WEBVTT

METADATA
Video-Count: 1
Video-1: youtube.com/watch?v=HSt0Ix69zd0

NOTE
MEETING SECTIONS:

Part 1 (Video ID: HSt0Ix69zd0):
- 00:11:56: Opening Remarks: Healthcare Costs and the MVP Plan
- 00:18:21: Renell Nolan: Affordable Coverage Requires Transparency and Trust
- 00:24:25: Debbie Ralph: Personal Experience and the Illusion of Coverage
- 00:30:17: Kathy U: Healthcare Consolidation and 340B Drug Pricing
- 00:37:56: TJ Woodard: PBMs, Vertical Integration, and Market Distortions
- 00:46:45: Open Conversation: Consumer Access and Advocate Roles
- 01:00:21: Individualized Policy Needs: Affordability vs High Deductibles
- 01:15:02: Public Policy Impact: Advocate Engagement and Gag Clauses
- 01:22:50: Price Transparency: Empowering Patients and Market Tools
- 01:34:13: Employer Insurance Costs: Impact on Business Growth
- 01:39:24: 340B Program: Reform and Benefit Concerns
- 01:45:18: ACA Fraud: Unscrupulous Agents and Loopholes
- 01:49:35: Public Comment: Engaging and Leaning-In to Research
- 01:55:12: Public Comment: Innovative, Private Sector and Patient Needs
- 02:01:20: Public Comment: Accountability and the Costic Business
- 02:07:29: Concluding Remarks: A Shared Responsibility


Part: 1

1
00:11:56.000 --> 00:12:11.680
The Senate Committee on Health, Education, Labor, and Pensions will please come to order. You know, uh, I talked to a lot of folks, and when you speak to people right now in Louisiana or across the country, the ability to afford things is

2
00:12:11.680 --> 00:12:29.200
the biggest issue. Uh, one example is healthcare. Way too expensive. So, premiums are climbing and even those with coverage face thousands of dollars of out-ofpocket costs when they seek care. Um, and I'll speak to my

3
00:12:29.200 --> 00:12:43.680
colleagues in the Senate and they'll say, "This is a great policy." I said, "Man, it's got $3,000 deductible. Do you think the average family has $3,000 just to sit there and um uh just to sit there and u uh when their child has an ear, go

4
00:12:43.680 --> 00:13:00.720
get it cared for?" And the answer is no. They don't have that kind of money in order to do that. So I have found as a physician practicing for many years that when you give the patient the power of knowing what the price is and the patient the power of controlling her

5
00:13:00.720 --> 00:13:15.440
healthcare dollar then prices tend to come down. And so we have to address not just the cost of health insurance but the cost you pay before the insurance kicks in. And that's what we're really going to look for. Uh, now one example

6
00:13:15.440 --> 00:13:31.440
I'll tell you. I was once in um DC. We have a crawfish bowl every year. You're all welcome when you're in DC. And there's a woman who found me on the street. She goes, "Hey, you're Dr. Cassidy." I said, "Yes, I am. I'm from Texas." Well, that's great, but you're not my voter.

7
00:13:31.440 --> 00:13:48.320
And she goes, "I saw your YouTube talking about price transparency and how if I paid cash and called the person doing the procedure, doing the X-ray, I could get a better price." And so my they ordered an MRI for my son. It was going to cost $2,000 for his shoulder. I

8
00:13:48.320 --> 00:14:05.199
called the MRI place and I said, "Uh, how much if I pay cash?" And they said, "Oh, you pay cash, it's not $2,000, it's $600." >> Well, her deductible was $2,000. So she already saved money. And she goes, "What if I pay you with cash and not a credit card?" "Oh, we'll give you another

9
00:14:05.199 --> 00:14:20.639
discount if you don't pay us with a credit card." So the fact is that she had the power of controlling the healthcare dollar but she was also through her own initiative knew the power of price transparency and she saved lots and lots of money. So that's

10
00:14:20.639 --> 00:14:37.760
our goal. So so I've introduced a bill we call the MVP plan money and value for patients the MVP plan. And it does exactly exactly that. using the tax code, it would forward money into an account

11
00:14:37.760 --> 00:14:54.480
that the patient would control. I always use the feminine because women rule the world, of course, and they certainly rule the healthcare expenditure for the average family. And so, you send it to the mama's account and she controls that dollar. Now, if it goes to the insurance company, we know that 20% goes for

