Bryce Platt | The New Frontier

(upbeat music) - Hello everybody and welcome to the Next Frontier podcast with Kevin and Jared. And today we have another great and special guest. His name is Bryce Platt. Bryce, welcome to the show. - Thanks for having me guys. - Now always good to see you, buddy. I think the audience is gonna be really excited and we've got so many nerds that watch us that we're going to be even more excited to go into real details of what medical costs are and how they changed the pharmacy kind of landscape today and really into the future, what we're gonna end up doing. So let's start off with the usual one, but just tell us a little bit more about kind of you and what you do. And then most importantly, like what do you do as a consultant pharmacist at Millman? Like what is that role and how did you get it? - Sure. So pharmacist, licensed pharmacist in North Carolina, went to school in University of Kansas. I ended up moving to North Carolina because I was able to kind of set up my own fellowship in population health management and stayed on there with the company after we had some good success with the programs we piloted and grew out the business there. After doing that a couple of years, I went to become an independent consultant with some like health tech, mostly health tech companies, startups, and one of the primary ones was like a PBM that uses cost plus pricing in their reimbursement contracts plus a lot of other random things, like rolling out a CDC program to all their independent pharmacies that they were in the network. And during that time, I spent a lot of time active in Slack groups for health tech and there was a principle at Milliman that noticed that I was posting and answering questions about pharmacy related topics and policy and then she followed me on LinkedIn where every weekday I post about something related to pharmacy or healthcare in the US and she recruited me or invited me to do the same thing I was doing as an independent but do it for Milliman within Milliman supported by their analysts and actuaries there. More what I spent a lot of time doing is we do like RX trends or RX analyses where we're looking into what's the experience of this payer or this provider and maybe how their reimbursement compares to other people in their area. Like if you're a pharmacy, how does your reimbursement for your contracts compare to the other pharmacies in the area even in your like your city or even your zip code if we're talking like Medicare, we have like data assets that can go all the way down to those details and so I oversee those and say like I wanna see these things and see compared to a percentage of Medicare or percentage of NADAC to see what actually how are you comparing on your pricing compared to others. So that's like a general idea. It's being the only pharmacist at the Seattle practice. I do all lines of business and do all kinds of projects. So that's a very brief idea of the stuff that I do. - That's so helpful Bryce and I guess for the rest of the audience and I really think one thing to know about Bryce that I've really appreciated after knowing him for now a few years. Is it Bryce? - Yeah. - But a few years of him and I connecting and knowing each other through like different networks as this, everybody's got good ideas, right? You just got a good idea comes to your head. Bryce is a guy that takes a good idea, compartmentalizes it, strategizes it and makes it an actuality, you know? And that's something that I think is really special about your skill set, Bryce. Just some examples, if you don't mind me sharing is, you know, Bryce looked at the real estate market and realized, hey, there's some unbelievable potential to be able to utilize a certain strategy in the real estate market to be able to be successful for your current and future success overall. Bryce, do you mind sharing a little bit about, you know, the model that you've looked at there? - Yeah, it's called, the strategy in general, it's called house hacking, but I've taken a spin on it. House hacking itself is where you buy a house and you live in it, it is your primary residence, but you rent out pieces of that house. So it could be extra bedrooms, it could be a mother-in-law suite or maybe have a garage you don't use and you rent it for storage. I took that to another step where there are pharmacist home loans that pharmacists qualify for. All you need is to have your pharmacy license and then you can apply for these loans and they don't charge you PMI, so they charge you like the additional private mortgage insurance that takes the risk off of the lender, not off of you, but they're having you pay that for them if you put less than 20% down. And they let you put down zero to 5% to buy the house with no PMI and they don't look out much to your total debt is for your student loan debt. It's just how much are you paying each month. And so I routinely use that loan. I, every 12 to 24 months, I move out of my old house, move into the new house using that loan and then I can do that routinely because I only have to put zero to 5% down. So I've done that every year for five years now and have enough houses that I don't really have to work anymore, but I like to do healthcare stuff and it allows me to have conversations with people and do work that I enjoy doing without being forced to do stuff that I disagree with necessarily. So that's the reason for the real estate, well, even though it's not my focus or my huge passion, it is a foundation of stability that I can use to do what I want in healthcare. - I just heard something this morning, Bryce that was this interesting and remind me of you on this one, it was a CEO talking to another executive and they were saying, if someone was strangling you by the throat, like what would you be thinking about? And it's like, well, escaping for freedom, right? And air, like those are the two things that you need. And oftentimes they kind of in this banter back and forth, they said, that's what money does to so many people. Like it, the only thing you can think about is, well, I can't do