Who Wins and Who Loses in the Snowball of Drug Pricing Proposals Coming Out of Washington, With Josh LaRosa (EP243)

Will All the Drug Pricing Reform Proposals in Washington Actually Stick — or Just Blow Over? Episode 243.

Big vested interests always want to maintain the status quo, and the drug supply chain is no exception. So here's the $106-billion-a-year question: will the wave of drug pricing proposals moving through Washington and state legislatures in 2019 actually change anything, or are Big Pharma, PBMs, and insurance carriers well girded enough to withstand them? In this episode, Stacey Richter talks with Josh LaRosa, MPP, policy associate at Wynne Health Group, to get up to speed on what's actually being proposed and what it means for the drug supply chain.

WHAT YOU'LL LEARN

✅ Whether health care legislation has reached an inflection point, and what obstacles stand in the way of Congress actually passing anything

✅ Which proposed measures are most likely to pass — and which would be most disruptive to the drug supply chain if they did

✅ How a catastrophic benefit proposal and the International Pricing Index Model would work, and why they'd have some of the greatest industry impact

✅ How the FTC could bring transparency to PBM contracting by mandating what's actually in those contracts

✅ Why brand and generic manufacturers face different pressures — and what generic reform would need to break down

WHY THIS MATTERS

It's easy to lose track of the sheer number of drug pricing proposals moving through Washington at any given moment, and just as easy for stakeholders with the most to lose to run out the clock waiting for public attention to move on. Understanding which proposals have real teeth — and which are more bark than bite — is the first step for anyone trying to figure out how the drug supply chain might actually change.

=== LINKS ===

🔗 Show Notes with all mentioned links: Episode Page

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00:00 Introduction.

01:48 This conversation happened at the end of August 2019.

02:32 Are we at an inflection point with health care legislation?

05:10 What obstacles stand in the way of seeing any legislation passed by Congress?

06:14 Most likely to happen and most disruptive among the health care measures being proposed.

09:03 The catastrophic benefit and how it works.

16:34 International Pricing Index Model.

20:12 The two areas that would have the greatest impact on the industry, if they transpire.

21:07 Federal Trade Commission (FTC), PBMs, and drug pricing.

21:46 Mandating PBM contracts, and what it would take at the FTC.

22:27 Bringing transparency to the forefront of PBM contracting.

27:10 Brand manufacturers vs generic manufacturers.

28:05 Breaking down barriers in generic reform.

