EP459: Cost Containment by Co-Pay Maximizer or Co-Pay Accumulator: Points to Ponder, With Bill Sarraille

[00:00:00] Episode 459, Cost Containment by Co-Pay Maximizer or Co-Pay Accumulator, Points to Ponder. Today I speak with Bill Sarraille.

[00:00:20] American healthcare entrepreneurs and executives you want to know, talking, relentlessly seeking value.

[00:00:28] If you have zero clue what Co-Pay Maximizers and or Co-Pay Accumulators are and the financial incentives involved,

[00:00:35] for PBMs and plan sponsors here. After you're done listening to this episode, go back and listen to the show with Joey Deesenhaus.

[00:00:42] Also the episode called Co-Pay Cards Gone Wild with Dia Belazi. Both these shows could fill in some blanks.

[00:00:49] Here's the micro mini of the Co-Pay Maximizer slash Accumulator deal.

[00:00:54] These are vehicles that are designed by vendors who are also sometimes called maximizers or sometimes they're also PBMs.

[00:01:02] But these programs are designed to get as much money out of pharma as possible in the form of co-pay support.

[00:01:09] So here's how the maximizers are supposed to maximize plan sponsors getting pharma money.

[00:01:14] Say for some drug, the pharma company has, I don't know, $12,000 max in co-pay support available to patients in total per year.

[00:01:22] Pharma does always cap the dollars that are available for patients. So in this hypothetical, 12K a year is available.

[00:01:28] What a forthright or well-run maximizer will do is figure out, you know, if there's 12K max available, then they'll set a co-pay.

[00:01:38] So there's variable co-pays for patients. So they'll set a patient co-pay of like $1,000 a month, which adds up to 12K over 12 months of the year.

[00:01:49] So, you know, every single month the patient has a $0 co-pay, but the plan maximizes the dollars that the plan gets or, you know, maybe they'll charge $1,025 a month.

[00:01:59] So the patient has some small in air quotes skin in the game and the plan sponsor just banked 12K.

[00:02:05] Sounds great, right? Well, sure.

[00:02:08] So, you know, I don't know if you're going to do this in a minute.

[00:02:09] But I'm going to do this in a minute.

[00:02:10] Accumulators, on the other hand, have no such, hey, let's make sure the patient actually gets their meds guardrails.

[00:02:16] They hear that the pharma is offering 12K and the accumulator vendor and their plan sponsor clients also are like, cool, let's get that money as fast as possible.

[00:02:25] So they make the co-pay for that drug, I don't know, like hypothetically $3,000.

[00:02:31] Great. Now the patient runs out of that co-pay money in May.

[00:02:35] And don't forget, and or let me inform you, for both maximizers and accumulators, dollars paid by the pharma generally don't count to the plan deductible for the patient.

[00:02:45] So now the patient walks into the pharmacy in an accumulator or in a poorly run maximizer program, they walk into the pharmacy in May and are told that if they want their drug, they're going to need to pay the $3,000 co-pay that was set out of pocket every month until they reach their deductible.

[00:03:03] With some of these co-pay maximizer slash accumulator plans, the plan sponsor may be a little bit out of the loop relative to what is actually going on here.

[00:03:11] The plan sponsor may think that members are doing fine.

[00:03:14] You know, they're getting their drug every month, so they may be surprised to learn about this running out of money in May issue.

[00:03:20] And what is true more often than it's not true, this $3,000 or whatever, hundreds or thousands of dollars payment due co-pay,

[00:03:28] the patient learns about it at the pharmacy counter or will try to get chemo.

[00:03:33] It comes as a complete surprise, the fact that they owe $3,000 or whatever.

[00:03:38] What patient just shrugs and pays up in that moment because they happen to have their entire deductible or thousands of dollars lying around and at the ready?

[00:03:46] What a shock to find this out at the pharmacy counter or at the infusion clinic.

[00:03:51] Some of these maximizer programs are also starting to veer back into accumulator zones.

[00:03:57] Like they're doing things such as saying that the member must pay their out-of-pocket max or their deductible or 30% of the cost of the drug, right?

[00:04:07] Like some number before the plan will allow the patient to use the co-pay reimbursement program to begin with.

[00:04:15] So there's other things that are emerging right now, which again, cause the patient to have a very, very large out-of-pocket in order for them to get a drug,

[00:04:25] which they have been prescribed and ostensibly at least need allegedly and sometimes for sure.

[00:04:31] Dollars raked in from pharma, make it across the PBM slash maximizer vendor middleman trench all the way over to the plan sponsor.

[00:04:38] For sure, especially for the administrative only maximizer vendors.

[00:04:44] Yeah, you're going to have the dollars actually making it to the plan sponsor.

[00:04:47] But sometimes the vendor running these programs is paid spread, right?

[00:04:51] So the more expensive the drug and the richer the co-pay card program, the more the vendor will make because they take a percentage of savings.

[00:04:58] So the more expensive, the more savings, therefore the more the vendor is going to make.

[00:05:02] In these cases where the vendor is paid a spread, can I take perverse incentives for 600, Alex?

[00:05:08] Right.

[00:05:09] But in some, again, there's a lot to this conversation with Bill Sorrell.

[00:05:12] So please do listen to the whole thing.

[00:05:13] Bill offers five main pieces of advice.

[00:05:17] So I'm just going to cover them right here up front.

[00:05:19] Spoiler alert, I guess.

[00:05:20] But just to keep them all in one place.

[00:05:22] Point of advice, number one, look into what is going on with a maximizer and or accumulator program.

[00:05:29] First of all, is the plan sponsor paying spread?

[00:05:31] And also, how are these programs being marketed to members and how aggressively?

[00:05:36] Because there are a lot of plan sponsors having way more negative impact than they suspect they are.

[00:05:42] So that's point of advice number one.

[00:05:45] Really look into actually what is happening on the ground with some of these programs.

[00:05:49] Number two, point of advice, eliminate surprise.

[00:05:52] Any plan sponsor listening, and Brian Reed also says this very crisply in an episode a month or so ago.

[00:05:56] If a plan sponsor wants to do stuff like this, like force a patient to pay hundreds or thousands of dollars out of pocket.

[00:06:03] If at any point during the year they are going to wind up with thousands of dollars in copay or coinsurance to get their Crohn's disease med or cancer med or whatever.

[00:06:12] Be really upfront about this, at least.

[00:06:14] It's really important if we really want to make sure that patients are taking maintenance meds and getting the medications, that they're prepared for the reality that at a certain point during the year they are going to have a really big bill.

[00:06:27] Third piece of advice, there is legal risk here.

[00:06:30] So also Bill's advice is check into whether accumulators and or maximizers are unlawful under the ACA and or by deceptive practices rules when maximizers or accumulators are teed up as a benefit.

[00:06:44] And again, reference point of advice number two, it's not explained that dollars they get from pharma will be taken by the plan and not applied to the patient deductible.

[00:06:53] I was just reading about the crazy aggressive marketing tactics that some of these vendors are using to get members to sign up and yeah, definitely look into deceptive practice rules.

[00:07:03] Four, if it's utilization management that we're trying to achieve here, then your utilization manager should be utilization managing.

[00:07:14] These maximizers are not meant to impact utilization management.

[00:07:18] Patients really cannot differentiate as per study after study.

[00:07:21] It's very difficult for patients to differentiate high value from low value care or meds.

[00:07:27] So pretty much the impact of having a patient with thousands or hundreds of dollars of out-of-pocket spend to get a med isn't going to be to ensure that the right people are taking the right med.

[00:07:38] Point is, use the right tool for the right job.

[00:07:40] So if we're trying to keep patients away from low value meds, the tool for that is utilization management.

[00:07:46] Also be aware, if the PBM says it cannot do utilization management or you lose your rebates and or is pushing into a maximizer accumulator program to do this instead, that's kind of a clue that they cannot do it because they are taking money from pharma to not have any restrictions on a drug.

[00:08:05] Read the article in the New York Times gift link in the show notes.

[00:08:10] You're welcome about how PBMs took secret payments for the free flow of opioids.

[00:08:15] And Chris Crawford also talks about this sort of same-ish thing in an upcoming show relative to GLP-1s.

[00:08:20] But if you're trying to do utilization management, then do utilization management.