12
00:14:54.480 --> 00:15:10.959
overhead and for profit. That's just a given. Instead, 100% goes for the care that she knows she needs. and it puts her in control of the money that she would use to pay for her child's healthcare. So imagine someone in Lafayette, her her daughter has an ear

13
00:15:10.959 --> 00:15:26.320
ache. She could pull out her phone and she could say, "Urtent care center near me, which has the best price." Now, we're going to team this, by the way, with tools being developed that are able to scrape and find out where what what

14
00:15:26.320 --> 00:15:41.600
the actual cash cash price is for various places. This is being developed. I've seen this happening now. It's being used now. So, she would say urgent care center near me, which has the best price for a routine visit for an earachche. It

15
00:15:41.600 --> 00:15:57.600
would pop up. It would say, "If you go down the street to the left, there's going to be a place they're going to charge $50. If you go down the street further, it's going to cost you $150." She is going to be able to shop for that care for her daughter as easily as she might shop for the best price for

16
00:15:57.600 --> 00:16:14.160
gasoline. Now, now this is a real situation. When I practice, I practice medicine in a hospital for the uninsured and the poorly insured and but it doesn't have to be there. You can see examples of the mother trying to balance the cost of

17
00:16:14.160 --> 00:16:30.560
care for her family versus other things she had to pay for. This is a real life example. I say if you make healthcare more affordable, you can also make gasoline and groceries more affordable because it's the same pot of money moving between the three. So let's make this more affordable and that will make

18
00:16:30.560 --> 00:16:45.199
the other two more affordable too. By the way, instead of families scrambling to pay bills, this makes life better for them. Most families, 60% of families will not have over $2,000 of healthcare

19
00:16:45.199 --> 00:17:01.680
expenditures in a given year. In our plan, we think that a family of four would have about $2,000. That would take care of 60% of the out of pocket. And I've got insurance people on here and they would say, "Wait a second. If the first $2,000 is covered,

20
00:17:01.680 --> 00:17:18.160
then probably I'd be selling them a policy with a higher touch point, which means the the premium would be as much as 10% lower." So, we're benefiting on the upfront cost. We're benefiting on the expenditure as regards the premium. So over time of course the health

21
00:17:18.160 --> 00:17:33.120
savings account accumulates if you don't spend it and that way it eventually covers the entirety of that gap. Now we can also get patients access to more affordable drugs and we hearing about affordable drugs by cutting that bureaucratic red tape that slows the

22
00:17:33.120 --> 00:17:49.840
approval of cheaper generics and biosimilars uh for the drugs that you infuse. By the way, my MVP agenda builds off of what Republicans are already doing. uh earlier this year a PBM reform bill that I negotiated, President Trump signed it

23
00:17:49.840 --> 00:18:06.000
into law, and this directly lowers the amount patients pay at the pharmacy counter. And his administration came and spoke to us about helping them write legislation for Trump RX, which will allow patients to buy drugs directly and transparently, cutting out bureaucracy

24
00:18:06.000 --> 00:18:21.360
and hidden fees. So, by putting money in the patient's pocket, delivering price transparency, the MVP agenda delivers what people in Louisiana have asked for, health care they can afford with power in their hands. Now, I thank the witnesses for being here. I will

25
00:18:21.360 --> 00:18:37.200
introduce each as she or he does their does their testimony. We're joined first by Renell Nolan, founder, president, and CEO of Health Agents of America, a national nonprofit trade association representing independent

26
00:18:37.200 --> 00:18:52.799
health insurance agents and brokers in all 50 states. She's a leading advocate for ACA enroles and agents, focusing on protecting consumers access to licensed professionals, reducing fraud within the marketplace, ensuring access to affordable plan options that fit their

27
00:18:52.799 --> 00:19:08.559
unique needs, and strengthening accountability within the ACA markets. Thank you, Miss Nolan. Please, >> Senator Cassidy, thank you so much for the opportunity to be here today. I'm here today to bring you a frontline perspective. The reality of healthcare

28
00:19:08.559 --> 00:19:23.280
affordability from the agents who sit across from the kitchen table from American families every single day. Let me be very direct. Health care is not just expensive. For many Americans, it's becoming unaffordable even with

29
00:19:23.280 --> 00:19:41.440
insurance. And agents and brokers are the ones delivering the message with once we are explaining to the family why the premium went up again, why their deductible is so high that they can't realistically use the

