Narrator - Dr. Abel 00:00 Welcome to HelixTalk, an educational podcast for healthcare students and providers, covering real life clinical pearls, professional pharmacy topics and drug therapy discussions. This podcast is Narrator - ? 00:12 provided by pharmacists and faculty members at Rosalind Franklin University, College of Pharmacy. Narrator - Dr. Abel 00:17 This podcast contains general information for educational purposes only. This is not professional advice and should not be used in lieu of obtaining advice from a qualified health care provider. Narrator - ? 00:27 And now on to the show. Dr. Sean Kane 00:31 Hey, this is Dr. Kane. Before we start today's episode, I just wanted to let you know that the audio quality for Dr. jolly was a little rough in the first few minutes, but about six or seven minutes into this, everything clears up very nicely, and he's very easy to hear. So if you hold on tight, I promise you it's worth the wait, because the content he delivers is absolutely amazing. So with that said, on to the show, welcome to HelixTalk episode 137 I'm your co host, Dr. Kane, and I'm Dr. Patel, and the title of today's episode is it's time for PBM reform. How PBMs have hurt pharmacies and increased drug costs. And we actually have a special guest today to help us understand the complex world of PBMs and pharmacy drug price reimbursements and things like that. And that's Dr. Benjamin jolly, thank you so much for joining us today. Dr, Jolly, could you just kind of introduce yourself to the audience before we get started. Speaker 1 01:23 My name is Spencer and jolly. I am a pharmacist. I work at my family's pharmacy, at jolly pharmacy in Salt Lake City. I am a third generation pharmacist. My grandpa started our family business back in 1954 my dad joined the business. Then I joined the business, and I've I've done everything at the pharmacy, from nuts to bolts, from being a, you know, cashier to being a pharmacist. And also, I do consulting work with pharmacies across the country to help them understand this stuff. Dr. Sean Kane 02:01 Love it and Dr, Jolly, one of the reasons I reached out to you was you actually done a different podcast episode that totally blew me away. And I wanted to dive deeper into some of the topics that you touched on in that other episode. It really seems like you are very familiar with the PBM world and pharmacy drug price reimbursement world, and I think you're the perfect person to have on the podcast episode for that reason. Dr. Khyati Patel 02:22 Dr. jolly, the current state of pharmacy is business oriented and not cognitive service oriented. Currently, the model is dispensing of the product. And therefore, I think we ought to lay out the ground for our audience to understand what are all these acronyms really mean. So maybe we can start with the basics. And let's start talking about, you know, what exactly is a PBM? It's referred to as pharmacy benefit manager. Speaker 1 02:48 So a pharmacy benefit manager, PBM, they are, in my view, the quintessential middle man. You know that they have their fingers in in between every transaction. Practically, in pharmacy, particularly outpatient pharmacy, and they're trying to insert themselves into a lot of inpatient work as well. They negotiate a contract between themselves and a network of pharmacies, and they then sell that network to an end payer. So if, if you wanted to go start, I don't know, a manufacturing company, and you had, you know, a couple 1000 employees, you would need to provide, legally, you have to provide health insurance as an option to them once you reach a certain size as a business. And one of the essential health benefits is prescription coverage. Prescription coverage, generally, you want to provide, you know, a nice big network where your members can get drugs at any pharmacy in whole country, practically. And so you would, you the manufacturer would hire a PBM to to rent their network out to you. And so then the pharmacy would give a prescription to a patient, build a PBM for the service, for the service of delivering that prescription. The PBM, in working with the manufacturer, would develop, you know, the list of covered drugs. They work with the employers to determine these coverage decisions, what kind of co pays you're going to have, like, you know, you've got your $10 $50 $100 25% whatever. And so they, they built these massive computer systems to determine all sorts of things that go on. The price that a pharmacy is paid. They determine the whether a member is eligible or not, they determine whether a drug is on formulary or off formulary. If it is on formulary, what tier of coverage it is to the credit of PBMs, they've built an exceptionally efficient computer system for real time adjudication. Of prescription claims. So I can submit a claim for prescription, and seconds later, have a coverage determination, have a price, know exactly how much the pharmacy is going to be paid, know exactly