[00:08:24] Last point of advice, use our understanding of this whole goings-on as a rationale or a way to tamp down perverse incentives.

[00:08:31] We want to wind up with patients getting charged a percentage of net prices, not a percentage of some wildly inflated list price with this whole accumulator maximizer contributing to, you know, just more wildly inflated list prices.

[00:08:45] So the copay programs can be bigger and someone can make even more money off of the percentage of savings.

[00:08:52] And plan sponsors addicted to rebates now have another bucket of cash.

[00:08:56] Like, this is just another example of how perverse incentives pervade the system.

[00:09:02] And we should certainly be aware of that.

[00:09:04] Bill Sorrell was a healthcare attorney for many years.

[00:09:07] He retired from his law firm on the first of last year.

[00:09:10] And now he's doing the things he wanted to do before but couldn't because his billable rate was too high.

[00:09:15] Bill is teaching at the University of Maryland Law School and doing some regulatory consulting, etc.

[00:09:20] He's working with a variety of patient groups.

[00:09:22] My name is Stacey Richter. This podcast is sponsored by Aventria Health Group.

[00:09:26] And here is my conversation with Bill Sorrell.

[00:09:28] Bill Sorrell, welcome to Relentless Health Value.

[00:09:30] Well, thanks for having me.

[00:09:31] I am really looking forward to speaking with you about accumulators slash maximizers.

[00:09:37] What's going on right now that plan sponsors might want to be aware of?

[00:09:44] Well, from my perspective, patients are being harmed in a variety of different ways.

[00:09:49] Sometimes in a program that spreads out the entire cost of the coupon-supported portion of the drug cost over the 12 months,

[00:10:01] we have situations where patients later in the year are experiencing problems.

[00:10:09] Other times, we have situations where there really isn't an attempt to smooth the coupon dollars over the course of the year.

[00:10:19] And the patient is experiencing an access problem much earlier in the year, maybe by mid-year or even in the first quarter.

[00:10:27] When you say experiencing a problem, you mean they go in to get their drug,

[00:10:31] they show up with the manufacturer coupon.

[00:10:34] Because we're talking about these specialty pharmacy products.

[00:10:37] A lot of times, the coinsurance that the plan sponsors put against these are based on a percentage of the list price.

[00:10:44] The list prices, as we know, they're very high.

[00:10:47] So when you're saying they wind up with a problem,

[00:10:49] what you mean is they show up at the pharmacy and they're told their drug costs thousands of dollars or something.

[00:10:55] Well, that's one problem, but it's not the only problem.

[00:10:59] The issue is that from the patient's perspective, and I think from the law's perspective,

[00:11:04] they have completely satisfied their deductible and their out-of-pocket maximum.

[00:11:10] And so whatever service they're going to, whether it's for a specialty drug or for a retail general med drug,

[00:11:18] or if it's just to go to a physician's office or for a minor procedure in the hospital outpatient department,

[00:11:28] no matter what the service is, they understood that their entire deductible

[00:11:33] and their entire out-of-pocket maximum had been fulfilled, and suddenly it's not.

[00:11:39] That's the problem from the patient's perspective.

[00:11:42] So in other words, the patient knew that pharma was paying their deductible,

[00:11:46] and now the patient thinks the deductible is met, except it's not.

[00:11:51] Yes. People tend to think that the only way that there can be a problem for a patient

[00:11:57] is that at some point in the year, they go to get the coupon-supported drug,

[00:12:04] and now the coupon doesn't work for them, perhaps because of the manufacturer's terms,

[00:12:10] where the manufacturer has placed a ceiling on the coupon.

[00:12:14] But that's not the only problem that can occur.

[00:12:18] The reality is because, at least in my experience, plans and PBMs do a very poor job,

[00:12:25] and maybe not even a lawful job, of trying to explain to patients

[00:12:30] what in fact is going to be their treatment of manufacturer-assisted payments by patients.

[00:12:38] The issue that I'm talking about, where patients think,

[00:12:42] not having been adequately informed by their plan or PBM,

[00:12:46] that in fact they are not going to get credit for coupon-assisted payments that they make,

[00:12:52] they are coming into treatment situations thinking that they have met their deductible,

[00:13:00] and thinking that they have met the out-of-pocket maximum, and they have not.

[00:13:04] And for, unfortunately, a number of those patients,

[00:13:08] they don't have the money to actually access the care.

[00:13:13] And so this becomes an access problem for them.

[00:13:17] It's interesting what you're saying,

[00:13:18] and I know there's going to be a lot of plan sponsors who are listening,

[00:13:21] who are thinking the things that some plan sponsors,

[00:13:24] when discussing these accumulators-slash-maximizer programs,

[00:13:28] or just copay cards in general, tend to think,

[00:13:32] and let's just go down the laundry list just to get these on the floor.

[00:13:35] And I'm not passing judgment here, right?

[00:13:36] Because these are really tough times we live in,

[00:13:39] and pharma costs are accelerating.

[00:13:41] Like I was talking to someone the other day who said

[00:13:43] her pharmacy costs have doubled in the past five years.

[00:13:46] So this is certainly an issue.

[00:13:48] Trying to keep premiums down,

[00:13:50] you know, family premiums have exceeded $26,000,

[00:13:53] or it's like $25,500, almost $26,000 a year, right?

[00:13:56] So you have premiums becoming unaffordable.

[00:13:59] There's obviously a lot of issues here.

[00:14:01] One of the big reasons why these maximizer-slash-accumulator programs

[00:14:05] get put into place to begin with is basically to get double the deductible, right?

[00:14:11] Because if the pharma company is paying the deductible,

[00:14:13] and then the patient is paying the deductible,

[00:14:15] now the plan can access two deductibles,

[00:14:19] and those two deductibles then go to lower premiums for the entire patient pool.

[00:14:23] So that's kind of one thing.

[00:14:25] The point that was made was that, you know,

[00:14:29] maximizers are a way to enable sick patients

[00:14:33] to make healthcare more affordable for healthy patients.

[00:14:37] And what I would say back to that is,

[00:14:40] that's not the purpose of insurance.

[00:14:41] And it certainly isn't consistent with either the law

[00:14:44] or the policy of the Affordable Care Act.

[00:14:47] That is fundamentally at odds

[00:14:49] with both the relevant legal structure

[00:14:52] and the policy that Congress put into place.

[00:14:55] People can think that that should happen,

[00:14:58] that sicker patients should be making payments

[00:15:02] that make premiums for healthier patients less expensive.

[00:15:06] But that's not a current reflection of the law as Congress has passed it.

[00:15:12] And I don't personally think that that's the right policy.

[00:15:16] I think that basically is an invitation to discriminate

[00:15:20] in favor of healthy patients to the detriment of sick patients,

[00:15:25] which in the pre-existing condition change

[00:15:27] and in multiple other changes,

[00:15:29] including the provision that forbids discrimination

[00:15:32] and based on health status,

[00:15:34] we see law actually moving in the opposite direction.

[00:15:38] So I don't have more to say about that.

[00:15:41] If people disagree with what Congress was actually trying to do,

[00:15:44] then they disagree with what Congress was trying to do.

[00:15:47] And the law can be changed, but that's not the law.

[00:15:50] The other plan sponsors thing is the notion

[00:15:55] that if one patient is taking a specialty pharmacy drug

[00:15:58] and gets their deductible paid for them,

[00:16:00] that's kind of unfair to somebody who needs a knee replacement

[00:16:03] or something like that,

[00:16:04] who actually has to pay their deductible by themselves.

[00:16:06] So then you create a situation

[00:16:08] where there's kind of this disparity

[00:16:10] where some people get their deductible paid for them

[00:16:12] and others do not.

[00:16:14] This concept is that it's unfair

[00:16:16] that some patients are able to be supported

[00:16:20] and some are not able to be supported

[00:16:23] with manufacturer coupons.

[00:16:25] Again, you know, as a lawyer,

[00:16:28] at least by training,

[00:16:28] if not currently in practice,

[00:16:30] what I would say to that is,

[00:16:32] well, that's a wonderful policy

[00:16:34] policy slash philosophical observation.

[00:16:38] But it seems irrelevant to me

[00:16:40] because what the statute says is the following.

[00:16:44] The terms cost sharing include deductibles,

[00:16:48] coinsurance, copayments, or similar charges.