this because I need money. I can't do this because I need money to pay the bills. I can't do this because I need money to pay for the kids's things. And so having that mindset of you thinking, I'm gonna create a freedom loophole for me to be able to do the things that I want as I think one, fantastic. Two, I think strategizing that to the point where now you've created it for yourself. - So it's illustrated in Bryce's life with, Bryce wasn't a fantastic speaker and you guys can already tell he's a great speaker. He joined Toastmasters and is probably already leading classes now in there. And LinkedIn, he wasn't posting. And instead of most people that randomly will post or in between things, Bryce posts every day. And how long is that streak, Bryce? - It's been about three and a half years. - Three and a half years every day. So that kind of dedication is just absolutely incredible. But yeah, Jiren, I'll pass it back over to you. I just wanted people to know like the incredible skill set that Bryce has and some very unique abilities that I think we can all learn from. - Yeah, that's a goal of mine. You know, I've been ridiculously overwhelmed lately. So I've been absent on social media, but that is a goal of mine. I wanna get to the point where I'm daily on social media posting something out there. So I love that, that's great. And that's a superpower to be able to just compartmentalize and operationalize. Just, you know, you get a concept and you bam, you just, you put it together and you make it happen. So a superpower, I always strive to implement myself. So props to you, Bryce, well done. Also just what are like the biggest cost drivers that you're seeing in all of healthcare right now in general? - Sure, you guys know that pharmacy is around half of the total increase in trends recently. So like we have a medical and pharmacy kind of what we were talking about earlier. And the pharmacy is 15, 25% of the total cost of care. And recently that 15 and 20% has been half of the total increase in trends. And so that 20, that 50, 20% has been increasing because it's becoming more and more of the increase in trend. The biggest cost drivers are mostly specialty drugs and GOP ones recently. Especially doesn't have a set definition. And that may be surprising to some people. Like the lists of specialty drugs are essentially created, determined by the PBMs or the plan sponsors. But these are really just high cost drugs for usually cancer or autoimmune conditions. But like I said, it could be literally anything they want to be. - Right. - In those specialty drugs, some of them have big changes that have happened recently. Like some of them have shifted to biosimilars to reduce the cost of those specialty drugs. So the recent ones were Humira and Stolara that were very impactful to the total cost of care and the trends recently. And some of the weird things there. Humira, even though the patent for the Aboriginal biologic, the original drug molecule expired in 2016, it took until 2023 for biosimilars to be approved and marketed and actually sold. From there, it took another several months for there to actually be any market share because a lot of the PBMs didn't change any of their formularies until CVS changed in April of 2024. And then the market share went from like 98% Humira down to like 77% Humira. And that was just because one of the PBMs changed their formulary and now multiple others of them have made that change as well. Usually preferring the biosimilar that they've also manufactured. 'Cause you know, they have the PBMs, they also own a payer, they own pharmacies. But in this case, they also have a partnership with a private label manufacturer to manufacture their own biosimilars. And so now that they have those biosimilars that are manufactured by them, they've changed the formularies to take off Humira and put on those biosimilars. And so those are leading to cost decreases. The questions that are out there just more like, is that an issue with the prices being higher than they could be if it was not controlled or influenced by the PBM more often than just if there was an open market with purely independent actors. - That makes a ton of sense. I love how you very politically walked around all the tentacles and webs behind the scenes on that one. I won't pull that back too far. I don't want to get any hot water on any of those pieces, but it's amazing the number of lovers behind healthcare. And I think one thing that we don't necessarily understand always, Bryce, depending on what we're facing in business, is that the next question for me is how it's gonna impact outpatient and pharmacy settings, like in particular, overall, long-term care, et cetera. But for the audience, a little bit of context, when we're saying this, some people might think, hey, Kimera, or any specialty drugs, GLP-1s, we're seeing that, hey, from the pharmacy's perspective, if you have a community pharmacy lens, GLP-1s could have been losers for you for a very long time. Now Costco, just talking with some folks over there, they went and they went a direct to consumer type of route and they did a good Rx kind of play that they ended up having their own ability to leverage that at 499 to reduce costs and at least break even if not make a little bit of money within Costco, so brilliant maneuver there and within the healthcare infrastructure, like you're saying, GLP-1s are a big driver in multiple ways. And usually we think of it as patient can't access, right? Patient can't get their Humira, patient couldn't get their GLP-1 because of access kind of components, or we might think the provider's office trying to make a decision on who to prescribe to, should it be those with diabetes only, should it be those with a BMI of 30 plus, 27 plus, plus it's condition, what does the Medicaid payer allow within a given state or area, all those things are meaningful. But on the back end of things, sometimes we don't actually think of how in the world is it going to change what's happening inside of the pharmacy for profit drivers and abilities. Can you give us a little bit more