how much the patient is going to have to pay. And that is that is unique in health care. So it's remarkable, but they have a lot of power as a result of being the middle of all this. Dr. Khyati Patel 05:28 And Dr. Kane, I think it's astonishing to think that there are three PBMs out there that control is about 76% of the market. You know, these are your Caremark, Express Scripts, OptumRx. And yes, there are three, and there is competition, but there are three giant ones, and it really kind of unfairly controls the market, and it leaves pharmacies and patients to kind of deal with the terms of the PBMs. And you know, the contracts are not agreed upon. It's more like a take it or leave it situation for the pharmacies Dr. Sean Kane 06:06 and Dr. jolly. I'm sure you can attest to this in your experience. You know if, if you want to contract with a PBM and they want to pay you, you know, 20% off of a WP for whatever branded products you have, but you have, but you want 10% off. You want some different reimbursement. I'm guessing that these PBMs are so large that you don't have a lot of negotiation process that happens in that contract. Again, it's this, take it or leave it. We're big. We don't have to deal with you, but if we want to deal with you, you have to kind of take our terms. Is that kind of how the market happens with these PBMs? Speaker 1 06:40 I mean, generally Yes, right. So I do the contracting for for the pharmacy where I work, and I have asked for modifications to terms, whether that be reimbursement, or, you know, the substantive terms of the contract, whether you can assign the contract, whether who has liability for what I've tried to negotiate these terms and have been flatly turned down practically every time. Just note that, take it or leave it. But like, literally, that was the response from one, one particular PPM was the terms from the terms you can accept contract or you can decline it, Dr. Sean Kane 07:19 you know. Dr. jolly, I think one way that we can talk about reimbursement and drug prices and appreciate kind of the monkey business, if you will, that goes on behind the scenes, is to come up with, you know, an example of how reimbursement actually happens. How is it that a PBM decides how much it will reimburse? How is it that a pharmacy decides how much you're going to ask for? Maybe we can talk a little bit about that. So clearly, a pharmacy can't charge $1,000 for a $1 drug and expect the PBM to pay $1,000 and the corollary to that is that clearly a PBM can't reimburse $1 for a $1,000 drug, otherwise pharmacies wouldn't stay in business. So there must be some kind of give and take process here to make sure that pharmacies are getting reimbursed and not overcharging PBMs and vice versa. How does this process happen? Sure. Speaker 1 08:08 So when a pharmacy submits a claim for reimbursement, they submit two prices, well, I guess three, they submit a charge for the drug itself. So the pills in the bottle, they submit a charge for the dispense fee, the fee for the pharmacist, professional service of determining that the drug is appropriate and so forth. And then they also submit what's usually just the sum of those other two numbers, a number called the usual and customary price, which would be the price that for this service you would charge someone who was paying out of pocket. Those are the charges submitted, but the charges are basically just a ceiling to how much the pharmacy will get paid. They don't represent what the PBM is actually going to pay in most cases, in in most cases, the PBM will have a contract with the pharmacy in which the PBM pays the pharmacy under what they call lesser of logic, which means you you pick four numbers and whichever one is the least the lesser of is the number that The pharmacy gets paid. So that would be the charge the usual and customary price, a discount off of a benchmark price called an average wholesale price, that would be some fixed percentage. It might be 10% it might be 12% it might be 20% it might be 30% and that depends whether it's brand or generic, and it'll all be laid out in the terms of the contract, of what kind of discount off of the average wholesale price that you would give, 30 day prescription, you would have one discount. 