[00:16:52] These are the cost sharing that have to be counted

[00:16:54] for purposes of a deductible

[00:16:56] at an out-of-pocket maximum under the law.

[00:16:59] And that's where the clause ends.

[00:17:02] The terms cost sharing include deductibles,

[00:17:05] coinsurance, copayments, or similar charges.

[00:17:08] That's it.

[00:17:09] It doesn't say unless a drug manufacturer

[00:17:12] is the source of the dollars.

[00:17:14] And, you know, talk about fairness.

[00:17:16] I mean, if we are to interpret that language

[00:17:19] to exclude manufacturer dollars

[00:17:22] that the patient uses to pay any of those charges,

[00:17:25] then the statute would have to be read the same way

[00:17:28] for any other third-party source.

[00:17:31] A father couldn't pay an adult child's cost sharing.

[00:17:36] A charity that doesn't get any money from a manufacturer

[00:17:39] couldn't pay the cost sharing for a patient.

[00:17:43] We're stuck with the language we have in front of us,

[00:17:46] and the language in front of us

[00:17:48] doesn't make a distinction about the third-party source.

[00:17:51] It simply says that the plan or the PBM

[00:17:54] is obligated to recognize cost sharing

[00:17:57] that includes deductibles, coinsurance, copayments,

[00:18:00] or similar charges.

[00:18:02] So I don't think the fairness question

[00:18:04] is the right question,

[00:18:05] but if we want to talk about fairness,

[00:18:07] what it would mean is the quite unfair result

[00:18:10] that no one could help that patient in need,

[00:18:13] and that can't be the right answer.

[00:18:15] And then the third thing that often gets brought up

[00:18:17] is that this whole skin in the game,

[00:18:20] where if somebody's deductible gets paid for them,

[00:18:23] then they wind up accessing the healthcare system

[00:18:26] and maybe in a way which is excessive

[00:18:31] because their deductible is paid,

[00:18:32] so they go get excessive medical treatment

[00:18:35] because they no longer have a deductible to pay.

[00:18:37] I agree.

[00:18:37] It gets raised all the time

[00:18:38] is this notion of skin in the game.

[00:18:41] That one makes my head explode

[00:18:44] because what I hear when I hear skin in the game is,

[00:18:48] oh yes, it's a medically necessary service,

[00:18:52] but we're hoping that by putting this barrier in place,

[00:18:56] we can convince people not to access

[00:18:59] the medically necessary care

[00:19:01] that they have been prescribed by their physician.

[00:19:04] And that is, if we want to use the word unfair,

[00:19:07] I think we could use the word unfair,

[00:19:09] but I'm just going to stick with unlawful on that one

[00:19:12] because that is a fundamental breach

[00:19:16] in the relationship that is supposed to exist

[00:19:19] between an insurance company,

[00:19:21] its agents, and an insured person.

[00:19:24] So those are the three things

[00:19:25] that plan sponsors bring up.

[00:19:27] Those do not resonate with me,

[00:19:29] unfortunately, at any level.

[00:19:31] There's this element of surprise

[00:19:33] which constantly exists here.

[00:19:36] And that is actually a big deal.

[00:19:39] That it would be one thing

[00:19:40] if the patients understood

[00:19:41] that this was how the plan operated.

[00:19:44] But it seems like very often

[00:19:46] when the patient shows up with their copay card,

[00:19:49] they are told that the copay card no longer works

[00:19:51] because the benefit has been maximized

[00:19:53] and that benefit has gone to the plan

[00:19:55] and they are now responsible

[00:19:56] to pay their deductible.

[00:19:58] Like there's shock at that point in time.

[00:20:00] Brian Reed said this as well.

[00:20:02] There feels like there's something wrong with that.

[00:20:03] I appreciate the comment that,

[00:20:05] you know, whatever one might think

[00:20:07] of issues one, two, and three,

[00:20:08] that we shouldn't have a situation

[00:20:11] where a patient shows up for care

[00:20:13] and they're hit with a bill

[00:20:15] that literally could be $10,000

[00:20:17] that they're expected to pay

[00:20:20] in order to access care.

[00:20:21] And this is why I believe

[00:20:24] that many of these programs

[00:20:26] are presented in a way

[00:20:29] which creates issues

[00:20:30] in terms of deceptive

[00:20:32] and unfair trade practice act liability.

[00:20:35] And I want to dig in on that for a sec,

[00:20:37] but I think the last point

[00:20:38] that you're making is just simply

[00:20:40] if this is, you know,

[00:20:42] there's a lot of hard questions

[00:20:44] that are being asked here.

[00:20:46] And I was talking to someone the other day

[00:20:47] who was basically saying

[00:20:48] the drug costs were so high

[00:20:49] that the employer laid off workers.

[00:20:52] You know what I mean?

[00:20:53] So like these are really difficult.

[00:20:57] I'm going to use the word trade-offs.

[00:20:59] It's this zero-sum game here

[00:21:01] that is at least how it's being played out

[00:21:04] right now.

[00:21:05] But the element of surprise

[00:21:08] is an overlying factor here.

[00:21:12] And you just connected the dots

[00:21:14] between deceptive practices,

[00:21:15] which I'm on the edge of my seat to hear.

[00:21:17] So maybe get into that a little bit

[00:21:19] that irrespective of like

[00:21:21] what someone's choosing to do here,

[00:21:23] if people get taken by surprise,

[00:21:25] that that's a thing in and of itself.

[00:21:28] Well, it certainly can be.

[00:21:29] Even when there is something

[00:21:31] that attempts to provide

[00:21:33] some level of disclosure

[00:21:34] about these programs,

[00:21:36] the word that sometimes is used

[00:21:38] to describe the program is a benefit.

[00:21:41] Well, I don't think that

[00:21:42] any average consumer

[00:21:44] would read that language

[00:21:45] and draw from that

[00:21:47] the parade of horribles

[00:21:49] that unfortunately

[00:21:49] they can subsequently experience.

[00:21:52] So yeah, I think that there are,

[00:21:55] in fact, some real legal issues

[00:21:57] that are presented here,

[00:21:58] not simply by the fact

[00:22:00] that these programs

[00:22:01] don't do what I think

[00:22:02] they have to do under the ACA,

[00:22:04] where the plan is subject

[00:22:06] to the ACA, of course,

[00:22:07] and honor these payments

[00:22:09] from both the deductible

[00:22:10] and an out-of-pocket

[00:22:11] maximum perspective.

[00:22:12] But separate and apart from that,

[00:22:15] just in terms of the obligation,

[00:22:17] obviously,

[00:22:18] not to deceptively induce a patient

[00:22:21] into carrying the insurance

[00:22:23] or staying with the insurance

[00:22:25] or making payments

[00:22:27] towards the insurance,

[00:22:29] that they think

[00:22:30] that they're getting

[00:22:31] a policy that allows them

[00:22:34] to use this coupon assistance,

[00:22:37] and they are not, in fact,

[00:22:39] getting an insurance

[00:22:40] that allows that to be the case.

[00:22:42] I think another important issue

[00:22:44] for employers to consider

[00:22:46] is whether they're potentially

[00:22:49] in violation of the ADA

[00:22:50] by implementing accumulator

[00:22:53] and maximizer programs.

[00:22:55] The ADA does apply

[00:22:57] to benefit designs

[00:22:59] employed by employers

[00:23:01] to the extent that

[00:23:03] the employer is taking

[00:23:06] particular benefit positions

[00:23:08] which reflect

[00:23:09] a disability-based distinction.

[00:23:12] So in a situation

[00:23:13] where a treatment

[00:23:15] or a procedure

[00:23:15] is used extensively

[00:23:17] or nearly exclusively

[00:23:19] to treat

[00:23:20] a particular disability,

[00:23:21] the negative creation

[00:23:24] or alteration

[00:23:25] of an existing benefit design

[00:23:27] can, in fact,

[00:23:28] be seen as a subterfuge

[00:23:30] to discriminate

[00:23:32] against disabled employees.

[00:23:35] And I have a real concern

[00:23:36] that that is exactly

[00:23:38] what's going on

[00:23:39] in at least

[00:23:40] a significant percentage

[00:23:42] of accumulator,

[00:23:44] maximizer benefit redesigns.