insight, Bryce, on how these trends are gonna impact pharmacy? - Yeah, the drugs that you're talking about have been noticed to be often under reimbursed compared to the cost to acquire them. And so a lot of these GLP-1s, especially drugs, have caught attention because the way the PBM contracts are written, it's more they try to incentivize generics by over-reimbursing generics relative to brands and under-reimbursing brands relative to generics. That has caused some issues with pharmacies, particularly ones that have a lot of GLP-1 utilization now. And so that GLP-1 increase utilization has kind of broken that model and that a lot of the PBMs are now shifting towards a more balanced, I don't know if it's truly at cost now, but it is a more balanced, a slightly increased brand reimbursement to make it to where the pharmacies aren't losing as much money or they're losing less money when they fill these GLP-1s. And kind of similar related is the Medicare MFP pricing and those things coming out here in 2020, 2026. Though the pharmacies don't always have the cash flow to like float the acquisition cost that's above the MFP and then have to wait for the rebate coming from the farm manufacturer later. And so there are a lot of independent pharmacies that have started to say, "We're just not going to stock the MFP drugs." And that's tough for the patients. Like the pharmacies can't just like fill drugs and have to float $40,000 a month because they don't have the cash flow to be able to do that. So it's a lot of things mixing here together that in the way that PBM contracts are written in these new, the IRA program are making it really tough for pharmacies to stay open when it's already a tough time for a pharmacy to stay open. - I'm going to take that, Jiren, and pass the question over to you actually, but what Bryce was mentioning there is really fascinating to me in a couple of ways. One of them is this, that we're seeing some trends, especially in independent community pharmacy that because they don't have the leveraged vertical integration that others might, what they end up doing with some of those losers is they basically have to pass them over to a mail order pharmacy, right? Further stripping the ability for us to unify care, you know, kind of under one umbrella. So now we're taking an individual, they have multiple touch points within the healthcare system just to procure drugs. The thing that I'm really curious from your perspective, Jiren, is this what I'm seeing in some trends, and I feel like I've been commenting a little bit more verbally, I guess, on some of the social media about it is, what really concerns me, Jiren, is we're seeing more direct consumer, direct from pharma to consumer drug utilization happening right now without a ton of oversight, without a whole lot of clinical integration amongst their primary care team or a collaborative kind of care practice team. What do you see in Jiren, or what are your thoughts about that trend that we're seeing of going direct from pharmaceutical manufacturer to individual patient without a whole lot of oversight or integration to the rest of the system? I'd say the system is perfect. - Are we talking mail order more, or are we talking just a team-based approach like what I'm doing? Is that what you mean? - I'll give you an example without saying any names because I'll probably be partnering with them someday, so I don't wanna do that. So with a number of drug manufacturers, especially in the GLP-1 space, which is gonna reduce those numbers down pretty easily for us to be able to guess which pharmaceutical companies, but within those particular companies, because they want to get their product out, and not that it is wrong, like there's number of players in the layers in between with PBMs, large payer organizations, et cetera, that may make it more difficult for them to get their drug out and potentially at a lower reimburse price for them back to the individual manufacturer, they're creating an avenue to go from pharmaceutical company to a clinical practice, that there is a telehealth model that someone can then be prescribed a medication that then reaches directly to their door, right? And so they've almost entirely bypassed the entire primary care provider relationship, the community pharmacy relationship, in order to go from drug to patient. That's the model that we're starting to see some trends in. And the worry for me, Jaren, is obviously this, it could start with one drug, but the success rate, if that is seen higher and higher, that Bryce knows intimately, what I want to ask him to comment on is, there's more high-cost drugs coming out in this particular space that I can see this avenue being very attractive, if successful. But I want to get your thoughts as a clinician on some of those things. - Yeah, I think that is one of many factors currently in the healthcare industry that could easily contribute to the eventual demise of a pharmacist providing any type of clinical service. 'Cause basically they're just gonna get a package insert that contains data from drugs.com. And once again, anybody can get data from drugs.com. It's how is that data, how is it assessed and how is it evaluated in regards to that individual? And without that component, we are replaceable. But that is a very critical component to good patient and good pharmaceutical care. So I'm not a fan of that, but I can see how it is healthcare and our society in general is definitely trending that way. And I think that's something we do need to keep in mind as we lobby and advocate for our profession to provide good care. As long, basically like several aspects of healthcare are kind of just being bypassed and overlooked and disregarded in a way. So I'm not a big fan of that. And I think that's something that could contribute to potential harm in the future. - One point I'd like to add there. I've had people in my daily life, like even at Toastmasters that have asked me a non-clinical pharmacist. Technically, I'm a licensed pharmacist and I can do this, but someone who's not worked with patients for seven years