90 day prescription, you'd have a different discount. And then the fourth is for generic drugs, the pharmacy benefit. Manager develops a list of so called maximum allowable costs. This is similar on the medical side. If you've ever looked at your explanation of benefits, it might say that your physician submitted a charge for $250 for your visit, and then it says allowed amount $85 and then it says contractual discount would be the difference between that 250 and the 85 and then it would say plan paid $50 leaving you a $35 copay. The same kind of thing here would be the maximum allowable cost would be similar to that allowable amount. So the maximum allowable amount for that physician visit was $85 similarly, for any given product, say Lisinopril, five milligrams, the maximum allowable cost would be expressed as some amount of dollars per tablet. And for Lisinopril, for typical PBM, it's probably like four cents or something. Say, I'm submitting a claim for 90 tablets of lisinopril at at an independent pharmacy, the owner has control of the pricing and what price is submitted to to the PBM. They don't have control of what the Mac price is. So they do have control of that submitted charge. So they could submit a price of $10,000 if they wanted, the PBM is still only going to pay them four sets of tablet plus the contracted dispense fee. Jolly. Dr. Sean Kane 11:30 What you're saying is that basically, the PBM is going to pay the lowest amount of these numbers, which could be what the pharmacy asked for, what the benchmark or the AWP price minus whatever percent, or this MAC price, which is a list, typically, of generic drugs, where the PBM will only pay, you know, some ceiling amount based on whatever drug and how many of the tablets you're getting. Speaker 1 11:56 Right, yes. And in the case where a drug does go up in price, PBMs under most state laws, are required to have a so called Mac appeal process where the pharmacy says, hey, my price on this went up. You need to increase your price. There's no guarantee, though, that the PBM will increase their the price they pay, they just have to at least review the price change. And so I've submitted Mac price appeal several times to various PBMs. And sometimes the price will come up. Sometimes it will come up enough to cover the cost. Sometimes it'll come up enough to cover part of the loss on a prescription. Dr. Sean Kane 12:46 Dr. jolly, I feel like the situation here gets more complicated, because the PBM is going to reimburse the pharmacy, but also the PBM has to charge the prescription drug plan like Blue Cross, Blue Shield for the cost of, you know the coverage so well. Let's say Dr. Patel filled her atorvastatin, and the prescription drug plan is going to have their own price in terms of what they're going to reimburse. Is that correct? Speaker 1 13:11 I mean, so this, this is a complex concept, actually. So there are a lot of different ways that a PBM can be reimbursed for for the service that they provide to to Blue Cross, right? So you could pay a PBM just a flat, I don't know, 50 cents for every single prescription that they process through their system for you. And then I will also pay the PBM separately for the pharmacy reimbursements. So the $10 prescription, I'll pay the PBM $10 that that's what so called pass through pricing with a per prescription. They could also do the same kind of pass through pricing, but instead just charge a flat rate per person per month. And so you might just price it at $1 per person per month, instead of 50 cents per prescription. And then a third way is what you're describing here is so called spread pricing, where the PBM charges, the charges Blue Cross a higher price than they pay to the pharmacy. So the pharmacy submitted this price of, I don't know, $100 for a prescription. The PBM said, okay, but our Mac price is $10 so here's $10 and then the PBM goes to Blue Cross and says, They said it cost $100 and we negotiated it down. Please pay us $20 and so the the PBM now is capturing $10 of profit on that prescription. And if everyone involved in this understands how that works, and it's transparent of how much they're taking, this can be an acceptable way for a PBM to make money. But. But in most cases, that's that's not how it works. It's usually the health plan the Blue Cross probably does not have someone who understands what a WP is. They probably don't understand what an atorvastatin is supposed to cost. You could tell them that it cost $20 you could tell them it cost $50 and they would believe you. Right, they wouldn't push back because they don't have the sophisticated line item detail of what this is supposed to cost. This is at least until about five years ago. This was the dominant way to pay PBMs, was through spread pricing. The problem that you see is that Blue Cross thinks that they're paying pharmacies really, really well, but the PBM is taking the lion's share of the compensation, and so the the PBM is making tons of money, and the pharmacies are struggling. That's the biggest problem with this spread pricing is that you have this disconnect between how much is being paid for pharmacy services, and how much the pharmacies are actually receiving to operate their businesses Dr. Khyati Patel 16:07 and not to make things messy even further, but PBMs are actually allowed To get rebates or kickbacks on making certain medications preferred on their formularies, or making formulary exceptions. Speaker 1 16:27 I view this as a mafia tactic. You got Fat Tony who comes by your by your place, and says, you know, it's a nice business you got there'd be a shame if no one could ever buy your your products, because