[00:23:47] They do focus

[00:23:49] on a high number

[00:23:51] of interventions,

[00:23:53] particularly drug interventions,

[00:23:54] that are very much

[00:23:56] associated with disabled status.

[00:23:58] So I think that's

[00:23:59] a really important issue

[00:24:00] for employers

[00:24:01] to consider

[00:24:02] in evaluating these programs.

[00:24:04] There are nuances here,

[00:24:05] obviously.

[00:24:06] I think in the states

[00:24:07] where accumulators

[00:24:08] have been banned,

[00:24:11] the specifics there,

[00:24:12] if the drug

[00:24:13] is the only drug

[00:24:15] that is available,

[00:24:17] then they're banned.

[00:24:18] But if it's a case

[00:24:20] where there's

[00:24:21] six competitors

[00:24:22] or there's a standard

[00:24:23] of care,

[00:24:24] then accumulators

[00:24:25] are okay.

[00:24:27] I also

[00:24:27] just kind of want

[00:24:28] to dip a toe

[00:24:29] into the fact

[00:24:30] that there are

[00:24:31] some drugs

[00:24:32] which are

[00:24:33] on a value

[00:24:34] formulary.

[00:24:35] You know,

[00:24:35] there are some plans

[00:24:36] that are really trying

[00:24:37] to create value

[00:24:38] formularies

[00:24:38] and they have determined

[00:24:40] that some drugs

[00:24:40] are not really of value

[00:24:42] and they're trying

[00:24:43] to not have people

[00:24:44] take those drugs

[00:24:45] and this is one

[00:24:46] of the means

[00:24:47] by which they

[00:24:47] are doing that.

[00:24:50] From my perspective,

[00:24:52] that sounds

[00:24:53] like a plan

[00:24:54] and a PBM

[00:24:55] that isn't doing

[00:24:56] what it is supposed

[00:24:57] to do.

[00:24:58] So if

[00:24:59] the actual

[00:25:01] concern

[00:25:01] is that

[00:25:03] they think

[00:25:03] that they can deliver

[00:25:04] the same therapy

[00:25:06] at a lower cost,

[00:25:08] that's what

[00:25:09] utilization

[00:25:09] management

[00:25:10] is for.

[00:25:11] Taking

[00:25:12] advantage

[00:25:12] of patients'

[00:25:14] lack of understanding

[00:25:15] about

[00:25:16] the position

[00:25:17] that the insurer

[00:25:18] is taking,

[00:25:19] I think,

[00:25:20] in disregard

[00:25:21] of the plain language

[00:25:22] of the federal

[00:25:23] statute,

[00:25:23] is not the means

[00:25:25] by which

[00:25:26] they should achieve

[00:25:27] that end

[00:25:28] or that they have

[00:25:29] to achieve

[00:25:29] that end.

[00:25:30] Plans

[00:25:30] and PBMs

[00:25:32] are expected

[00:25:32] to engage

[00:25:33] in utilization

[00:25:34] management.

[00:25:35] One of those

[00:25:36] elements

[00:25:37] of utilization

[00:25:38] management

[00:25:38] could be

[00:25:39] a step

[00:25:39] at it

[00:25:40] where

[00:25:40] if they

[00:25:41] believe

[00:25:41] that in fact

[00:25:42] one therapy

[00:25:43] is just

[00:25:44] as good

[00:25:44] as another

[00:25:45] and is

[00:25:45] lower cost

[00:25:46] to the plan,

[00:25:47] that they

[00:25:48] can in fact

[00:25:49] require

[00:25:50] that the patient

[00:25:51] fail first

[00:25:52] on that

[00:25:53] less expensive

[00:25:54] drug

[00:25:54] before migrating

[00:25:55] to the more

[00:25:56] expensive drug.

[00:25:57] But do

[00:25:58] your job

[00:25:59] plan,

[00:25:59] do your

[00:26:00] job

[00:26:00] PBM,

[00:26:01] don't victimize

[00:26:02] the patient

[00:26:02] as a response

[00:26:04] to your failure

[00:26:04] to do

[00:26:05] the thing

[00:26:05] that you're

[00:26:06] being paid

[00:26:07] to do?

[00:26:07] So if I

[00:26:09] wanted to

[00:26:09] get very

[00:26:10] cynical

[00:26:11] about this

[00:26:11] whole thing,

[00:26:12] if there

[00:26:13] is a plan

[00:26:14] who has

[00:26:15] a maximizer

[00:26:16] but not

[00:26:17] utilization

[00:26:17] management,

[00:26:19] it would

[00:26:19] make me

[00:26:19] very curious

[00:26:20] whether that

[00:26:21] maximizer

[00:26:22] was being

[00:26:22] paid a

[00:26:23] spread

[00:26:23] because

[00:26:24] and what

[00:26:25] being paid

[00:26:26] a spread

[00:26:26] is that

[00:26:27] that maximizer

[00:26:28] gets some

[00:26:28] percentage

[00:26:29] of the

[00:26:30] savings

[00:26:30] or the

[00:26:31] cost of

[00:26:32] the drug.

[00:26:32] Because if you

[00:26:33] think about it

[00:26:33] that way,

[00:26:34] it would be

[00:26:34] very profitable

[00:26:35] for that

[00:26:35] maximizer

[00:26:36] to not have

[00:26:37] any utilization

[00:26:38] management,

[00:26:38] right?

[00:26:38] Like let the

[00:26:39] patient get

[00:26:39] prescribed the

[00:26:40] really expensive

[00:26:41] drug,

[00:26:42] take the

[00:26:44] available

[00:26:45] pharma dollars,

[00:26:46] right?

[00:26:46] Like I can

[00:26:47] get them.

[00:26:47] I mean,

[00:26:48] some of it

[00:26:48] goes to the

[00:26:49] plan,

[00:26:49] but some of

[00:26:49] it also

[00:26:50] goes to

[00:26:50] the maximizer.

[00:26:51] Now I have

[00:26:52] a whole lot

[00:26:52] of money.

[00:26:52] I mean,

[00:26:53] patients still

[00:26:53] going to wind

[00:26:54] up not having

[00:26:55] a script

[00:26:55] in May or

[00:26:56] June,

[00:26:56] but the

[00:26:57] maximizer

[00:26:57] got a lot

[00:26:58] of money

[00:26:58] before that.

[00:27:00] I know

[00:27:00] you know

[00:27:01] because you

[00:27:02] have devoted

[00:27:03] your podcast

[00:27:04] to this

[00:27:05] subject over

[00:27:05] and over

[00:27:05] again.

[00:27:06] We have

[00:27:07] incredibly

[00:27:08] perverse

[00:27:08] incentives

[00:27:09] that manifest

[00:27:10] themselves

[00:27:11] throughout

[00:27:11] the system.

[00:27:12] You know,

[00:27:13] part of what

[00:27:14] I see

[00:27:15] as

[00:27:16] particularly

[00:27:16] objectionable

[00:27:17] about

[00:27:18] accumulator

[00:27:19] and maximizer

[00:27:19] programs

[00:27:20] is the way

[00:27:21] that it

[00:27:21] interplays

[00:27:22] with some

[00:27:23] of the other

[00:27:24] perverse

[00:27:24] incentives

[00:27:25] that you're

[00:27:25] talking about.

[00:27:26] You know,

[00:27:26] if you have

[00:27:26] a drug

[00:27:28] with a given

[00:27:29] list price,

[00:27:30] it's already

[00:27:31] providing a

[00:27:32] 50% rebate

[00:27:34] to that plan.

[00:27:35] The plan

[00:27:36] then imposes

[00:27:37] a 40%

[00:27:39] coinsurance

[00:27:40] on the

[00:27:41] patient.

[00:27:42] We start

[00:27:43] with $1,000

[00:27:44] post-rebate,

[00:27:46] a $500

[00:27:47] drug,

[00:27:48] 40%

[00:27:48] of the list

[00:27:49] price,

[00:27:50] the patient

[00:27:51] pays $400.

[00:27:52] Ridiculous.

[00:27:53] The patient

[00:27:54] is paying

[00:27:54] 80%

[00:27:55] of the

[00:27:56] total

[00:27:56] actual

[00:27:57] cost

[00:27:57] of the

[00:27:58] product.

