21:20,265 --> 00:21:22,265 What? How does that help? So I am 569 00:21:22,265 --> 00:21:24,904 very sympathetic that people have to find their 570 00:21:24,904 --> 00:21:25,404 ways 571 00:21:25,705 --> 00:21:26,445 to affordability. 572 00:21:27,305 --> 00:21:30,025 But if we don't data share and care 573 00:21:30,025 --> 00:21:32,505 coordinate to make sure all of our current 574 00:21:32,505 --> 00:21:33,005 safeguards 575 00:21:33,465 --> 00:21:33,965 operate, 576 00:21:34,759 --> 00:21:36,460 I'm not sure what we've accomplished. 577 00:21:38,360 --> 00:21:40,299 It's fascinating and big predictions 578 00:21:40,600 --> 00:21:43,880 from you, Ronis. Yeah. Any anything else we're 579 00:21:43,880 --> 00:21:46,680 missing? Any any final thoughts you wanna provide 580 00:21:46,680 --> 00:21:48,424 while you have the ears of a lot 581 00:21:48,424 --> 00:21:51,085 of health plan peers all over the country? 582 00:21:52,184 --> 00:21:54,285 You know, I think we can't get distracted, 583 00:21:54,585 --> 00:21:56,365 and we have to weather the storm. 584 00:21:56,744 --> 00:21:58,924 It is like I said, it's pretty intense 585 00:21:59,065 --> 00:22:00,365 environment right now, 586 00:22:00,820 --> 00:22:03,080 and it's also, you know, being, 587 00:22:04,259 --> 00:22:07,140 driven by it's complex on the medical side 588 00:22:07,140 --> 00:22:09,220 as well. And so for the first time 589 00:22:09,220 --> 00:22:11,059 in a long time, you know, drug was 590 00:22:11,059 --> 00:22:12,440 kind of the sidecar, 591 00:22:13,804 --> 00:22:16,125 but, you know, you've seen all the Medicare 592 00:22:16,125 --> 00:22:16,625 Advantage, 593 00:22:17,325 --> 00:22:18,224 all the utilization. 594 00:22:19,085 --> 00:22:21,085 You've seen a lot of the challenges with 595 00:22:21,085 --> 00:22:21,585 Medicaid. 596 00:22:22,204 --> 00:22:23,664 And then drug is just 597 00:22:24,285 --> 00:22:26,525 you could in the past, maybe have bailed 598 00:22:26,525 --> 00:22:28,720 some of that out, and now it's just 599 00:22:28,799 --> 00:22:31,519 it's really challenging in drug as well. And 600 00:22:31,519 --> 00:22:32,960 I think it just puts a lot of 601 00:22:32,960 --> 00:22:34,419 pressure on, but we've gotta 602 00:22:34,880 --> 00:22:36,980 stay committed to the membership. 603 00:22:37,919 --> 00:22:40,019 I think there's a lot of value 604 00:22:40,474 --> 00:22:43,434 in good clinical care and education that makes 605 00:22:43,434 --> 00:22:45,835 up for the dollars and the cents. It's 606 00:22:45,835 --> 00:22:48,315 harder to do, takes more resources, and you've 607 00:22:48,315 --> 00:22:49,615 gotta be able to engage. 608 00:22:50,154 --> 00:22:52,394 But I I don't I don't think that's, 609 00:22:52,634 --> 00:22:54,419 I think that's the answer. I think that's, 610 00:22:54,740 --> 00:22:56,339 that's one of the levers that we're gonna 611 00:22:56,339 --> 00:22:57,159 have to develop. 612 00:22:58,339 --> 00:22:58,839 Fantastic. 613 00:22:59,299 --> 00:23:00,839 Really great insights. Cronos, 614 00:23:01,220 --> 00:23:03,379 really appreciate you taking the time to sit 615 00:23:03,379 --> 00:23:05,379 down with us and for sharing your insights 616 00:23:05,379 --> 00:23:08,234 with our listeners. We truly appreciate it. Thank 617 00:23:08,234 --> 00:23:10,075 you, Jacob. If you'd like to listen to 618 00:23:10,075 --> 00:23:12,154 more podcasts from Becker's Health Care, you can 619 00:23:12,154 --> 00:23:12,974 visit beckershospitalreview.com.