there's a guy with a gun telling him to go away. I mean, there's no, no guy with a gun involved in PBMs, but we have, you know, the the example of like Stig, latro versus FARC, Sega versus versus Jardiance are all very similar drugs. There might be a very small amount of additional clinical benefit to the one versus the other, and their price is somewhat similar as well. And so the PBM basically says to Bristol Myers, Squibb, that's a that's a nice drug you've got. There be a shame if no one could buy it, because it was not on our list of covered drugs. And so they negotiate a kickback, as you describe, a rebate in which the PBM will receive, I don't know, 20% 50% of the cost of that drug back after the fact. And from the drug manufacturer standpoint, this is a good thing, because then they edge out the competition. If you're with this Blue Cross plan, you can get Jardiance, you can't get Farxiga or steglatro Unless your physician demonstrates through a long appeal process that you've tried and failed Jardiance, that there's no better alternative for you, which seems exceptionally unlikely in diabetes. And so the PBM, basically, is now saying, anyone who's on our health plan, if they want an sglt Two inhibitor, they're getting jardians period. That means that now there's, I don't know, 1000 people that can only get Jardiance and not Farxiga or Steglatro. So from jardians perspective, that's great, and they're willing to pay some portion of their total price. That's the theory here. The practice is that this is now so entrenched in the industry that a PBM will say, Okay, last year, you gave me 40% discount. This year, I need a 45% rebate. It's it's a way to extract discounts out of manufacturers and to deal with the insanely high drug prices that we have in our country compared to the rest of the world. But it also means that now the manufacturer has every incentive in the world to increase their price by, I don't know, $10 so that they keep making about $60 a prescription. And so we see that drug manufacturers increase their price every year. They blame it on the PBM. The PBM says, well, they control the price, but then they're also demanding an increased rebate every year, and so the both of them get fat and happy at the expense of everyone else in the system. Blue Cross, Blue Shield. You yourself, Dr. Kane and Dr. Patel. Each of us pays more for drugs because the price keeps going up to compensate for these rebates that also keep going up. And I mean, in extreme examples, these rebates can reach greater than half of the total price of a prescription. In the case of insulin, Eli Lilly puts out a drug price transparency report every year, and they say that on a. Average, they paid out 50% of the cost of Humalog as a rebate. That's on average. That doesn't mean for every single every single payer, they paid out 50% that means that some of them paid, they paid 60 or 70% some of them, they paid 20 or 30% Dr. Sean Kane 20:16 Dr. jolly, just to clarify what you're saying with these percentages, is that Eli Lilly said that PBMs got a kickback on average of about 50% of whatever the manufacturer Eli Lilly initially set the price for, and that rebate was more or less an exchange or quid pro quo for having Humalog on the formulary, as opposed to Novolog. That's exactly what we're saying. Yes. Now I'm pretty sure I know the answer to this, but I just want to clarify, when the PBM receives that kickback or rebate, where does that money go? Does it go back to the patient? Does it go back to the health plan? Does it go back to the PBM? Speaker 1 20:55 If, if you believe the PBMs trade association, about 90% of those dollars go back to the plan sponsor, so Blue Cross would get back 90% of that money. That's if you believe their marketing materials, and maybe that's true. The issue with that marketing is the contracts between a PBM and a manufacturer are lengthy and include a lot a lot of different discounts, rebates, service fees, and so it's not just the rebate, per se. And so Blue Cross might be getting 90% of the money that they said was a rebate, but they won't get any of the money that was a service fee, or any of the money that was a discount. A lot of the money is probably going back towards the plan sponsors, I have to believe that at least, at least a fair amount is but it depends also on the size and the savvy, I guess, of that plan sponsor, because Walmart probably is very competent in negotiating with their PBM to extract most of that rebate back from the PBM, whereas Joe's taco stand here in Salt Lake City, I don't know. I'm just making up a company they don't really exist who has, like, 100 employees, probably doesn't have the savvy to know what to ask for in their contract with their PBM, and so they probably get nothing back. It depends. In some cases, the patient might receive some portion of that as a basically as a discounted co payment. Like the school district here in Salt Lake demands their