Pharmacy View Podcast Pharmacy View Podcast

Episode: 98
Episode Title: Pharmacy Showdown: Inside the PBM Power Play in the U.S.

In this episode of the Pharmacy View Podcast’s Rx to Riches stream, international host Michael Alexander, a Pharmacist, entrepreneur, digital health enthusiast, Co-Founder of Audrie, and the Regional Vice-President of Health Plans at Omada Health, interviews Dr. Drew Oliveira, Executive Director, Washington Health Alliance and Clinical Associate Professor, University of Washington; and Denise Giambalvo, Director, Member Engagement & Business Strategy, Washington Health Alliance. Together, they explore the intricate dynamics of the Pharmaceutical market, focusing on the impact of PBMs and the broader disparities in the U.S. healthcare system. Tune in to uncover how vertical integration, financial incentives, and payment model reforms could reshape patient care and outcomes.

Denise delves into the complexities of the pharmaceutical market, particularly focusing on the role and impact of PBMs. They highlight the dominance of three major PBMs that control 80% of the market, creating a system that often prioritizes profits over patient care. Denise explains how vertical integration enables PBMs to manipulate drug pricing, even within programs aimed at assisting low-income patients, and describes the financial challenges faced by Pharmacies due to PBM practices like clawbacks, which often result in financial losses for Pharmacies.

Denise elaborates on the challenges independent Pharmacies face due to PBMs' vertical integration, where PBMs own Pharmacies and manage the entire supply chain. This integration allows PBMs to benefit from practices like spread pricing, where they charge health plans more than they reimburse Pharmacies, pocketing the difference. Denise underscores the lack of transparency in PBM operations and its impact on costs for both employers and patients. Additionally, the discussion covers the significant role of specialty drugs in healthcare costs and how PBMs leverage their control to profit through rebates and preferred drug listings.

Further, Dr. Drew and Denise discuss the disparities and complexities within the U.S. healthcare system, emphasizing the dominance and profit mechanisms of PBMs at various stages of the pharmaceutical supply chain. The conversation reveals how PBMs and consultants create a biased market, influencing employer choices through back-end financial incentives, exacerbating the lack of transparency, and ultimately affecting drug costs. Denise also highlights the need for data-driven strategies to address health inequities, stressing the importance of removing financial and access barriers to improve patient outcomes.

In a thought-provoking exchange, host Michael Alexander asks Denise and Dr. Drew Rivera about the most impactful change that could improve patient care in the U.S. healthcare system. Both suggest that changing the payment model to a global or episode-based payment for primary care would be transformative. Dr. Rivera also proposes a federalized healthcare system as a controversial yet potentially effective solution for aligning incentives and enhancing care quality. The episode concludes on a lighter note, with Dr. Rivera sharing his passion for jazz music and Denise discussing their enjoyment of dancing and pickleball, highlighting the importance of balancing professional and personal interests.

In this episode of the Pharmacy View Podcast’s Rx to Riches stream, international host Michael Alexander, a Pharmacist, entrepreneur, digital health enthusiast, Co-Founder of Audrie, and the Regional Vice-President of Health Plans at Omada Health, interviews Dr. Drew Oliveira, Executive Director, Washington Health Alliance and Clinical Associate Professor, University of Washington; and Denise Giambalvo, Director, Member Engagement & Business Strategy, Washington Health Alliance. Together, they unravel the complexities of the U.S. healthcare system, exploring solutions and challenges in enhancing quality and affordability.

Denise discusses their journey from the retail industry to their current role, focusing on enhancing healthcare quality and reducing costs. They emphasize the importance of employer-led coalitions and their commitment to improving employee care delivery, particularly in Seattle, where they are engaged in their third coalition endeavor.

Dr. Drew Oliveira shares their diverse background, transitioning from family physician to the insurance industry, gaining insights into U.S. healthcare practices. They highlight the employer's role in creating self-insured health plans and their current focus on improving quality, access, and affordability in healthcare. They are dedicated to addressing health disparities, especially within the employer community. Dr. Oliveira delves into the evolution of the U.S. healthcare system, from apothecary-driven care to the establishment of Medicare and Medicaid, while addressing persistent challenges like the uninsured population and rising healthcare costs.

Further, Dr. Oliveira explores historical attempts to implement national healthcare programs, highlighting resistance from various stakeholders and discussing proposed solutions like Medicare for All. They emphasize the importance of aligning physician workforce distribution with population needs to enhance healthcare quality and cost-effectiveness. Denise reflects on the cultural challenges associated with implementing a single-payer or government-led healthcare system in the United States, expressing concerns about government intervention potentially limiting individual freedom in healthcare decisions.

Additionally, Denise and Dr. Oliveira delve into the multifaceted role of Pharmacy Benefit Managers (PBMs), discussing their functions in claims adjudication, formulary development, and rebate negotiations. They highlight the complexities of formularies and rebate negotiations, shedding light on how these processes impact healthcare costs and patient access to medications. Overall, the episode provides insightful discussions on healthcare challenges and strategies for improvement.

Note: Stay tuned for Part 2 as we explore the American healthcare system with Dr. Drew and Denise next week.

