In this episode, we investigate the rise of Alternative Funding Programs (AFPs) that bypass coverage for vital specialty drugs.  Kyle Crowell, an expert consultant on AFPs, discusses how payers avoid their responsibility for costs by collaborating with third-party companies to exclude specific drug coverage and directing patients towards manufacturer-sponsored patient assistance programs (PAPs).  Patient advocate, Amy Niles from the PAN Foundation, describes how the mounting tension caused by AFPs are leaving patients to navigate the uncertain waters of their medication coverage and access, potentially risking their health and even their lives.

Kyle Crowell, Principal (Partner) at ZS Associates

Amy Niles, Chief Advocacy and Engagement Officer, PAN Foundation

Patient Assistance programs (PAPs)

Alternative funding programs (AFPs)

“AFP Caution For Patients”

“Pharma faces tough choices as alternative funding programs exploit charitable giving”

Medicare Part D

“AbbVie sues a behind-the-scenes company for exploiting its patient assistance program”

Federal Trade Commission

Carl Schmidt from the HIV and Hepatitis Policy Institute

Copay Accumulator Adjustment Programs Lawsuit

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Patients are experiencing remarkable weight loss thanks to the new generation of GLP-1’s and the downstream health benefits may go well beyond diabetes. In spite of the dramatic results for patients, insurance plans have started to put up more barriers and are even denying the drugs on a more consistent basis. For this special Obesity Week 2023 episode, we interview Dr. Angela Fitch, President of the Obesity Medicine Association, a faculty member at Harvard Medical School and most recently a Co-Founder and Chief Medical Officer for knownwell, a new obesity-focused primary care company.

Show Notes:

Dr. Angela Fitch, President, OMA

Obesity Week

Obesity Medical Association

Dr. Fitch’s patient care center: Knownwell

Seeking treatment for obesity? Find a clinician here or here.

The Treat and Reduce Obesity Act of 2023

The drugs discussed in this episode: 

An article on the use of “bootlegged” Semaglitude: Demand Rising for 'Bootlegged' Weight-Loss Drug | MedPage Today

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Employers are discovering this fall that they are expected to shoulder a 6% health insurance increase for 2024. What can employers do to combat the accelerating cost of health insurance without jeopardizing access to vital drugs? In this podcast episode, we talk with Matt Ohrt, a former HR executive who achieved a 20% reduction in health insurance costs for his employer. Matt has a new book and new company to help other self-funded employers strategically lower their sponsored health insurance costs for 2024 while ensuring employees have optimal access to care and treatments. This is an essential listen for employers seeking to balance cost-efficiency with the provision of comprehensive, high-quality healthcare benefits to their employees.

Matt Ohrt, Co-founder, Chief Healthcare Officer, Self Fund Health

Self Fund Health

Merrill Steel 

How Does Direct Primary Care Work?

Matt Ohrt’s book:  “Save Your Company: Don't Feed the Beast: The Employer Healthcare Success Formula”

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Many of the most beneficial therapies are prescribed or administered within physician offices yet these providers face a multitude of challenges attempting to get authorization and coverage. In this podcast, we interview a practice manager who is not only on the frontlines of the battle to help patients but is also an award-winning advocate for access. This episode will explore the barriers faced by providers and their offices and what can be done to win the day-to-day battles with insurance companies and PBM’s so patients can access and remain on treatment.

Julie Baak, Practice Manager, Arthritis Center

Arthritis Center

Rheumatoid Arthritis

Psoriatic Arthritis

Reactive Arthritis

The importance of ultrasound in identifying and differentiating patients with early inflammatory arthritis: a narrative review.

Growing Shortage of Rheumatologists “Very Concerning”

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This episode delves into the intricate web of Washington's influence on patient access, exploring the multifaceted factors that shape healthcare legislation, policies and their impact on patients, other key stakeholders and drug pricing. With an insightful interview from one of Washington’s top healthcare experts, listeners gain insight to the complexities of legislation, such as the Affordable Care Act and Inflation Reduction Act. This is certainly the “wonkiest” podcast episode as we attempt to provide an understanding of the current landscape of patient access and look ahead to how Washington's decisions will shape the future of patient access.

Lance Grady, Executive Vice President, Avalere

Avalere

Cardinal Health.

Public Health Emergency (PHE) 

AMP cap 

The Affordable Care Act (ACA) 

Innovation Center 

The Inflation Reduction Act (IRA) CMS

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In this podcast, we interview a consultant and a leading patient advocate to better understand and explore the challenges of copay accumulator and maximizer programs for specialty drugs. We discuss the difference between the two programs and their impact on the various stakeholders including the overwhelming burden placed on patients. We also discuss the legal issues and potential policy changes that could eliminate these programs or minimize their impact on patients. Ultimately, our goal is to shed light on this important issue and identify strategies for improving access to critical medications for patients who need them.

Carl Schmid, Executive Director, HIV And Hepatitis Policy Institute

Lauren Crawford Shaver, Senior Managing Director, FTI Consulting

HIV And Hepatitis Policy Institute

FTI Consulting

President's Advisory Council on HIV/AIDS

National Association of Insurance Commissioners. 

Department of Health and Human Services (HHS)

What are co pay maximizers?

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Pharmacy benefit managers (PBM’s) manage the drug benefits for millions of Americans and as a result, they can have a positive or negative impact on patient access. Mesfin Tegenu, an early pioneer in the PBM industry, is interviewed by Scott and Mark and offers his candid perspective on what PBM’s do, their impact on stakeholders and how the PBM industry could evolve over the next few years to better serve patients, employers, health plans and government payers.

Mesfin Tegenu, CEO, Chairman, RxParadigm

RxParadigm

PBM (pharmacy benefit management)

PMS (pharmacy management services)

Vanquishing Hepatitis C: A Remarkable Success Story

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In this episode, we interview Dr. Steven Pearson, the founder and President of the Institute for Clinical and Economic Review (ICER). Over the past 16 years, ICER has evolved from a Harvard research program to the independent authority on cost-effectiveness and value of new drugs. Dr. Pearson has been an advocate of “Fair Pricing for Fair Access” and in January 2023, ICER published their 2nd Annual Assessment of Barriers to Fair Access Within US Commercial Insurance Prescription Drug Coverage.

Dr. Steven Pearson, Founder, President, Institute for Clinical and Economic Review (ICER)

Institute for Clinical and Economic Review (ICER)

Barriers to Fair Access Report 

Gross-to-Net Bubble

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In this foundational episode about drug pricing, we interview Dr. Jamie Robinson, the Leonard D. Schaeffer Professor of Health Economics, and Director of the Berkeley Center for Health Technology at the University of California, Berkeley. Dr. Robinson is the author of 3 books and 150 peer-reviewed articles on health economics and drug pricing.

James Robinson PhD, MPH, Chair, Health Policy and Management Division, Berkeley School of Public Health

Clarification on term “drug pricing”:

Nomenclature for this episode refers to the price of drugs from wholesale acquisition or list price. Other prices include the price of patient cost sharing or hospital/physician administered medication.

Biosimilars

Generics Versus Biosimilars

PBMs (Pharmacy Benefit Managers)

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This episode features an interview with Peyton Howell discussing the evolution of patient access over the past three decades, the creation of the hub industry, and the continuing challenges faced by pharma companies and service providers in supporting patient access to medications.

Peyton Howell, Chief Operating and Growth Officer, Parexel

Parexel

Lash Group

Genentech

Biologics

How Automation Is Transforming Healthcare Jobs

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