30
00:19:41.440 --> 00:19:56.640
coverage, why their doctor is no longer in the network, and why their plan they worked for and worked with last year does not exist. During this past open enrollment, we saw something very concerning. For the first time in a

31
00:19:56.640 --> 00:20:12.480
significant way, families who wanted coverage simply could not afford the coverage and couldn't purchase it. We had individuals making difficult decisions to go uninsured, not because they didn't value coverage, but because

32
00:20:12.480 --> 00:20:30.880
the cost was beyond their reach. We saw parents making heartbreaking decisions, choosing to cover their children, and going without coverage themselves. The crisis is real. And let's talk about fraud. The fraud is loud through a broke

33
00:20:30.880 --> 00:20:47.360
system. The federal marketplace has a huge hole which allows bad entities to come in and change Americans from one plan to another without their knowledge. This plan could be closed very simply by

34
00:20:47.360 --> 00:21:04.559
CMS implementing a two-factor authentication. We ask for that win. And I'd like to share an example from Louisiana. Husband and wife were reviewing their options during open enrollment. The husband had just had a transplant.

35
00:21:04.559 --> 00:21:21.120
He was on life-saving medication and coverage just wasn't optional. Their monthly premium went from $1,000 to $3,000 a month. With no meaningful alternative available for them, they had no choice. They look to borrow money,

36
00:21:21.120 --> 00:21:38.320
start a GoFundMe. They went to their church just to afford the premium. Not even talking about the skyigh deductible. This is not sustainable and it is happening. Agents are not the problem. We are the

37
00:21:38.320 --> 00:21:55.600
translators of a system that has become so complex and so costly the average American cannot navigate this alone. When affordability breaks down, comp consequences are real. People delay care. They skip medications. They choose

38
00:21:55.600 --> 00:22:11.280
between coverage and groceries. As the senator said, this is not a coverage issue. This is an affordability crisis. From our perspective, there are three drivers that must be addressed. First, rising premiums without

39
00:22:11.280 --> 00:22:28.400
corresponding value. Consumers are paying more, but they do not feel more protected. In many cases, they are paying for coverage they can't even use. Secondly, the instability in offerings of networks, constant changes, the

40
00:22:28.400 --> 00:22:44.080
confusion, disruption in care, and the road in the trust in the system. And third, barriers to professional guidance. When agents are removed from the process, whether it's through um reduced commissions, administrative burdens, platform restrictions,

41
00:22:44.080 --> 00:23:00.559
consumers lose access to the one resource that makes and helps them uh with those informed decisions. So, let me be clear with this point. When you remove the agent, you do not simplify the system. You leave the consumer alone

42
00:23:00.559 --> 00:23:18.080
in it. Agents don't sell policies. We advocate, we educate, and we help the consumer remain covered and protected over time. Senator Cassy, we sincerely appreciate your leadership, particularly your work with the greater transparency,

43
00:23:18.080 --> 00:23:34.080
accountability to healthcare. Those efforts matter and we strongly support continued progress in that direction. Transparency is a critical step towards restoring fraud, trust, and helping consumers understand the true cost of

44
00:23:34.080 --> 00:23:49.919
care and coverage. Affordability is not just the price of premium. It's about whether the coverage works when the people need it. It's about access, stability, and trust. And right

45
00:23:49.919 --> 00:24:07.840
now, Americans are losing all three. If we want to fix the health care system affordability in this country, we must continue to focus on transparency, accountability, and real world input impact on the people that we serve. Coverage should not depend on whether

46
00:24:07.840 --> 00:24:25.440
someone can fund raise to stay alive. I sincerely thank you for your time. >> Thank you, Rell. We're next joined by Debbie Ralph, owner of the Coffee Connection and Aadian Coffee Roasters, which I just learned does organic coffee.

47
00:24:25.440 --> 00:24:41.440
>> Yes. >> And she looked around and said there's no coffee here. So, you know, memo to staff. Um, she can supply it at a discount. As a small business owner, she is passionate about serving her community and deeply values improving the health of pe the health of people in

48
00:24:41.440 --> 00:24:58.159
our in our state. So, thank you for joining us. >> Yes, it's a pleasure. Thank you uh Senator Cassidy for the opportunity to speak here today. I am going to come at this at um in a personal way. Healthc care is often discussed in terms of

49
00:24:58.159 --> 00:25:13.600
percentages and billions of dollars. I am here to speak about those numbers and what they mean in real life. The human cost behind them. I'm going to talk about the real uh reality of survival.