to review their medications. And that's because they don't have a relationship with a pharmacist. And they're like, you're the only pharmacist I know. I know you don't work with patients, but you're a licensed. So they've come to me to give them feedback and like, I can do it, but that's like, I shouldn't have to do that, it's my point. - That's a great point. - Exactly. - And I think the contextualization that you talked about right there, Jerron, how do we contextualize the information being given to patients so it could be more successful for them is a massive piece, but I'd be really remiss not to say that the piece that you illustrate there, what the role is moving forward for us as individual clinicians and where do the payment models kind of end up stopping is this. We worry so much about access to drugs that we don't prioritize access to health first. Like we are saying, how do we get these drugs into patients' hands, into their bodies? Not how do we get them healthier and how do we look at those overall outcomes? And I think it's highly problematic that when we try to find a way to commoditize and or commercialize the healthcare space, like these are the trends we'll continue to see, like how do we get this individual drug into somebody and make more profit based on it? But I won't get on that soapbox too tall right now. - Yeah, you know, I would like to see a system, if this access to drugs is important and getting it to them is important, what if that drug cannot be dispensed or mailed until a conversation takes place with that professional, you know, like it's prescribed or whatever, it just generates that discussion somehow. I think that would be a more ideal way to do it. You know, 'cause I don't like to just bring up problems. I like to at least consider finding a solution or discussing one rather than just pointing into them. That's another problem we have, just identifying problems without any solutions. So, you know, it seems like GLPs are kind of a frequent talking point as far as cost goes, but what surprises you most, Bryce, about pharmacy spending trends in institutional settings versus the retail or outpatient settings? - Yeah, it's primarily the markup variation and the missed opportunities for savings with biosimilars that's partially related to the 40B incentives and we can get more into that if you want, but my natural tendency is to take like the perspective of the payer and not always the perspective of the provider in this. So, I'm thinking of the cost of these drugs, the markup variation can be dramatically different for institutions and particularly on like the commercial side. And if you aren't like benchmarking or checking the transparency data on what you're paying versus what other people are paying, there's very high likelihood that you're paying way more than what everyone else is and a huge opportunity for savings and related that the biosimilars, like you can get for a lot of these biosimilars now in the institutional side even, you can get medical drug rebates, some of these biosimilars. So, there are many opportunities for most of the clients that I've seen have some opportunity in switching these to like doing a medical drug rebate policy or just doing a benchmarking to see like, here's how much different your pricing is compared to others and then you go renegotiate or whatever you need to do after that. - Great, yeah, I think it might have been with Bryce that I was talking about this before, but I know that interestingly, when we're just comparing institutional to outpatient kind of settings, I've been in institutions and we literally put tape on the floor to be able to say, here's clinic and here is outpatient of hospital, right? So, we could designate where the difference was. Two payers or two auditors so that we knew like this area and or room was designated as this versus the other because of reimbursement alone, you know? And when you're dealing in my case, this was a critical access hospital, like that's the difference between keeping the doors open or closing them, keeping staff or losing them, right? And those kinds of situations, but that doesn't justify the model of payment for healthcare of us having to do that, you know, in general. So, tell me this Bryce, so if you're looking at some of the specialty medications and biologics, let's talk about, we talk clinic, outpatient, but talking about like nursing homes and alphas in particular, like how do you see these crazy drug prices that are out there and just like the biologics that are coming in with those drug prices, reshaping the way we do things inside of those nursing homes and alphas or assisted living facilities? - Sure, the pharmacy cost projections are rising annually. And that's even when the utilization for a lot of these institutions are relatively flat. And the main reason there, the main driver isn't necessarily the volume, it's the drug mix, even then that kind of falls under utilization. When you're thinking of trends, you have utilization and you have unit cost. The drug mix kind of falls under utilization, but it's drug mix. So there are more of these high cost drugs that are being prescribed, like the specialties and GOP wands that we talked about earlier. So more of those newer and higher cost drugs are being prescribed. And we've seen in some recent articles that not all of them have the value that they were expected to have. They might have been approved by accelerated approval from the FDA. And so they have to then continue to do studies. And some of them aren't doing those, some of them have been in process of doing those for a long time. And the value or effectiveness of those drugs are still in question, even though the costs are set just like they were approved normally and have the full value that they expected. And so some things I've seen that are like, how can we balance this is if this drug is approved under like an accelerated approval pathway, maybe you price it to where you price in that uncertainty into the price. And so that allows while you're doing your post-marketing effective study that it's