their PBM care Mark tells us to dispense brand Adderall, XR, rather than generic amphetamine salts. Er, even though they're therapeutically equivalent, they want us to dispense the Adderall because they get a rebate, and Adderall would normally have a brand copay of like 50 bucks for them, but when we adjudicate the claim, it comes back as a $10 copay. So in some cases, the patient gets the benefit of of that rebate in the form of a lower CO payment. And in other cases, it goes almost entirely to the plan sponsor. And in in some cases, it goes to the PBM practically exclusively. So it depends on who, who the negotiating parties are. Dr. Khyati Patel 23:25 It is astonishing to understand the math behind and then for us to hear arguments, you know, on TV, or the politics about what's happening in terms of lowering drug cost. And a common man, a mom, showing up at your counter for, you know, prescription pickup doesn't understand what goes behind in calculating a copay, and usually it becomes the person behind the counter selling the drug responsible for, why are you charging me so much for my prescription, you know, and the bottom line here is that it is much more complex than as a common or our patients, as common men, understand how the drug prices are decided. That brings us to further discuss yet another acronym. We call it dir fees, direct and indirect and remuneration fees. Can you kind of provide a little bit of background on where these dir fees for pharmacy came from? And you know, where are we with those now? Speaker 1 24:32 Yes, I do want to touch on something you said as you were closing out that last bit though. You know, you hear politicians all the time saying, We got to bring drug costs out. We got to drink bring drug costs down. The remarkable thing to me, when I look in the data, is the actual amount paid for prescriptions over the last three years has gone down in total after you account for these rebates. Because these rebates are so large. Amount actually paid out for prescriptions on average across the country has gone down, not up. And the reason that we have this disconnect between politicians and the actual reality of of how much money is being spent on drugs is because the average person doesn't see these price negotiations happening, and they don't care about the difference between the PBM paying the pharmacy $5,000.05 $1,100 they don't care about the manufacturer getting 5000 versus $4,000 for a prescription. They care about the prices that they see at the pharmacy counter, and those prices keep going up because PBMs and plan sponsors like Blue Cross keep increasing deductibles and increasing co pays. I just wanted to make that comment before we moved on to Dir. But yeah, so dir is yet another acronym that exists in the world of pharmacy pricing, but dir is, is a term that is codified in Medicare regulation. Dir stands for direct and indirect remuneration. And remuneration means, you know, payment. And we're talking about this from the perspective of the plan sponsor, so and this this, we're again talking Medicare, not Medicaid, not commercial business. We're talking Medicare coverage for folks that are over 65 years old and folks that have disability. So this concept of direct and indirect remuneration is basically all of the money that a prescription drug plan sponsor in Medicare receives outside of their premium and risk corridor payments from CMS. So this includes those rebates that we were just talking about. What we're particularly talking about when we say dir fees is so called pharmacy price concessions. That's what Medicare CMS calls these In short, this is the same kind of tactic that a PBM plays with the manufacturer to extract these these rebates. They pit pharmacies against each other for preferred pharmacy placement. So if you look at a Medicare Plan Contract with a patient, it'll say, if you go to a preferred pharmacy, you pay $1 copay for a tier one generic. If you go to a standard pharmacy, as they're called, you'll pay a $10 co payment. And so this, this originated with back in like 2010 about I was a technician at the time. Actually remember this, Walmart had become the preferred pharmacy for Humana, and so we kept getting all of these transfer requests from Walmart, and just tons of business flew out the door to Walmart, because Humana had said, we are preferring Walmart over jollies pharmacy. So the patient's copay would be, you know, $1 versus $10 depending on whether they went to Walmart or jolly's. And in exchange for that, Walmart accepted a lower price, or they accepted terms of the these price concessions of they would pay back to Humana some portion of the cost. That concept has now metastasized across all of Medicare Part D, so that practically any Medicare business that a pharmacy has will have an associated dir fee. For example, a pharmacy might sign a contract that says that for brand name drugs, we'll pay you a WP minus 11% and then you'll pay us 