50
00:25:13.600 --> 00:25:32.159
This is my personala account. In 2017, I suffered a heart attack. In that moment, my only concern was survival. I spent four days in intensive care unit under constant mon monitoring and

51
00:25:32.159 --> 00:25:48.559
receiving the uh kind of lifesaving care our medical system is known for. At the time I could only afford the catastrophic insurance. I could not afford uh healthc care coverage.

52
00:25:48.559 --> 00:26:06.000
But the moment I left the hospital, that survival uh came with a devastating financial consequence. The total charges when I was discharged was $11,000. My insurance paid 5300.

53
00:26:06.000 --> 00:26:26.000
So, my responsibility was $95,700 for a medical emergency that I could not prevent. I was left responsible for nearly the entire cost. I could not afford the coverage insurance. So, I could only take what I could afford at

54
00:26:26.000 --> 00:26:41.120
the time. So, the mathematical impossibility of of care. I'm going to ask, how is any working American expected to absorb $95,000

55
00:26:41.120 --> 00:26:56.320
in a medical bill? This is this was not simply a bill. It represents the cost of a home, my years of retirement, and my savings. It is placed on individuals at the most vulnerable when they are still

56
00:26:56.320 --> 00:27:15.120
recovering physically and emotionally. The stress caused by this level of a financial burden is not abstract. It directly impacts health outcomes. In my case, the financial strain became a

57
00:27:15.120 --> 00:27:33.039
continued threat to my very heart condition that I had just survived. There is a systematic failure in billing and coverage. My experience reflects that. The illusion of coverage.

58
00:27:33.039 --> 00:27:51.120
Possessing insurance does not guarantee meaningful protection. When less than 6% of critical ICU stay is covered, the promise of insurance is fundamentally undermined. The charges of approximately

59
00:27:51.120 --> 00:28:07.120
$25,000 a day in ICU care are disconnected from financial reality faced by all American families. Patients are effectively placed between

60
00:28:07.120 --> 00:28:26.559
providers and insurers, absorbing the financial fallout or disputes over reimbursement. The financial stability becomes collateral damage. I respect I respectfully urge this committee this committee to take

61
00:28:26.559 --> 00:28:41.919
meaningful action to ensure that life saving emergency care is covered at substantial and a consist consistent level. No insured patient should ever face catastrophic debt due to gaps

62
00:28:41.919 --> 00:28:57.840
between provider charges and insurance payment. Yes, my doctors did save my life, but the financial aftermath nearly destroyed the st my stability. No American should have to consider in

63
00:28:57.840 --> 00:29:12.640
the middle of a medical emergency whether seeking health care will lead to a financial ruin. What I have personally experienced has changed my outlook drastically. It has shaped how I view my

64
00:29:12.640 --> 00:29:28.159
health and the importance of what we consume daily. This is not just a belief, but it's what I live out and I teach every day. I have dedicated myself to consistently reading labels and being

65
00:29:28.159 --> 00:29:45.120
intentional about everything that we do. I do I do choose to serve in my restaurant in my coffee shop in my cafes all clean products because I do feel that that is a start. I firmly believe

66
00:29:45.120 --> 00:30:01.600
that much of our health care can begin with greater aware awareness of being intentional in all we do. This is not a trend but it is a necessity. Thank you Senator for your time and consideration. Thank you for

67
00:30:01.600 --> 00:30:17.679
powerful testimony, Miss Hoop. >> Oh, I'm supposed to introduce you first. I'm sorry. Excuse me. Um, I was so intent on listening to the testimony. We're joined now by Kathy U, the CEO of

68
00:30:17.679 --> 00:30:34.640
the Pont Train Cancer Center, a treatment and cancer prevention center specializing in blood disorders and providing compassionate care to patients navigating difficult diagnosis. She's a leader in healthcare as she serves on several ancologic boards including those

69
00:30:34.640 --> 00:30:50.799
uh involved uh nationwide. She's a speech pathologist who earned a degree from LSU and helps patients rehabilitate from cancer, excuse me, cancer treatments. Thank you for being here. Please. >> Good morning, Chairman Cassidy, and thank you for the opportunity to speak

70
00:30:50.799 --> 00:31:07.760
on healthc care affordability. You know, first I'd like to acknowledge your your leadership in the work of the health committee on pharmacy benefit manager reform and 340B accountability. You know, these issues are central to whether patients can access timely