at a price commiserate with the actual value that we know we're getting and incorporate that uncertainty into there. - The Alzheimer's space, Jiren, is one that I think of immediately. We're seeing drugs that Bryce is mentioning there that they've had some ridiculous numbers. And then the value that we've seen actually in clinical practice has been very limited overall, and there's even some concern that we're targeting the wrong biomarkers overall inside of the space and now starting to pivot within the pharma space to be able to target different biomarkers. So I guess this, Jiren, for just conversation's sake, what are you doing and we're advising within the facilities you're working with for them to be able to deal with, the patient is saying, I want my mom or dad or whoever to have the best, right? And Bryce is saying in the background, well, what the best really means from a cost perspective and from a value perspective is debatable for some of these drugs. How do you work working that out with patients so that the facilities can avoid some of those additional burdens that are put on them or on the patients themselves? - Yeah, education, right now we're at a very specific point in our timeline in the healthcare industry where we've spent a few years, I think, over prescribing. And so now I think we're in a bit of a course of correction where a lot of people are saying, hey, we're prescribing too many, let's, so there's always a balance here. A lot of these drugs do have a benefit and a lot of them have minimal, and in many cases, there's a ton of data that says polypharmacy is probably one of, if not the biggest problem in healthcare. So educating these families on what these medications are, how relevant, what benefit they provide, which ones are actually contributing to the problem, 'cause polypharmacy, when you get all these meds on board, some of them are gonna conflict with each other and undo some of the work we're trying to accomplish, such as your cholinergics with your anticholinergics and things like that. So I think the biggest point is just, first of all, educating them on which medications are providing benefit, which ones can we do without and start deep prescribing some of these. And also educating them that a lot of these nursing homes are regulated in a very specific manner on their psychotropic regimen. And so if you think you're gonna go here and get a different care, you're gonna get the same problem. All these nursing homes are held to the standard of, we have to do reductions on these psychotropics. And if you think that it was just this one nursing home, it's not, it's all of them. And so the heart and intent behind those regulations are good because we have overprescribed and these regulations are kind of trying to help us find the right candidates to take off of psychotropic drugs. So, and educating them on, hey, this regulation is here for a reason, we have overprescribed. It may not be providing the benefit we want. Let's focus more on giving them comfort and not giving them more drugs that cause more side effects with more drugs. So that's typically the direction I would go. I don't know if that answers your question. - I love that, Geron. And I think it really speaks to how we develop metrics overall. Like if we're looking at metrics as being very simplistic, that, hey, if you have this number and it's this high, then it's bad rather than having some contextualized components or maybe even some risk-based components within metrics. So I'll jump to this one, Bryce, just from a, I guess, practical application standpoint. If we're trying to make the shift, we're metrics and utilizing value-based care, like that word's been around. I think you and I even laughed about the first time we met, like how exciting of a word it was and the buzz it was. And now it's really fallen interestingly flat and gaining some more steam when it's contextualized within some quality pieces. But let's say this, like, how do you see the role of pharmacists evolving in value-based care models, like particular and long-term care? - Yeah. The pharmacists I see as an extension or a supplement to primary care, particularly for chronic conditions. And so, you know, I see the, like particularly the community pharmacies could be utilized more for their appointment-based model where they have an appointment with their patients once a month or once a quarter, and they get to not only deliver their patients to medications, which is helpful for the pharmacy 'cause they know that patient's coming and when they're coming, but also have extra time to discuss the extra things that they don't normally get to talk to their patients about. And so, when we think a lot of these chronic conditions are primarily based around medications and adjusting those medications up and down, some lab adjustments or lab diagnostics that they then use to adjust the drugs, pharmacists are able to handle that kind of thing. And they could do that completely on their own from their own clinical experience. Pharmacies teach this in pharmacy school, pharmacotherapy classes. You are given, here's the patient with their diagnoses and their drugs, like what would you prescribe them as the next drug that you would give them to treat their condition, their new or changed condition? So, having the pharmacist as an extension or supplement to the primary care providers, I think is where they should be going in value-based care models, and particularly like with these, whether they're seeing consistent patients in long-term care facilities, there's no reason that they couldn't take off some of that work from the primary care provider or the other people in the facility to take on more of that role, and they would be completely qualified to do that. - Yeah. - I want to hug you for that response. - You're in the same risk bucket. - What's that, Darren? - I want to hug you for that response. That was perfect. - Oh, wow, the hugging, I love it. The bromance begins. (laughing) - Yeah, I think the dots being connected inside a long-term care spot that you really tie together, their