10% of that back later as a fee. Dr. Sean Kane 28:56 Sounds like these fees are kind of built into your contract for Medicare patients, and what's going to happen is that within the contract there's some agreed upon fee called the DIR fee, that is going to have implications for how the pharmacies reimbursed. Then, is that correct? Speaker 1 29:12 Yeah, and they're not always called dir fees in the contract. Some PBMs call them contingent performance fees. Some PBMs call them Performance Network program fees. I mean, it's it's all ostensibly tied to some kind of performance metric for quality of pharmacy service delivery. I say ostensibly tied to it, because that's the justification for taking these fees. The actual fees themselves are very, very much just a financial game. So you'll have this, you know, extremely complex protocol that says, Okay, we're going to measure these four things from you pharmacy, and we'll measure how. Many of your patients are taking their drugs on time? We'll measure how many generic fills you do. We'll measure what proportion of your patients with diabetes have a statin on board. And then we'll turn all of that into a score for your pharmacy. And then we'll take some portion of your payments back based on how your pharmacy does. That sounds great in theory, right? If you're better at your quality metrics than someone else, then you get better payment, right? But the reality is that the difference between a pharmacy that is perfect at these and the pharmacy that does not care at all, and their patients never take their drugs on time, is in most cases, 2% out of $100,000 of sales. We're talking $2,000 which isn't which isn't nothing, but it's also not like this huge concept, especially when you consider that these fees can be as much as 40% of the total cost of the drug. What one plan has a dir fee that's between 39% if you're perfect on your measures and 41% if you are the worst pharmacy on your measures. This would be like if you dispense a prescription to someone for eloquence, the PBM will say, Okay, we'll pay you $100 for this, and then the patient picks it up, and then the pharmacy will then have to pay back a fee to the PBM for brand name drugs. Say, say, our contract says it's 10% so PBM will pay me 100 bucks. I pay them back $10 six months from now. And by pay, I mean they just take it out of my next check. It's not like they send me an invoice. You owe us $10 they they just take the $10 out of your next payment. Dr. Sean Kane 31:59 Dr. jolly, what's going on here, then is, you know, when a patient is filling that prescription at the time of the counter, like when they're picking it up, these fees are not implemented in the reimbursement at that time. It's almost retroactive. In the case of months down the road, you just don't get reimbursed as much as you normally would, because that PBM is taking back this fee that you, as a pharmacy owner, wouldn't even know about the fee, per se, unless you looked at your contract at the time you know that you signed the contract to fully understand what you're actually getting reimbursed now and also several months from now, when those dir fees kick in. Is that correct? Speaker 1 32:37 Exactly, yes. And in fact, I talked to a pharmacy on Saturday who was doing a lot of a drug called spravato. It's a medication to treat depression. And they were buying this drug for, I think, $450 and then the PBM was reimbursing them $465 and then they didn't realize that there was a 15% fee on that, on those prescriptions. So 15% of $465 we're talking like a $70 fee. The pharmacy only made about 15 bucks on the prescription to start with. So the owner, when I was talking to him, he had like, 30 or $40,000 of sales of this drug to a Medicare plan that was taking back this 15% fee, and so he was in the hole $75 on every single one of these prescriptions that he had sold for the last two months. And he's outlaying all of this money to buy the drug, give it to his patients, thinks he's making money, right? And then when he actually gets paid, or when the PBM comes and takes the money, in about six months, he's going to be in the whole $75 on each one of those prescriptions. So you can't, you can't have a sustainable business model when you when you're losing $75 every time you give someone a prescription, it doesn't work. Dr. Khyati Patel 34:06 So talking about all these fees and how pharmacies are losing business, I've heard that there's some changes at the law level happening. I know that Arkansas took up a case that was heard by Supreme Court, and that was one of the big deals, and a lot of other states have kind of joined similarly to fight against these rules and logics of the PBMs. Can you fill us in on what is coming in the pipeline as far as the laws and regulations are concerned, Speaker 1 34:43 absolutely so there are a lot of a lot of movement on lawsuits. There's a lot of movement on state laws being passed to reign in the biggest abuses