71
00:31:07.760 --> 00:31:25.440
affordable care. And as you've heard already today, our health care system is facing a deepening affordability crisis. Patients, employers, and taxpayers are all paying more while care is harder to access and

72
00:31:25.440 --> 00:31:42.559
disconnected from the vital physician patient relationship. And this problem is simply not cost. It's federal policy that has allowed marketplace to consolidate, distort prices, and reward institutional power over patient

73
00:31:42.559 --> 00:31:58.720
centered care. If I had to, you know, identify the root cause in one word, it would be consolidation. Hospitals have merged into dominant regional systems. Insurers have vertically integrated with PBMs,

74
00:31:58.720 --> 00:32:14.480
pharmacies, and physician groups. Independent community-based practices, including community oncology, are being pushed out by payment rules that favor large systems. This consolidation has raised prices,

75
00:32:14.480 --> 00:32:31.600
limited patient choice, and does not reliably improve quality. You know, independent community oncology like Poncha Train Cancer Center, we strive every day to deliver high quality cancer care close to where our patients live in

76
00:32:31.600 --> 00:32:47.120
our very own communities. But when those practices close or are required, patients are often shifted into hospital outpatient departments where the same drugs and services can cost far more.

77
00:32:47.120 --> 00:33:03.360
So, if I may be so bold, I would like to see Congress first implement sight neutral payment reform so Medicare pays the same amount for the same service regardless of the site of care of delivery. You know, current

78
00:33:03.360 --> 00:33:20.640
policy current often pays more because of ownership, not clinical complexity. Broader sight neutral reform could save taxpayers, employers, and patients billions over time. Second, I would like to see Congress,

79
00:33:20.640 --> 00:33:35.679
with your leadership, sir, continue your work on 340B, the 340B drug pricing program. This vital program has was created to support safety net care but has grown far beyond

80
00:33:35.679 --> 00:33:52.320
its original purpose. Hospitals are not required to pass those 340B savings directly to patients and 340B revenue can fuel hospital expansion. Physician practice acquisition and movement of cancer care into more

81
00:33:52.320 --> 00:34:09.520
expensive settings. I appreciate that you and this committee have begun asking the hard questions about whether 340B is serving patients as intended. Congress should build on that oversight by requiring transparency,

82
00:34:09.520 --> 00:34:25.839
patient eligibility standards, charity care obligations and safeguards to ensure 340B benefits patients in need rather than financing consolidation. And third, I would ask Congress to

83
00:34:25.839 --> 00:34:41.760
continue addressing insurer and PBM consolidation. The largest PBMs are no longer neutral administrators. They are part of vertically integrated corporations that own insurers, specialtyarmacies,

84
00:34:41.760 --> 00:34:58.079
mail orderies, and in some cases physicians and drug manufacturers. You know, the three largest PBMs control access to 80% of the prescriptions in the United States. This gives them enormous power over formularies,

85
00:34:58.079 --> 00:35:14.000
reimbursement, prior authorization, and pharmacy choice. For cancer patients, these practices can delay or deny treatment. At Pont Train Cancer Center, when we write a prescription and can dispense it through

86
00:35:14.000 --> 00:35:30.160
our pharmacy, we can often obtain prior authorization and start a patient on therapy in 24 to 48 hours. When we must use a PBM owned specialty pharmacy, we see an average delay of 5 to 15 business

87
00:35:30.160 --> 00:35:45.680
days. The son and daughter of one of our patients accompanied me to the hill during one of my first visits to your office where we had discussed how their mother experienced a 35day delay and

88
00:35:45.680 --> 00:36:02.800
passed away before being able to try her physician prescribed medication. We had that medication in our pharmacy, but we were not allowed to dispense it because her plan's PBM required use of their internal specialty pharmacy, but

89
00:36:02.800 --> 00:36:20.240
the insurer would not authorize it. We will never know what if that drug would have helped her cancer, but what it certainly did was delay that patient in her family of hope. And delays in cancer treatment are not

90
00:36:20.240 --> 00:36:36.240
harmless. They impact families. They impact patients and they impact survival. Congress should continue its work on PBM transparency. Prohibit spread pricing patient steering which does exist.