The Price We Pay: What Broke American Health Care and How to Fix It, With Marty Makary, MD (EP242) "Billing Quality Is Medical Quality": A Conversation on What Broke American Health Care. Episode 242. If operating on the wrong leg is a medical error, what do you call operating on someone who didn't need surgery in the first place? In this episode, Stacey Richter talks with Dr. Marty Makary about his book The Price We Pay: What Broke American Health Care—and How to Fix It, covering both basic price gouging — surprise billing and predatory pricing at scale — and the second, subtler category: high total prices driven by unnecessary care. WHAT YOU'LL LEARN ✅ Why hospital bills are so often overinflated, and whether Americans are actually responsible for paying marked-up sticker prices ✅ Why Dr. Makary argues we should call it "predatory billing" instead of softening it as "bad debt" ✅ Why billing practices often happen without hospital leadership even realizing it — and what that means for accountability ✅ Concrete advice for hospital administrators, board members, and employers on how to start restoring honesty in health care pricing ✅ How overtreatment and the "crisis of appropriateness" drive overpricing, and why relationship-based clinics and "choosing wisely" approaches are part of the fix WHY THIS MATTERS Large hospitals are on track for the largest profit margins in their history even as patients, employers, and even hospital staff are hungry for honesty about pricing. Dr. Makary's framing — that billing quality is medical quality — reframes egregious pricing not as a side issue to clinical care but as a core part of it, which means fixing it requires the same rigor hospitals already apply to clinical outcomes. === LINKS === 🔗 Show Notes with all mentioned links: Episode Page ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter 🫙 Support the podcast with a small donation to the Tip Jar 🎤 Listen on Apple Podcasts 🎤 Listen on Spotify 📺 Subscribe to our YouTube channel === CONNECT WITH THE RHV TEAM === ✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X 00:00 Introduction. 02:11 Marty's new book and its multiple examples of egregious pricing in health care. 02:41 The reason why hospital bills are often overinflated. 03:31 "Are Americans responsible for paying these marked-up, sticker-priced bills?" 04:58 Explaining the complexities of medicine, simplistically. 07:27 Balancing stories of price gouging with responsible billing. 07:59 "Hospitals were created in America as a safe haven for the sick and injured." 09:29 How everyone can work toward changing this at the individual level. 11:23 "Have a conversation with your hospital." 12:59 Marty's advice to hospital administrators and board members. 16:56 "We can restore honesty in health care." 17:01 How billing practices happen unbeknownst to hospital leaders. 17:35 Bad debt and mischaracterizing bad billing practices. 19:12 "Why don't we call it 'predatory billing'?" 22:12 "People are hungry for honesty in health care right now." 23:25 "Large hospitals are on track for the largest profit margin in their history." 24:50 Marty's advice for how employers can help address these egregious prices. 25:47 "Billing quality is medical quality." 27:03 Overtreatment as an element of overpricing in health care. 28:07 The "crisis of appropriateness." 30:19 "How can we talk about the root drivers of poor health?" 31:18 The grassroots movement to start the health care system from scratch. 32:04 Relationship-based clinics. 37:08 Choosing wisely. 37:39 Improving wisely. 43:48 "People are willing to pay for quality, but they just want honesty."

Putting the Squeeze on Community Pharmacies, With Vinay Patel, Founder of Self Insured Pharmacy Networks (EP241) 65,000 Community Pharmacies Face an Existential Threat From PBM Pressure. Episode 241. There are 65,000 community pharmacies in the United States, and the total cost to locate, staff, and operate all of them is about 9% of national drug spending — less than 1% of total national health expenditure, and falling. In this episode, Stacey Richter talks with Vinay Patel, pharmacist and founder of Self Insured Pharmacy Networks, about the mounting pressure traditional PBMs are putting on community pharmacies, and what's at stake if that pressure pushes them out of business. WHAT YOU'LL LEARN ✅ Why community pharmacies matter disproportionately given how little they actually cost the system — especially since roughly 85% of the nation's prescription fills are unbranded generics ✅ Why many patients rely on walk-in pharmacies for same-day fills, pharmacist advice, and an extension of their care team — especially in rural areas where a pharmacist may be the only accessible provider ✅ How the three dominant PBMs — Express Scripts (ESI), CVS Caremark, and OptumRx — are increasingly squeezing community pharmacies through the pressures they apply on the demand side ✅ Who actually hires and pays these PBMs: employers, insurance carriers, and government programs like Medicare Part D WHY THIS MATTERS Community pharmacies operate on razor-thin margins relative to the value they provide, and PBM mail-order pressure threatens to push many of them out of business entirely. For patients — especially in rural areas — that's not just an inconvenience; it can mean losing the only accessible point of care they have. === LINKS === 🔗 Show Notes with all mentioned links: Episode Page ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter 🫙 Support the podcast with a small donation to the Tip Jar 🎤 Listen on Apple Podcasts 🎤 Listen on Spotify 📺 Subscribe to our YouTube channel === CONNECT WITH THE RHV TEAM === ✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X