of PBMs. But to me, the most exciting thing because it crosses industries. It. Not just pharmacy that it affects is the Federal Trade Commission, who's in charge of competition policy, has a spine again, in particular, the Biden administration, appointed in the Senate, confirmed a new chair for the Federal Trade Commission, whose name is Lena Khan. She is this brilliant lawyer, she was a business journalist, and she and and her colleagues have changed the position of the Federal Trade Commission just over the last five months. When she was she was confirmed back in April, and she's changed the direction of the Federal Trade Commission for the first time in 40 years, in the direction of being more concerned about business structure and about the market structure that we see, rather than for the last 40 years, basically, the government has said, oh, yeah, you can merge whatever. I don't, I don't care. Even if it says that mergers to monopoly are legal, you can merge. But they've taken the position that this is this is harmful to the government. It's harmful to the citizens. It's harmful to small businesses to allow large companies to just merge and merge and merge and merge and merge. The most obvious example in our industry of of a merger that I don't think should have happened is actually two. One is the merger of CVS pharmacy and Caremark PBM, and then the second merger of of CVS Health with Aetna. So you have this now integrated monopoly, vertical monopoly, that goes from health plan to PBM to pharmacy, it's all one company. So there's all sorts of problems with that business structure, but the Federal Trade Commission has basically said that they have the they are planning to investigate past mergers like that and potentially sue to overturn those mergers. They have a pending case against Facebook that says that Facebook bought Instagram and attempted to buy WhatsApp in an illegal manner under under the antitrust law. This, this, to me, is the most exciting thing that's happening in in the world of a pharmacy, I spoke to the Federal Trade Commission. They had their first public meeting where you could see what the commissioners were doing in 20 years. In July, I spoke to them for one minute and said, Please investigate PBMs and wholesalers. And then this last month, the APHA CEO, Scott kenore spoke to the Federal Trade Commission and said, Please Be bold. Break them up. These PBMs are too big, they're too integrated, and it kills our profession. Break them up. And similarly, the current president of the National Community Pharmacy Association, Brian Caswell, also talk to the Federal Trade Commission. This is a sea change in federal government policy towards big corporations versus small businesses. And I am, I am so here for it. Dr. Sean Kane 38:15 Dr. jolly, I think that sounds really exciting. Clearly, there are some changes that need to happen to have a fair playing field, but also to make this whole thing a little bit more transparent, you know, for the patient, for pharmacies, for everyone, so that how reimbursement occurs and that we're wasting money, right? Expediting the process and making it more efficient probably is in everyone's interest. Speaker 1 38:38 Absolutely, yes, and I'm excited to see where we will be in five years, because I do not think that the vertically integrated entities that exist today that are destroying community pharmacy will exist as they currently do. In five years, I think that they'll be broken up Dr. Sean Kane 39:01 well, dr, Jolly one, I wanted to thank you for your expertise. And time two, for the audience, we've just barely scratched the surface in terms of some of the reimbursement and facets of PBMs. So if you want to know more, the national community of Pharmacists Association and CPA, we have links to some of their documents to talk about PBM reform and Dr. fees and storybook on PBMs that I found very interesting and really helped help me understand this very complex topic. So if you want to see that, if you go to our website, HelixTalk.com, we're episode 137 you can see references to those we're also on Twitter at HelixTalk. So we love hearing from our audience, and we always put out some clinical pearls from past episodes that you may find useful. And then finally, we love the five star reviews in iTunes, so keep those coming as well. So Dr. jolly, again, thank you for your time, and with that, I'm Dr. Kane. Dr. Khyati Patel 39:56 I'm Dr. Batal, and thank you as well. Dr. jolly and. To our audience, study hard. Narrator - Dr. Abel 40:02 If you enjoyed the show, please help us climb the iTunes rankings for medical podcasts by giving us a five star review in the iTunes Store. Search for HelixTalk and place your review there Narrator - ? 40:13 to suggest an episode or contact us. We're online at HelixTalk.com thank you for listening to this episode of HelixTalk. This is an educational production copyright Rosalind Franklin University of Medicine and Science.