brides make a lot of sense, because one thing off camera we're even talking about is that kind of the slices of pie in value-based care, sometimes they get, here's medical, here's pharmacy, and in the outpatient world, you could have an entirely separate, depending on clinical model, you could have a separate community pharmacy and a separate independent practice clinic, and they're not necessarily under the same roof or collaborating intimately all the time on every patient. And so maybe it adds a little bit of mudding to the water. I'll save that for another conversation we can have on how I don't think it does and how we can actually be able to bring those together rather simplistically, but long-term care doesn't have any of those issues. Like we're literally under the same roof. We have consultant pharmacists, we have facility pharmacists, we have the facilities, MD, RMP, et cetera, they're all working together for the betterment of those individuals and some value-based care drivers, Darren, within those facilities that we're trying to target and improve for metrics and ratings and et cetera. Do you think, Darren, that there's, and I know interestingly, this podcast will end up showing after your guys' talk, but I'm sure you and Thea and Lee will get into this at ASCP's national event. We're really looking at like, how do we jump into some things that are related to star metrics for these individual facilities or for quality metrics for these individual facilities that we may not have tapped into before because we weren't as integrated? Are you seeing some things right now on the front lines, Darren, that have been rather beneficial for you to land contracts and to potentially expand services based on those? - Yeah, just the general discrepancies or shortcomings of healthcare are all things that we pharmacists thrive at because we have a problem with polypharmacy, we have a problem with a shortage of providers, we have a problem with several comorbidities being present all at once, all of which are things that pharmacists thrive at, taking care of. So our problem isn't really a whole lot of diagnosing new issues, it's managing the current issues. And those are things that pharmacists thrive at. And the biggest obstacle to getting that, getting for us to do anything is just convincing them to give it a shot. 'Cause once they give it a shot, they never wanna go without a pharmacist on their team ever again. - Give a shot and measure it. - Yeah, yeah. And measure it is one of my shortcomings. That's one of the things that I'm trying to put together. I'm great at just chasing my tail and saying, "Hey, I'm great at doing this and I can do it." And proving it that I'm great at chasing my tail, but then I have to eventually stop and measure the benefit of what I'm providing. But yeah. That's an awesome opportunity. - So Bryce, where do you think we are headed next? What are the emerging trends, like biosimilar GLP or Medicare policy changes? What should consultant pharmacists be preparing for in the next two to three years? - Sure, the main one is the IRA negotiated prices rolling out for the first time here in January, 2026. So there are still questions about exactly how that will be implemented for the pharmacies because of the pricing changes and the potential cash flow issues we talked about earlier. This year will be very illuminating for how the IRA negotiated prices work out. And there will be another potentially big change in 2028 as well when the Part B drug start getting included and negotiated as well. 'Cause that may have an impact on the ASP reimbursement and lead to payment issues on those drugs. And I've heard the word death spiral called out if you're including MFP in the ASP calculation because it'll continue to drive down the price of those Part B drugs and lead to reimbursement that might be lower than what the drugs actually cost for the institution of require to a choir. One last thing I thought of was the biological patent cliff. So there are a lot of biologics that are going to lose their primary patent here in the next five to 10 years. And those are dozens of blockbuster drugs that will see their primary patent, the molecule patent expire and face biosimilar competition. And that's assuming they can get around the secondary patents 'cause if we're thinking like with Humira expired in 2016 and didn't see biosimilars until 2023, that there could be others that have similar issues. But there are a lot of high cost, high revenue, high sales biologics that are going to lose their patent here in the next five to 10 years. And so that's a big focus and drive towards biosimilars and biosimilar competition that we should be seeing. - That makes a ton of sense. You know, I'm really curious on this one too, Jared for you and I to touch base on is, I just went to, so Josh is a good friend of mine that works with the American Diabetes Association and he was telling me that it's just so difficult to be able to keep up with the new additions to care, right? And be able to take the algorithms that we previously had when Metformin, when like the S and three of us were all training, Metformin was every diabetic. Here we go, Metformin, it's starting, it's going forward with the type two diabetic. Now it's been relegated quite far down the line with some very expensive substitutes going in between, right? And so when, you know, Rice is talking about things coming off patent, I'm sure a lot of people are thinking, well, it can't come soon enough, you know, because one, we need to utilize those because now they're the primary treatments or the algorithmic first steps for all these individuals to utilize within these particular disease states. It's going to keep coming. They're just going to be more and more new, better, exciting drugs, you know, that are out there. And now that we've, we're updating our guidelines more frequently than every seven years, you know, like we used to and actually updating that knowledge in the systems more rapidly. We're almost hitting a knowledge and industry crunch, you know, that we have, here's the