[00:27:58] And then

[00:27:58] they're

[00:27:59] being

[00:27:59] lied to

[00:28:00] on top

[00:28:00] of that,

[00:28:01] being told

[00:28:02] that,

[00:28:02] oh,

[00:28:02] you're only

[00:28:03] paying 40%.

[00:28:04] What they

[00:28:04] don't realize

[00:28:05] is they're

[00:28:05] paying 40%

[00:28:06] of a

[00:28:06] made-up

[00:28:07] number

[00:28:07] that doesn't

[00:28:08] apply.

[00:28:09] You can

[00:28:09] definitely

[00:28:10] see why

[00:28:11] over half

[00:28:12] of Americans

[00:28:13] with commercial

[00:28:14] insurance

[00:28:14] right now

[00:28:15] are considered

[00:28:15] functionally

[00:28:16] uninsured,

[00:28:16] that they're

[00:28:17] paying all

[00:28:17] this money

[00:28:18] for insurance

[00:28:19] that they

[00:28:19] then can't

[00:28:19] afford

[00:28:20] to use.

[00:28:21] What I'm

[00:28:22] hearing you,

[00:28:22] and again,

[00:28:23] I really want

[00:28:24] to emphasize

[00:28:24] to listeners

[00:28:25] is that you

[00:28:26] have plan

[00:28:26] sponsors who

[00:28:27] are trying

[00:28:27] to figure

[00:28:28] out how

[00:28:28] to solve

[00:28:28] for these

[00:28:29] rapidly

[00:28:30] escalating

[00:28:30] pharma costs.

[00:28:32] But I think

[00:28:32] the point

[00:28:33] that you're

[00:28:33] making is

[00:28:33] there's

[00:28:34] different ways

[00:28:34] to do

[00:28:35] that and

[00:28:35] doing it

[00:28:36] in such

[00:28:37] a way

[00:28:38] where either

[00:28:39] the patient's

[00:28:39] caught in

[00:28:40] the middle

[00:28:40] or the

[00:28:41] patient's

[00:28:41] caught by

[00:28:41] surprise

[00:28:42] is maybe

[00:28:44] not as

[00:28:44] palatable

[00:28:46] or legal.

[00:28:47] I don't

[00:28:47] think it's

[00:28:48] either palatable

[00:28:49] or legal

[00:28:49] from my

[00:28:50] perspective.

[00:28:51] Look,

[00:28:51] we are

[00:28:52] on the

[00:28:53] verge

[00:28:53] of

[00:28:54] a

[00:28:55] premium

[00:28:56] explosion.

[00:28:56] That's

[00:28:57] just the

[00:28:58] reality

[00:28:58] of the

[00:28:58] situation.

[00:28:59] That is

[00:29:00] not

[00:29:00] just a

[00:29:01] function

[00:29:02] of

[00:29:02] pharmaceutical

[00:29:02] prices.

[00:29:03] It would

[00:29:04] be lovely

[00:29:04] if we

[00:29:05] could just

[00:29:05] point our

[00:29:06] finger

[00:29:06] in one

[00:29:07] very

[00:29:08] specific

[00:29:09] direction

[00:29:09] and magically

[00:29:10] poof,

[00:29:11] the problem

[00:29:12] could go

[00:29:12] away

[00:29:13] without

[00:29:13] having to

[00:29:14] face

[00:29:14] the

[00:29:15] harsher

[00:29:15] realities.

[00:29:16] But that

[00:29:17] is,

[00:29:17] I think,

[00:29:18] completely

[00:29:18] inconsistent

[00:29:19] with the

[00:29:20] actual

[00:29:20] data out

[00:29:21] there.

[00:29:21] That's

[00:29:22] definitely

[00:29:22] pretty

[00:29:23] clear.

[00:29:23] Most

[00:29:23] self-insured

[00:29:25] employers

[00:29:25] who look

[00:29:25] through

[00:29:25] their

[00:29:26] data

[00:29:26] will

[00:29:26] discover

[00:29:27] like

[00:29:28] Marilyn

[00:29:28] Bartlett

[00:29:29] from

[00:29:29] Montana,

[00:29:30] 48%

[00:29:30] of her

[00:29:31] spend

[00:29:32] was

[00:29:32] acute

[00:29:32] hospitals.

[00:29:33] I've

[00:29:34] heard

[00:29:34] as high

[00:29:34] as

[00:29:35] 56%

[00:29:35] are

[00:29:36] not

[00:29:36] just

[00:29:37] acute

[00:29:37] hospitals

[00:29:37] but

[00:29:37] hospital

[00:29:38] care.

[00:29:39] So

[00:29:39] hospital

[00:29:40] care

[00:29:40] is

[00:29:41] generally

[00:29:41] speaking,

[00:29:42] I don't

[00:29:42] think I've

[00:29:43] ever

[00:29:43] encountered

[00:29:43] a plan

[00:29:44] sponsor

[00:29:44] who didn't

[00:29:44] say that

[00:29:45] dollars

[00:29:45] going to

[00:29:45] hospitals

[00:29:46] was their

[00:29:46] biggest

[00:29:47] category

[00:29:47] of spend

[00:29:48] but not

[00:29:49] rising as

[00:29:49] fast as

[00:29:50] pharmaceutical

[00:29:51] trend.

[00:29:52] I was

[00:29:52] talking to

[00:29:53] someone the

[00:29:53] other day

[00:29:53] whose

[00:29:54] pharma

[00:29:54] spend

[00:29:54] doubled

[00:29:55] in the

[00:29:55] past

[00:29:55] five

[00:29:55] years.

[00:29:56] So

[00:29:56] not

[00:29:57] not

[00:29:57] necessarily

[00:29:58] how

[00:29:58] much

[00:29:58] of

[00:29:58] that

[00:29:58] money

[00:29:59] is

[00:29:59] making

[00:29:59] its

[00:29:59] way

[00:29:59] back

[00:30:00] to

[00:30:00] pharma

[00:30:00] but

[00:30:01] just

[00:30:01] the

[00:30:01] trend

[00:30:02] for

[00:30:02] self

[00:30:02] insured

[00:30:03] employer

[00:30:03] the

[00:30:04] pharma

[00:30:04] trend

[00:30:05] is

[00:30:05] quite

[00:30:05] high

[00:30:06] which

[00:30:06] is

[00:30:06] obviously

[00:30:06] of

[00:30:07] a

[00:30:07] concern.

[00:30:07] Now

[00:30:08] it's

[00:30:08] still

[00:30:08] 25%

[00:30:09] 23%

[00:30:10] of

[00:30:10] overall

[00:30:11] plan

[00:30:12] spend

[00:30:12] a lot

[00:30:12] of

[00:30:12] times

[00:30:13] whereas

[00:30:13] hospitals

[00:30:14] are

[00:30:14] 50%

[00:30:16] let's

[00:30:16] just

[00:30:16] say

[00:30:16] so

[00:30:17] obviously

[00:30:18] hospitals

[00:30:18] are

[00:30:19] the

[00:30:19] highest

[00:30:20] category

[00:30:20] here

[00:30:21] but

[00:30:21] if

[00:30:21] you're

[00:30:21] just

[00:30:21] talking

[00:30:21] about

[00:30:22] trend

[00:30:22] that

[00:30:22] that's

[00:30:23] why

[00:30:23] some

[00:30:24] employers

[00:30:24] are

[00:30:24] super

[00:30:24] concerned.

[00:30:25] I

[00:30:25] totally

[00:30:26] get

[00:30:26] that.