Are Patients Consumers? A Definitional Deep Dive (INBW24) "It Is Tough to Be a Consumer When You Don't Have the Information You Need to Be One." Episode INBW24. Are patients consumers? Literally, by Webster's definitions, yes — a consumer is a person who uses or pays for something, and patients use and sometimes pay for health care. But the literal answer isn't the interesting one. In this episode, Stacey Richter digs into why the "consumer metaphor" in health care both illuminates and obscures what patients actually need, and why the question itself may be more useful than any answer to it. WHAT YOU'LL LEARN ✅ Why the literal, dictionary answer to "are patients consumers?" is yes — and why that answer isn't very useful ✅ How the "consumer metaphor" can erode physician professionalism and why some see it as a problematic way to talk about patient care ✅ Why patients are, in a meaningful sense, "basically incapable of achieving health care consumer status" in the current system — because being a good consumer requires information that patients often don't have ✅ Practical tips for patients who want to be better health care consumers anyway: being suspicious, getting second and third opinions from subspecialists, and more WHY THIS MATTERS Whether you call patients "consumers" shapes how the entire system treats them — as informed shoppers who should bear responsibility for their choices, or as people navigating a system that rarely gives them the information they'd need to shop well. Getting this framing right matters for anyone designing benefits, communications, or care navigation aimed at patients. === LINKS === 🔗 Show Notes with all mentioned links: Episode Page ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter 🫙 Support the podcast with a small donation to the Tip Jar 🎤 Listen on Apple Podcasts 🎤 Listen on Spotify 📺 Subscribe to our YouTube channel === CONNECT WITH THE RHV TEAM === ✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X 00:00 Introduction. 02:32 Why patients are not consumers. 02:41 A better way to define consumer. 03:15 When "patients are not consumers" is even more correct. 03:40 Where the definition of consumer starts to devolve or evolve. 04:17 The definition of consumer according to an article by The Hastings Center. 05:01 The "consumer metaphor" and eroding physician professionalism. 05:26 The problematic points at demonizing the consumer patient. 06:36 EP205 with Maya Dusenbery. 08:59 How "patient" may not be the best way to define our goals for the patient experience. 10:34 "It is tough to be a consumer when you don't have the information that you need to be one." 13:08 The paradox: Patients are not, and also are, consumers. 13:31 "The question itself is the answer." 13:41 "Patients … are basically incapable of achieving health care consumer status in this country today." 13:57 Things to consider for those who don't think patients should try to be consumers. 15:21 "If you're a patient … do the best you can to be a good health care consumer." 15:59 Tips for being a good health care consumer. 16:30 Articles on how to be a good consumer online. 17:00 "It pays to be suspicious." 17:15 Get second, third, and fourth opinions from subspecialists.

How Medical Travel to Centers of Excellence Improves Outcomes and Lowers Costs, With Olivia Ross (EP240) "If Operating on the Wrong Leg Is a Medical Error, What Do We Call Operating on Someone Who Didn't Need Surgery?" Episode 240. Quality metrics in health care today mostly assess care from a patient-safety standpoint — but they rarely ask whether the patient needed the procedure in the first place, or whether the outcome matched what the patient actually hoped for. In this episode, Stacey Richter talks with Olivia Ross, associate director of the Employers Centers of Excellence Network (ECEN), about how a curated network of centers of excellence is helping employers get patients to providers who not only deliver excellent outcomes but also only treat the patients who are truly appropriate to treat. WHAT YOU'LL LEARN ✅ How ECEN selects centers of excellence (COEs) — provider organizations that commit to prospective bundled payments for services like orthopedic surgery, oncology, and bariatric surgery ✅ Why COEs distinguish themselves not just by delivering excellent outcomes, but by only treating patients who are genuinely appropriate candidates for treatment ✅ How employers like Walmart, Lowe's, and McKesson use the ECEN network to intercept employees at the right point in their care journey ✅ How employees travel to a COE for care and are then repatriated back to their local primary care provider for follow-up WHY THIS MATTERS Most quality measurement in health care today stops at "was the procedure done safely," without asking "did the patient need the procedure at all." Medical travel to centers of excellence is one concrete way employers are trying to close that gap — steering employees toward providers who are rigorous about appropriateness, not just technical execution. === LINKS === 🔗 Show Notes with all mentioned links: Episode Page ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter 🫙 Support the podcast with a small donation to the Tip Jar 🎤 Listen on Apple Podcasts 🎤 Listen on Spotify 📺 Subscribe to our YouTube channel === CONNECT WITH THE RHV TEAM === ✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X