91
00:36:36.240 --> 00:36:52.079
Dellink PBM compensation from drug prices. Prevent mandatory use of affiliated. ensure that cancer prior authoriz decisions are made timely and reviewed by physicians with appropriate specialty

92
00:36:52.079 --> 00:37:08.079
expertise. Patients do not experience health care in silos. They experience it as a bill they cannot afford, a prescription they cannot fill, or a treatment that is delayed by prior authorization or

93
00:37:08.079 --> 00:37:24.800
because their far their physician is no longer in business. Chairman Cassidy, you know, I appreciate your leadership and the health committee's work on PBM and 340B reform. These reforms are about whether patients

94
00:37:24.800 --> 00:37:39.200
can get their care their physicians prescribe when they need it. And I urge this committee and Congress to continue its work on healthc care affordability, not to protect institutions, but pro to

95
00:37:39.200 --> 00:37:56.160
protect patients. Thank you. Thank you. Uh, next we're joined with, and I feel like I should almost recuse myself by my pharmacist. So, maybe a little bit of a conflict of interest as I sit here and praise him. Um, but TJ Woodard is the owner of

96
00:37:56.160 --> 00:38:14.000
Prescriptions to Go, that's G Aux, a local independent pharmacy with two locations in Baton Rouge. He's passionate about delivering health care services to his community. uh during the pandemic for example set up the immunization practice and did very well with that and um and by the way whenever

97
00:38:14.000 --> 00:38:30.960
I am talked to by independent pharmacists across the country they all happen to know TJ so TJ I'm not quite sure what it is ma'am but you've done a good job of connecting please >> uh thank you Senator Cassie and uh Miss thank you couldn't have set this up any better for me so u I'll try to be brief

98
00:38:30.960 --> 00:38:46.960
uh it's tough with the uh list of grievances that we need to address but Chairman Cass Y. Uh, thank you for coming home to Louisiana and for the opportunity to testify about the skyrocketing cost of health care. My name is TJ Woodard and my wife Amy and I are both pharmacists who own and operate

99
00:38:46.960 --> 00:39:02.960
two independentarmacies in Baton Rouge prescriptions to go. I am uniquely situated in this discussion as a patient, a provider, and an employer. I've seen the cost of care increase exponentially while quality and access have decreased. Like many providers, I spend way too much time navigating the

100
00:39:02.960 --> 00:39:19.520
unnecessarily complicated pharmacy benefits model. Time that would be better spent on patient care or efficiently running my small business. The bad news is this is a universal problem that affects every community in America and is an enormous expense to families, employers, states, and the

101
00:39:19.520 --> 00:39:34.960
federal government. The good news is there is a tremendous opportunity to write the ship. In pharmacy, we love acronyms. There's AWP, NAK, DI, GE, PSAO, and numerous others. I won't bore you by explaining these things that contribute to the unnecessarily

102
00:39:34.960 --> 00:39:52.480
complicated model that I just mentioned. Today, the only acronym that matters is PBM or pharmacy benefit managers. They are the single biggest problem in the prescription supply chain and a major contri contributing factor to the explosion of cost in healthcare in America. To be fair, not all PBMs are

103
00:39:52.480 --> 00:40:08.160
bad actors and the concept behind their creation was somewhat valid. To streamline the process for efficiency and cost savings, as Miss mentioned, uh that's certainly not what they've evolved into today. The big three, CVS Health, United Optimum, and uh

104
00:40:08.160 --> 00:40:24.960
Expresscript Sigma control 80% of the drug market. They are vertically integrated monopolies who dictate every aspect of patient care in America, and it is almost never for better care or lower costs. Good PBMs are those that simply streamline the process, are transparent, and charge a fee for their

105
00:40:24.960 --> 00:40:41.200
service. Think of using a credit card at a large department store to buy an assortment of products. They provide a valuable service and are paid a nominal fee for doing so. Unfortunately, the bad PBMs are the overwhelming majority of the market and their offenses are too numerous for my introduction. Not only

106
00:40:41.200 --> 00:40:57.119
are they driving up cost and negatively affecting patient care, they are putting out of business at an alarming rate. This is a real threat to access for millions of Americans and it isn't just independentarmacies. Ask right aid when Dixie or Target. This is truly a bipartisan issue that affects every

107
00:40:57.119 --> 00:41:12.640
community and many struggling small businessies in each of your communities. Not only can we put health care back where it belongs in the hands of patients and their providers. We can do it at an enormous cost savings which will make health care affordable again. I find it best to explain how

108
00:41:12.640 --> 00:41:28.560
devastating their behavior is by listing some of these activities and giving specific examples. Taken individually, they're obviously unfair trade practices. Taken together, they've created a healthc care climate that is unsustainable for most independentarmacies in America. If you don't believe me, ask any independent