In this episode of Pharmacy Podcast, a stream of Pharmacy View Podcast that provides regular interviews with Pharmacy leaders, entrepreneurs, and members of The Independent Pharmacies of Australia (IPA), host Melody Mugari, a Pharmacist and Programs and Corporate Partnerships Manager at The Independent Pharmacies of Australia Group (IPA) is joined by Steven Kastriaskis, Managing Director, Pharmacist, and Partner of the Independent Pharmacies of Australia Group (IPA). Listen to the episode for an insightful discussion on innovation, empowerment, and the future of independent Pharmacies.

In this episode of the Pharmacy View Podcast’s Rx to Riches stream, international host Michael Alexander, a Pharmacist, entrepreneur, digital health enthusiast, Co-Founder of Audrie, and the Regional Vice-President of Health Plans at Omada Health, interviews Anthony Sapountzis, Co-Founder and CTO of Aerion Technologies. Listen to the episode and delve into the transformative role of technology and AI in the Pharmacy sector. The episode also covers insightful discussions on entrepreneurship, AI development, and the future of Pharmacy operations.

Anthony talks about their journey from university to entrepreneurship and the evolving landscape of technology. Anthony's lifelong passion for technology has guided their career, transitioning from a developer's role to a business leader, driven by problem-solving and a desire to assist others. They recount the inception of their entrepreneurial journey during a summer internship, where they seized an opportunity to collaborate on a project with La Trobe University, leading to the establishment of their own business—Aerion Technologies.

Anthony then delves into the intricacies of AI development, emphasizing the importance of utilizing AI to enhance processes rather than integrating chatbots for the sake of it. They discuss the challenges of setting up effective guardrails within AI-driven applications and caution against overreliance on AI to handle tasks without human oversight autonomously. Despite AI's transformative potential, Anthony stresses the need for caution, ethical considerations, and human judgment in its implementation.

The discussion extends to the impact of AI in the Pharmacy sector, highlighting its role in price comparison, marketing analysis, and administrative tasks. While AI streamlines certain aspects of Pharmacy operations, Anthony emphasizes the continued importance of human interaction and cautions against expecting AI to replace Pharmacists entirely. They advocate for a nuanced approach to integrating AI into daily Pharmacy operations, considering the complexities of Pharmacist-patient interactions and the ethical implications of AI usage.

Looking ahead, Anthony anticipates further advancements in AI and its integration into programming and development processes. They highlight the potential for AI to revolutionize industries but emphasize the importance of maintaining control over autonomous systems. Anthony also shares insights on storytelling in movies and their company's presence on various social media platforms, aiming to provide valuable content to assist individuals in app and software development.

In this episode of Pharmacy View Podcast’s Full Scope Pharmacy Leadership stream, host, Chantelle Turner, a Pharmacist Leadership and Business Coach at TURN Pharmacy Leadership, engages in a dynamic conversation with Maria Cooper, a Community Pharmacist and a PhD Candidate at the University of South Australia. Maria advocates for enhancing the mental health of the Pharmacy workforce through peer support, reflecting on their journey and the need for support during unprecedented challenges like the COVID-19 pandemic. The conversation spans topics from the transition of early-career Pharmacists to mid-career professionals to Cooper's serendipitous entry into research, leading to a Ph.D. focusing on peer support in community Pharmacies.

Maria delves into their ongoing research addressing the historical stigma towards Community Pharmacy, the challenges young Pharmacists face, and the unique role community Pharmacies play during crises. They stress the importance of recognizing the value of Community Pharmacy, especially in providing crucial in-person support during emergencies. The survey data presented highlights the job satisfaction of Community Pharmacists, emphasizing the need for acknowledgment, remuneration, and public awareness regarding the complexity of their work.

The conversation unfolds to encompass the necessity of substantial organizational and legislative changes within the Pharmacy profession, including a shift in workplace cultures. Maria advocates for equipping Pharmacists, especially recent graduates in leadership roles, with conflict resolution and leadership skills. The discussion underscores the importance of peer support among employee Pharmacists, drawing attention to the unique challenges those in Community Pharmacies face.

Maria provides historical context to peer support, tracing its presence in various forms for centuries. They highlight the feasibility study on peer support in early career Pharmacists, encouraging an open-minded and calm approach to maximize its benefits. The episode concludes with Cooper emphasizing the significance of longitudinal data in understanding changes in the Community Pharmacy climate and inviting participation in the survey, offering five $100 Visa gift cards as an incentive.

Maria's survey for ECPs: https://www.linkedin.com/posts/maria-cooper-130275253_hi-all-me-again-i-hope-youve-all-had-activity-7157920591243530240-Z8c8?utm_source=share&utm_medium=member_desktop

In this episode of PAGCAST, a stream of Pharmacy View Podcast that provides regular interviews with Pharmacy leaders, entrepreneurs, and members of The Platform Alliance Group, host Melody Mugari, a Pharmacist and Programs and Corporate Partnerships Manager at The Platform Alliance Group, is joined by Gary Khoo, Proprietor of the Chemist Discount Centre Gosnells. Gary is no stranger to excellence in Pharmacy services, as his Pharmacy has earned its place among the six finalists competing for the prestigious Guild Pharmacy of the Year 2024. Uncover Gary's remarkable journey, from challenging industry norms to transforming his Pharmacy with CDC strategies. This episode delves into innovation, patient-centric care, and the continuous pursuit of excellence in the ever-evolving landscape of Pharmacy.