new, the exciting, the quote, unquote, tested, that they're going to be more beneficial. But here's our guidelines that had older medications that were established that were less expensive and now they're being replaced, you know, without the ability to justify those from a cost standpoint. How are you, Jaren? I guess as a consultant pharmacist, thinking about what am I going to do for my facilities and/or my patients to be able to help them navigate those waters? - You know, there's a lot of Medicaid payment in our population. So I don't really have to fight cost a ton unless they're like a post-acute stay and it's a medicare payment, then we are looking at that. And there's a lot of people who would say, no, we're going to not administer GLP one until they go home. And that's, we help managers with stuff like that. But as far as out with the old and in with the new type of situation, new patents, replacing older, more established data and medications. You know, I play that on a case-by-case basis because, you know, replacing oxybutamine with newer agents that are a lot more expensive that are not anti-colonergic, huge benefit there, huge value add, totally worth it. But getting rid of metformin or sidestepping it for several of these newer agents, I'm not a big fan of that. It metformin is still like really good with anti-aging properties. Sure, it upsets your stomach, it has some other side effects that are not great. However, it's still a huge value add at a very low cost. And, you know, I think we have a tendency to have big pharma push these new patents. And I think that does potentially add influence to our updated guidelines whenever they occur. That's not to say that it is the actual factor, but I think it does influence it, unfortunately. So we have a tendency to get rid of the old and replace it with the new, probably a little more than we should or need to. And that's why I base it on a case-by-case basis. Where is this beneficial for this individual? - Yeah, I can't agree more. And I think the other thing that it always brings back home to me is the things that don't get put at the top of the algorithm. I am uniquely biased by this, and I guess several ways. One, being a big, deep prescribing drug optimization guy, and also being big into lifestyle medicine components. Like, if we can't get our diet, our movement, our social relationships, and our sleep locked in, we're really struggling in so many ways that we need to prioritize those in the system so much more often. And it goes back to the same kind of trainings we've looked at. I'm sure we've all encountered in one way, shape, or form, Bryce, probably even at Toastmasters, on questions of how do I sleep better? And like, how do I find a way to get better sleep? What drug should I take? Like, that's the immediate kind of responsiveness. And I think there are some real opportunities for us to say, you know what? Because of the new prices that are being pushed upon us, that could be a burden. Maybe let's start looking a little more often toward how can we make those lifestyle interventions and those non-drug, non-procedural interventions, kind of to make sense. But I'll switch back over to Bryce here with this question. And Bryce, when you're looking at the future of health care and you're thinking about, you know, all the folks in pharmacy, I mean, it doesn't matter if it's in institutional settings, hospital settings, community settings, whatever the case might be, I feel like, and maybe this is just me, I know it's not, I know it's all three of us on this call, so I should just broaden it out. We struggle to really say how we are creating ROI or return on investment for the services that we're putting in place for payers. How do we do a better job of communicating that, Bryce? Like, how do we find a way to really show, like, here are those, as Jaren was mentioning, how do we show that Jaren isn't just chasing his tail, he's making real strides, and that's meaningful for payers. - Jaren, you should take close notes here, 'cause I think we have some stuff to do together. - I know. - So I talked to a lot of pharmacists and permanent care providers, and they rarely have the direct impact on revenue to prove their ROI. So the value is more difficult to prove to the leadership, like you said. There are other ways to prove your value to payers without requiring a lot of your own data, but the data does make it, having your own data makes it a lot easier. One of those is to see what the payers are paying other providers, or providers like you, with similar services, using aggregated claims data or the transparency data, and you can think of this as like benchmarking, your benchmarking, your costs, or your payments to what other people are saying. The second one is you can turn literature data for how valuable pharmacists are, or permanent care pharmacists, and take that data and put it into an ROI calculator for others to enter their unique characteristics of their populations, and see how much you could save them using like on their quality measures, or whatever else they're trying to improve, and how you doing that with their population, how much that would theoretically save them through the preventing adverse drip reactions, through hospitalizations, through readmissions, within the 30 days, all that with theoretical savings from only literature data. If you have some of your own data, some claims data for your pharmacy, or your institution, you can run an effectiveness study on your services with a statistically equivalent control group, and this is just like with clinical trial for pharma, you can have the control group, and then you have your data, and your treatment group comparison, and show a going forward, it's a retrospective study for history, and history, but we can show how much of a difference were the patients that you worked with the pharmacist group compared to the control group on total cost of care, or the diabetes management, whatever specific metric you want to get into, and we can do all of that with aggregated claims data, and then once you have all of