[00:30:26] I

[00:30:26] would

[00:30:27] say

[00:30:27] from

[00:30:27] my

[00:30:27] perspective

[00:30:28] even

[00:30:28] if

[00:30:29] you

[00:30:29] look

[00:30:29] at

[00:30:29] this

[00:30:30] at

[00:30:30] the

[00:30:30] drug

[00:30:31] spend

[00:30:31] in

[00:30:32] many

[00:30:32] cases

[00:30:32] you're

[00:30:33] often

[00:30:33] looking

[00:30:33] at

[00:30:34] spend

[00:30:35] that

[00:30:35] is

[00:30:35] in

[00:30:36] fact

[00:30:36] influenced

[00:30:36] by

[00:30:37] hospital

[00:30:37] charges

[00:30:38] hospitals

[00:30:39] not

[00:30:39] insignificantly

[00:30:41] because

[00:30:41] of

[00:30:41] 340B

[00:30:42] but

[00:30:42] certainly

[00:30:43] in

[00:30:43] part

[00:30:43] because

[00:30:44] of

[00:30:44] 340B

[00:30:44] are

[00:30:45] making

[00:30:46] tremendous

[00:30:47] inroads

[00:30:48] into

[00:30:48] the

[00:30:49] specialty

[00:30:49] pharmacy

[00:30:50] marketplace

[00:30:51] and

[00:30:52] are

[00:30:52] among

[00:30:53] other

[00:30:54] third

[00:30:54] parties

[00:30:55] involved

[00:30:55] the

[00:30:55] PBMs

[00:30:56] as well

[00:30:57] as a

[00:30:58] significant

[00:30:58] issue

[00:30:58] contributing

[00:30:59] to that

[00:31:00] spend

[00:31:00] so

[00:31:01] even

[00:31:01] if

[00:31:01] we

[00:31:01] focus

[00:31:02] and

[00:31:02] you're

[00:31:02] right

[00:31:03] to

[00:31:03] get

[00:31:03] us

[00:31:03] to

[00:31:03] focus

[00:31:04] on

[00:31:04] the

[00:31:05] drug

[00:31:05] specific

[00:31:06] spend

[00:31:06] as

[00:31:07] you're

[00:31:07] indicating

[00:31:08] that's

[00:31:09] a

[00:31:09] multifaceted

[00:31:10] component

[00:31:10] with

[00:31:11] multiple

[00:31:11] players

[00:31:12] who

[00:31:12] are

[00:31:12] contributing

[00:31:13] to

[00:31:13] those

[00:31:13] costs

[00:31:14] totally

[00:31:15] understood

[00:31:15] so

[00:31:15] let's

[00:31:15] get

[00:31:16] to

[00:31:16] the

[00:31:16] advice

[00:31:16] portion

[00:31:17] of

[00:31:17] this

[00:31:17] conversation

[00:31:18] again

[00:31:19] we've

[00:31:20] got

[00:31:20] rock

[00:31:20] hard

[00:31:20] place

[00:31:21] going

[00:31:22] on

[00:31:22] here

[00:31:22] but

[00:31:23] there's

[00:31:23] probably

[00:31:24] better

[00:31:25] or worse

[00:31:25] ways

[00:31:26] to do

[00:31:26] many

[00:31:27] things

[00:31:27] and

[00:31:28] managing

[00:31:28] pharma

[00:31:29] trend

[00:31:29] is

[00:31:30] certainly

[00:31:30] one

[00:31:30] of

[00:31:30] them

[00:31:31] so

[00:31:31] if

[00:31:31] I'm

[00:31:32] going

[00:31:32] to

[00:31:32] distill

[00:31:32] this

[00:31:33] conversation

[00:31:34] down

[00:31:34] into

[00:31:34] some

[00:31:34] pieces

[00:31:35] of

[00:31:35] advice

[00:31:35] that

[00:31:36] I'm

[00:31:36] hearing

[00:31:36] you

[00:31:36] say

[00:31:37] one

[00:31:37] of

[00:31:37] them

[00:31:38] is

[00:31:38] can't

[00:31:39] have

[00:31:39] this

[00:31:39] element

[00:31:39] of

[00:31:40] surprise

[00:31:40] right

[00:31:40] like

[00:31:41] that's

[00:31:41] not

[00:31:41] fair

[00:31:42] to

[00:31:42] have

[00:31:42] people

[00:31:43] who

[00:31:43] have

[00:31:44] to

[00:31:44] get

[00:31:44] sick

[00:31:45] and

[00:31:45] be

[00:31:45] standing

[00:31:45] at

[00:31:45] a

[00:31:46] pharmacy

[00:31:46] counter

[00:31:46] or

[00:31:47] waiting

[00:31:48] to get

[00:31:48] their

[00:31:48] infusion

[00:31:49] it

[00:31:49] can't

[00:31:49] be

[00:31:49] in

[00:31:50] that

[00:31:50] moment

[00:31:50] where

[00:31:51] they

[00:31:51] figure

[00:31:51] out

[00:31:51] that

[00:31:52] they

[00:31:52] actually

[00:31:52] don't

[00:31:53] have

[00:31:53] coverage

[00:31:53] for

[00:31:54] a

[00:31:54] treatment

[00:31:54] right

[00:31:54] so

[00:31:55] there

[00:31:55] has

[00:31:55] to

[00:31:55] be

[00:31:55] something

[00:31:56] that

[00:31:57] is

[00:31:57] done

[00:31:57] so

[00:31:58] that

[00:31:58] the

[00:31:58] benefits

[00:31:59] you

[00:32:00] know

[00:32:00] if

[00:32:00] a

[00:32:00] plan

[00:32:24] be

[00:32:24] covered

[00:32:24] by

[00:32:25] state

[00:32:26] and

[00:32:26] federal

[00:32:26] laws

[00:32:27] that

[00:32:27] create

[00:32:28] liability

[00:32:28] for

[00:32:29] unfair

[00:32:29] and

[00:32:29] deceptive

[00:32:30] trade

[00:32:30] practices

[00:32:31] which

[00:32:32] can

[00:32:32] include

[00:32:32] communications

[00:32:33] in the

[00:32:34] context

[00:32:34] of

[00:32:34] insurance

[00:32:35] in

[00:32:35] at

[00:32:36] least

[00:32:36] some

[00:32:36] instances

[00:32:36] so

[00:32:37] yes

[00:32:37] I

[00:32:38] certainly

[00:32:38] think

[00:32:38] that

[00:32:39] a

[00:32:39] good

[00:32:39] step

[00:32:40] would

[00:32:40] be

[00:32:40] to

[00:32:41] at

[00:32:41] least

[00:32:42] rub

[00:32:42] our

[00:32:43] poor

[00:32:43] patients

[00:32:44] nose

[00:32:44] in

[00:32:54] the

[00:32:54] form

[00:32:54] of

[00:32:54] both

[00:32:55] deductibles

[00:32:55] and

[00:32:56] out

[00:32:56] of

[00:32:56] pocket

[00:32:56] maximums

[00:32:57] so

[00:32:57] number

[00:32:58] one

[00:32:58] be

[00:32:59] upfront

[00:32:59] about

[00:32:59] it

[00:33:00] so

[00:33:00] you're

[00:33:00] not

[00:33:00] taking

[00:33:00] people

[00:33:01] by

[00:33:01] surprise

[00:33:01] and

[00:33:01] they

[00:33:01] do

[00:33:02] understand

[00:33:02] what

[00:33:03] benefits

[00:33:03] they

[00:33:03] actually

[00:33:04] have

[00:33:04] that's

[00:33:05] only

[00:33:05] fair

[00:33:05] the

[00:33:06] second

[00:33:06] thing

[00:33:07] if

[00:33:07] you

[00:33:07] don't

[00:33:08] so

[00:33:08] maybe

[00:33:08] this

[00:33:08] is

[00:33:09] part

[00:33:09] B

[00:33:09] of

[00:33:09] the

[00:33:10] first

[00:33:10] one

[00:33:10] if

[00:33:10] you

[00:33:11] don't

[00:33:11] there's

[00:33:12] some

[00:33:12] legal

[00:33:12] risk

[00:33:13] there

[00:33:13] right

[00:33:14] because

[00:33:14] it

[00:33:14] could

[00:33:14] be

[00:33:15] deemed

[00:33:16] deceptive

[00:33:16] especially

[00:33:16] if

[00:33:17] a

[00:33:17] maximizer

[00:33:18] or

[00:33:18] whatever

[00:33:18] is

[00:33:18] teed

[00:33:19] up

[00:33:19] as

[00:33:19] a

[00:33:19] benefit

[00:33:19] which

[00:33:20] I

[00:33:20] definitely

[00:33:20] have

[00:33:20] seen

[00:33:21] in

[00:33:21] some

[00:33:21] cases

[00:33:21] yeah

[00:33:22] I

[00:33:22] mean

[00:33:22] I

[00:33:23] think

[00:33:23] we're

[00:33:23] headed

[00:33:23] to

[00:33:24] some

[00:33:24] pretty

[00:33:24] serious

[00:33:25] litigation

[00:33:26] here

[00:33:26] I

[00:33:26] mean

[00:33:27] I

[00:33:27] think

[00:33:27] we're

[00:33:27] in

[00:33:27] a

[00:33:27] holding

[00:33:28] pattern

[00:33:28] where

[00:33:29] obviously

[00:33:30] we had

[00:33:30] one

[00:33:31] district

[00:33:31] court

[00:33:31] ruling

[00:33:32] that

[00:33:32] focused

[00:33:33] not

[00:33:33] on

[00:33:33] the

[00:33:33] statute

[00:33:34] but

[00:33:34] instead

[00:33:34] on

[00:33:35] the

[00:33:35] regulation

[00:33:35] we

[00:33:36] have

[00:33:37] HHS

[00:33:38] declaring

[00:33:38] that

[00:33:39] it's

[00:33:39] not

[00:33:39] going

[00:33:40] to

[00:33:40] enforce

[00:33:40] that

[00:33:41] policy

[00:33:41] as a

[00:33:42] matter

[00:33:42] of

[00:33:42] federal

[00:33:42] law

[00:33:43] we

[00:33:43] have

[00:33:43] some

[00:33:44] state

[00:33:44] insurance

[00:33:45] commissioners

[00:33:45] who

[00:33:46] have

[00:33:46] said

[00:33:46] well

[00:33:46] that's

[00:33:47] great

[00:33:47] that

[00:33:47] you're

[00:33:47] not

[00:33:47] but

[00:33:48] I

[00:33:48] am

[00:33:48] and

[00:33:49] at

[00:33:50] some

[00:33:50] point

[00:33:50] in

[00:33:50] the

[00:33:50] new

[00:33:50] administration

[00:33:51] probably

[00:33:52] not

[00:33:52] that

[00:33:52] far

[00:33:53] into

[00:33:53] the

[00:33:53] new

[00:33:53] administration

[00:34:15] we're

[00:34:15] that's

[00:34:16] I

[00:34:16] think

[00:34:16] where

[00:34:17] we're

[00:34:17] headed

[00:34:17] and

[00:34:18] specifically

[00:34:18] around

[00:34:19] this

[00:34:19] like

[00:34:19] maximizer

[00:34:20] slash

[00:34:20] accumulator

[00:34:21] type

[00:34:21] activity

[00:34:22] litigation

[00:34:23] yes

[00:34:24] I

[00:34:24] think

[00:34:24] so

[00:34:24] what

[00:34:25] was

[00:34:25] the

[00:34:25] one

[00:34:25] case

[00:34:25] that

[00:34:26] you

[00:34:26] had

[00:34:26] mentioned

[00:34:27] you said

[00:34:27] that

[00:34:27] there

[00:34:27] was

[00:34:27] a

[00:34:27] case

[00:34:28] yes

[00:34:28] it

[00:34:28] was

[00:34:29] brought

[00:34:29] by

[00:34:29] three

[00:34:30] patient

[00:34:31] advocacy

[00:34:31] organizations

[00:34:32] and

[00:34:33] three

[00:34:33] patients

[00:34:34] against

[00:34:35] the

[00:34:35] Department

[00:34:35] of

[00:34:36] Health

[00:34:36] and

[00:34:36] Human

[00:34:36] Services

[00:34:37] in

[00:34:38] the

[00:34:38] U.S.