that, you can decide what value-based care things you want to target in your contracts, or what things you want to take risk on, because you probably wouldn't want to take risk on doing a lot of stuff if you weren't sure that you could actually deliver on those things, unless you truly want to take risk, like I want to check these things, and see like, okay, I am doing well, compared to benchmarks, before I start taking risk in contracts on those things. And so there's three-ish ideas that could probably be used in a lot more primary care and pharmacist-focused things that don't directly generate revenue. - I love that. - Yeah, I think there's the data components price. I mean, I think that's the one thing that we often struggle when we're doing the ROI, and is we can see, hey, this individual has had a PDC, which I hate that metric, but with proportion to the days covered, when we're looking at this individual value in a community pharmacy, we can readily grab that from any PMS system and pull that out, same thing with long-term care. We can see that, we can even look at nursing chart records and see when it was administered, if it was taken by the individual patient or fused. We can look at adherence-related data to a certain extent, and have that kind of at our fingertips. We can even get a, I mean, I think you and I probably have a number of friends that would say, maybe you can actually know what the cost of individual drugs are truly, but we can look at kind of what the costs are and what we avoided and cost avoidance by deep prescribing and doing some other interventions. But when you mention the biggest piece really to me is this, like there's two different factors. There's clinical outcomes and there's cost outcomes. And I would love to say the entire world of medicine operates on clinical outcomes, but I would be full beans. Like it is all cost outcomes, right? Overall, how would you, and if you can't answer this one, that is just fine, but how would you recommend that a pharmacist look to grab more cost outcomes data or collaborate to get cost outcomes data so they can actually show that and evaluate if a risk-based model with a payer would be appropriate? - I think the first thing is you're building in these relationships with your hospitals, your facilities that are nearby you. If you haven't talked to them about like, could we work together on showing the value that we're doing together? Like the best metric is total cost of care and you need to be able to see the medical side of that for your patients to truly get an idea of how much you're saving. Like, yeah, you can do the, I saved money from deep prescribing or I improved adherence and we don't know exactly how much money that turned into, but the deep prescribing directly has savings. But if you want to use total cost of care, like you need to talk to the facilities that you're working with. And I think you would be surprised how often that they're open to, like, we know the value you're going because we're working with you right now and we see what the pharmacist, like it's more often the issue when you have people who haven't worked with you before and you have to convince them, yes, I'm valuable. And that's usually a tougher conversation, but if people who you're already working with, like get the data from them and I've worked with pharmacies like a pharmacy in a community that has some contracts or often has hospitals in that area that they work with and they've asked them, like, can we, can you give data to Bryce at Milliman to help us do like an ROI calculator to show how much value our pharmacy is providing to the community? And those have been like, all the hospitals that for one, I'm thinking of right now were open to doing that. And they just took like the effort of asking and then going through the data sharing process. So the answer is to try. - I love that and I think the collaborative nature is sometimes highly underestimated, especially when it's for a cost driver, you know, overall, and you know, having shared patient relationships is a massive piece. I was just talking to another buddy the other day about, hey, do we have anything related to community pharmacy versus mail order pharmacy versus other pharmacy types and overall cost of care, right, delivery? And his answer is no, that he was aware of. And then I looked and I found a 2019 study, it was not very positive for most of us pharmacists because it ended up showing that the mail order 90 day refill ended up being much more cost effective, you know, overall, the design of the study, everything else can be debated. But I do think Bryce, like for us to be able to be armed with the information necessary for our profession to matter, right? When it comes to cost drivers, we have to study those things. You know, without it, it's really an irrelevant conversation on a risk-based model. And I know, you know, we have all several colleagues that have studied it, they've looked at it, they've seen significant ROI, seven to one, six to one spending ROI numbers that are just wild for certain populations. And I think that's the other piece, when I say certain populations, what do I mean? I mean, you don't have to go at risk for an entire population. You can stratify down to where it really makes sense for you and the payer or the organization to collaborate. And I think that's really where the sweet spot is for utilizing this high level of medical knowledge. But thanks for that, Bryce, appreciate it. - Yeah, I mean, you're talking population health management. So that's my fellowship. - Right. Well, this was awesome, Bryce. We really appreciate you taking the time to chat with us today. It means a lot. - Yeah, thanks for having me guys. So it's a good time. I've got to share a few things that hopefully we're valuable to people, including a random thing on a clinical podcast about real estate. So hopefully some people can get some value out of that. - Definitely, agree. All right, really appreciate you, Bryce. Have a good rest of the day. Thank you everybody for tuning in. We'll see you next time. (upbeat music)