[00:34:38] District

[00:34:39] Court

[00:34:39] for

[00:34:40] the

[00:34:40] District

[00:34:40] of

[00:34:40] Columbia

[00:34:41] it

[00:34:42] basically

[00:34:42] struck

[00:34:43] down

[00:34:43] HHS's

[00:34:45] rule

[00:34:46] which

[00:34:47] said

[00:34:47] that

[00:34:48] its

[00:34:49] regulation

[00:34:50] could be

[00:34:51] interpreted

[00:34:51] as both

[00:34:52] permitting

[00:34:53] ACA

[00:34:54] covered

[00:34:54] plans

[00:34:55] to

[00:34:56] count

[00:34:56] these

[00:34:57] amounts

[00:34:58] towards

[00:34:58] the

[00:34:59] out-of-pocket

[00:34:59] maximum

[00:35:00] and deductibles

[00:35:01] and that

[00:35:02] it also

[00:35:02] permitted

[00:35:03] the same

[00:35:04] insurers

[00:35:04] not to

[00:35:05] count

[00:35:05] the same

[00:35:06] amounts

[00:35:06] towards

[00:35:07] deductibles

[00:35:08] and

[00:35:09] out-of-pocket

[00:35:09] maximums

[00:35:10] and

[00:35:10] what

[00:35:10] Judge

[00:35:10] Bates

[00:35:11] said

[00:35:11] was

[00:35:12] well

[00:35:12] that's

[00:35:12] kind

[00:35:13] of

[00:35:13] the

[00:35:13] definition

[00:35:13] of

[00:35:14] arbitrary

[00:35:14] and

[00:35:14] capricious

[00:35:15] government

[00:35:15] action

[00:35:16] you

[00:35:16] can't

[00:35:16] say

[00:35:17] that

[00:35:17] the

[00:35:18] same

[00:35:18] regulation

[00:35:18] means

[00:35:19] two

[00:35:19] different

[00:35:20] things

[00:35:20] at

[00:35:20] the

[00:35:20] same

[00:35:21] time

[00:35:21] so

[00:35:22] he

[00:35:22] struck

[00:35:23] down

[00:35:23] that

[00:35:23] regulation

[00:35:24] that

[00:35:24] reinstituted

[00:35:25] a prior

[00:35:26] regulation

[00:35:26] and

[00:35:26] that

[00:35:27] regulation

[00:35:27] says

[00:35:28] that

[00:35:28] you

[00:35:29] in

[00:35:29] fact

[00:35:29] have

[00:35:30] to

[00:35:30] honor

[00:35:30] those

[00:35:31] payments

[00:35:31] so

[00:35:32] long

[00:35:33] as

[00:35:33] the

[00:35:33] coupon

[00:35:34] is

[00:35:34] not

[00:35:34] used

[00:35:35] on

[00:35:35] a

[00:35:35] drug

[00:35:36] for

[00:35:36] which

[00:35:36] there

[00:35:36] is

[00:35:37] a

[00:35:37] generic

[00:35:37] equivalent

[00:35:38] which

[00:35:38] is

[00:35:38] kind

[00:36:03] because

[00:36:03] I

[00:36:03] do

[00:36:04] get

[00:36:04] the

[00:36:04] feeling

[00:36:04] that

[00:36:04] there

[00:36:04] are

[00:36:05] a

[00:36:05] number

[00:36:05] of

[00:36:05] plan

[00:36:05] sponsors

[00:36:05] who

[00:36:06] are

[00:36:06] wholly

[00:36:06] unaware

[00:36:06] that

[00:36:07] this

[00:36:07] is

[00:36:07] going

[00:36:07] on

[00:36:08] yeah

[00:36:08] I

[00:36:08] mean

[00:36:08] my

[00:36:09] other

[00:36:09] two

[00:36:09] pieces

[00:36:09] of

[00:36:10] advice

[00:36:10] I

[00:36:10] suppose

[00:36:10] would

[00:36:11] be

[00:36:11] that

[00:36:11] if

[00:36:12] you

[00:36:32] are

[00:36:33] not

[00:36:33] a

[00:36:33] means

[00:36:34] to

[00:36:34] affect

[00:36:35] utilization

[00:36:36] management

[00:36:36] there

[00:36:37] is

[00:36:37] a

[00:36:37] tool

[00:36:38] belt

[00:36:38] use

[00:36:38] the

[00:36:39] tool

[00:36:39] belt

[00:36:39] I

[00:36:40] think

[00:36:40] the

[00:36:40] other

[00:36:40] observation

[00:36:41] that

[00:36:41] I

[00:36:41] would

[00:36:41] make

[00:36:42] is

[00:36:42] that

[00:36:43] this

[00:36:43] particular

[00:36:44] issue

[00:36:45] fits

[00:36:46] into

[00:36:46] the

[00:36:47] wider

[00:36:48] question

[00:36:48] of

[00:36:49] unraveling

[00:36:50] the

[00:36:50] perverse

[00:36:51] incentives

[00:36:51] that seem

[00:36:52] to dominate

[00:36:53] this

[00:36:53] space

[00:36:54] there

[00:36:54] are

[00:36:55] at

[00:36:55] least

[00:36:55] some

[00:36:56] emerging

[00:36:56] options

[00:36:57] out

[00:36:57] there

[00:36:58] that

[00:36:58] are

[00:36:59] focused

[00:37:00] on

[00:37:00] net

[00:37:00] pricing

[00:37:01] as

[00:37:02] a

[00:37:02] way

[00:37:02] to

[00:37:02] structure

[00:37:03] healthcare

[00:37:03] services

[00:37:04] and

[00:37:05] part

[00:37:06] of

[00:37:06] the

[00:37:06] problem

[00:37:07] here

[00:37:07] from

[00:37:07] the

[00:37:08] patient

[00:37:08] perspective

[00:37:08] is

[00:37:09] their

[00:37:10] coinsurance

[00:37:10] is a

[00:37:11] percentage

[00:37:12] of a

[00:37:12] made-up

[00:37:13] number

[00:37:13] a

[00:37:14] list

[00:37:14] price

[00:37:14] that

[00:37:15] your

[00:37:15] plan

[00:37:16] is

[00:37:16] not

[00:37:16] paying

[00:37:17] your

[00:37:17] PBM

[00:37:18] is

[00:37:18] not

[00:37:18] paying

[00:37:19] and

[00:37:20] if

[00:37:20] we

[00:37:20] could

[00:37:21] get

[00:37:21] to

[00:37:21] a

[00:37:21] place

[00:37:22] where

[00:37:23] people

[00:37:23] are

[00:37:24] actually

[00:37:24] being

[00:37:25] charged

[00:37:25] a

[00:37:26] percentage

[00:37:26] of a

[00:37:27] real

[00:37:27] number

[00:37:28] that

[00:37:29] would

[00:37:29] go

[00:37:29] a

[00:37:29] long

[00:37:29] way

[00:37:30] towards

[00:37:30] making

[00:37:31] all

[00:37:32] services

[00:37:32] not

[00:37:32] just

[00:37:33] specialty

[00:37:33] drugs

[00:37:34] but

[00:37:34] all

[00:37:34] services

[00:37:35] more

[00:37:35] affordable

[00:37:36] and

[00:37:36] a

[00:37:37] big

[00:37:37] point

[00:37:37] that

[00:37:38] you're

[00:37:38] making

[00:37:38] there

[00:37:38] is

[00:37:38] still

[00:37:39] you

[00:37:39] have

[00:37:39] patients

[00:37:40] who

[00:37:40] are

[00:37:40] paying

[00:37:40] coinsurance

[00:37:41] and

[00:37:42] this

[00:37:42] is

[00:37:42] true

[00:37:43] across

[00:37:43] the

[00:37:43] board

[00:37:43] they're

[00:37:44] paying

[00:37:44] coinsurance

[00:37:45] based

[00:37:45] on

[00:37:45] the

[00:37:46] list

[00:37:46] price

[00:37:46] which

[00:37:47] is

[00:37:47] artificially

[00:37:48] inflated

[00:37:48] because

[00:37:48] everybody

[00:37:58] more

[00:37:58] than

[00:37:58] the

[00:37:59] cost

[00:37:59] of

[00:37:59] the

[00:37:59] drug

[00:37:59] because

[00:38:00] the

[00:38:00] list

[00:38:00] price

[00:38:00] is

[00:38:01] so

[00:38:01] high

[00:38:01] so

[00:38:02] yeah

[00:38:03] I mean

[00:38:03] indeed

[00:38:04] if

[00:38:04] there

[00:38:05] is

[00:38:05] a

[00:38:05] way

[00:38:05] that

[00:38:06] the

[00:38:06] patients

[00:38:07] aren't

[00:38:07] being

[00:38:07] subjected

[00:38:08] to

[00:38:08] these

[00:38:08] artificially

[00:38:09] high

[00:38:09] list

[00:38:10] prices

[00:38:10] and

[00:38:11] yeah

[00:38:12] butting

[00:38:13] up

[00:38:13] against

[00:38:14] the

[00:38:14] whole

[00:38:14] plan

[00:38:15] sponsors

[00:38:15] are

[00:38:15] addicted

[00:38:16] to

[00:38:16] rebates

[00:38:16] again

[00:38:17] because

[00:38:18] they

[00:38:18] enable

[00:38:19] lower

[00:38:20] premiums

[00:38:21] at

[00:38:22] least

[00:38:22] that's

[00:38:23] the

[00:38:23] way

[00:38:23] they're

[00:38:23] presented

[00:38:23] you

[00:38:24] know

[00:38:24] a

[00:38:24] rebate

[00:38:25] guarantee

[00:38:25] may

[00:38:25] or

[00:38:26] may

[00:38:26] not

[00:38:26] actually

[00:38:26] be

[00:38:27] leading

[00:38:27] to

[00:38:27] lower

[00:38:28] prices

[00:38:28] and

[00:38:29] because

[00:38:30] you

[00:38:30] as

[00:38:31] the

[00:38:31] sponsor

[00:38:31] don't

[00:38:32] actually

[00:38:32] know

[00:38:32] what

[00:38:32] the

[00:38:33] net

[00:38:33] prices

[00:38:33] are

[00:38:33] underneath

[00:38:34] it

[00:38:34] you

[00:38:34] don't

[00:38:35] actually

[00:38:35] know

[00:38:35] whether

[00:38:36] it's

[00:38:36] leading

[00:38:36] to

[00:38:37] lower

[00:38:37] prices

[00:38:37] or

[00:38:37] not

[00:38:38] listen

[00:38:38] to

[00:38:39] the

[00:38:39] show

[00:38:39] with

[00:38:39] Scott

[00:38:40] Haas

[00:38:40] for

[00:38:40] a

[00:38:41] very

[00:38:42] eloquent

[00:38:42] breakdown

[00:38:43] of

[00:38:43] exactly

[00:38:43] what

[00:38:44] you're

[00:38:44] talking

[00:38:44] about

[00:38:45] there

[00:38:45] and

[00:38:45] the

[00:38:46] one

[00:38:46] with

[00:38:46] Paul

[00:38:46] Holmes

[00:38:46] where

[00:38:47] he

[00:38:47] gets

[00:38:47] into

[00:38:47] like

[00:38:48] what

[00:38:48] is

[00:38:48] rebate

[00:38:48] actually

[00:38:49] whoever

[00:38:50] gets

[00:38:50] to

[00:38:50] define

[00:38:50] the

[00:38:50] rebate

[00:38:51] gets

[00:38:51] to

[00:38:51] determine

[00:38:51] exactly

[00:38:52] how

[00:38:52] much

[00:38:52] money

[00:38:53] winds

[00:38:53] up

[00:38:53] in

[00:38:53] the

[00:38:53] plan

[00:38:53] sponsors

[00:38:54] pocket

[00:38:54] and

[00:38:54] that

[00:38:55] is

[00:38:55] yeah

[00:38:55] the

[00:38:56] PBM

[00:38:56] so

[00:38:57] there's

[00:38:58] just

[00:38:58] so many

[00:38:58] so

[00:38:59] much

[00:38:59] it's

[00:39:00] a

[00:39:00] fracas

[00:39:00] it's

[00:39:01] a lot

[00:39:02] of

[00:39:02] perverse

[00:39:02] incentives

[00:39:03] is

[00:39:03] what

[00:39:03] it

[00:39:03] is

[00:39:04] indeed

[00:39:04] Bill

[00:39:05] Sorrell

[00:39:13] let me

[00:39:14] just

[00:39:14] say

[00:39:15] your

[00:39:15] whole

[00:39:15] retirement

[00:39:16] game

[00:39:17] not

[00:39:18] strong

[00:39:18] yeah

[00:39:19] no

[00:39:20] I'm

[00:39:20] failing

[00:39:20] retirement

[00:39:21] that's

[00:39:21] that's

[00:39:22] quite

[00:39:22] clear

[00:39:22] Bill

[00:39:23] Sorrell

[00:39:24] thank

[00:39:42] a

[00:39:43] small

[00:39:43] for

[00:39:45] listening