109
00:41:28.560 --> 00:41:44.319
pharmacy in your state. Vertical integration. If I had to rank the PBM's activities, this would be the most concerning. I worked at CVS when the merger with Caremark happened, and I remember vividly that there would be a firewall between the two companies. Today, this is laughable, but it's much

110
00:41:44.319 --> 00:41:59.440
worse than we could have ever imagined. The big three PVMs that I mentioned are all vertically integrated and control an enormous percentage of the overall health care market. United Health Group generates more revenue than Ford and General Motors

111
00:41:59.440 --> 00:42:16.000
combined. The specific part of the vertical integration that is most troubling is that they are both the PBM and the pharmacy. This creates an obvious conflict of interest when I submit claims for payment to a PBM that also owns a pharmacy that directly competes with mine. In what world will

112
00:42:16.000 --> 00:42:32.000
we allow someone's direct competitor to dictate their payment terms and perform invasive on-site audits? I'm happy to elaborate on this concern, but in short, a company should be a PBM or a pharmacy, but not both. We've seen in Arkansas, Louisiana, and now Tennessee that they

113
00:42:32.000 --> 00:42:47.440
will go to extreme lengths to prevent this from happening. They've repeated the claim that if their vertical integration is prohibited, they will be forced to closeies, leaving pharmacy desert. This is quite telling that they would choose to close the pharmacies that often provide critical life-saving

114
00:42:47.440 --> 00:43:03.440
care to keep the PBM. The PBM is obviously the more profitable segment of their business steering. As I mentioned, we must submit patient health information to the PBM to process the claim. The PBMs often use this HIPPA protected information to market to their

115
00:43:03.440 --> 00:43:20.000
competitors patients and incentivize the use of their ownies. This is specifically pre prevented in some states, including Louisiana, but they do it anyway, often under the guise of ORISA preeemption, which takes me to another common tool they use, ORISA preeemption. We have passed many good

116
00:43:20.000 --> 00:43:35.040
laws in Louisiana, but our insurance commissioner can't enforce many of them because they are prevented by overriding federal law. The intent behind ORISA was sound, but is now being used as something of a get out of jail free card by the PBMs. I suggest suggest it should

117
00:43:35.040 --> 00:43:50.319
be reviewed and adjusted to fit the current landscape which has changed significantly in the last 50 years. If it isn't soon seniors with Medicare advantage plans will have a pretty card in their wallet that no pharmacy or doctor can afford to take. The Medicare Advantage plans are an enormously

118
00:43:50.319 --> 00:44:06.240
overinflated cost to the federal government and an enormous driver of profit for the PBMs. Which is why every other daytime commercial is an NFL legend selling you on their plan. This is a segue to another topic that I'd like to bring to your attention. Auditing Triricare. Triricare via

119
00:44:06.240 --> 00:44:22.560
Express Scripts provides pharmacy benefits to nearly 10 million active duty military personnel, retirees, and their beneficiaries. Express Scripts has administered the program for years and to my knowledge has never been audited. This is concerning and I think potentially offers an enormous cost-saving opportunity for the

120
00:44:22.560 --> 00:44:37.760
government payer of this program. Not only does Triricare prevent many independentarmacies from prevent participating in their network, but we also know they bill the federal government significantly more for some drugs than they than they are paying ouries. We've seen Express Scripts pay

121
00:44:37.760 --> 00:44:53.119
itself over $3,000 for on dancatitron, a common anti-nausea medication that should cost about $20. This should be audited and investigated after preventing vertical integration. The second most important step that should be taken is dellinking. This is essentially delinking a PBM's

122
00:44:53.119 --> 00:45:09.520
compensation from the price of the drug. This is a perverse incentive that often leads to a much more costly drug being placed on a PBM's formulary, and it quite clearly is baked into the overall cost of the medication. If a manufacturer must pay a rebate, which would be called a kickback in any other

123
00:45:09.520 --> 00:45:26.560
situation, to be included on the PBM's formulary, this will necessarily increase the cost of that medication. This defies logic other than it is a major profit driver for PBMs and the manufacturer must pay a sort of syntax to ensure their drug is covered in the market. For the sake of brevity, I'll

124
00:45:26.560 --> 00:45:42.000
stop there and simply list some numerous other PVM activities that stifle competition and a fair market and undoubtedly drive up the cost of healthcare. spread pricing, steering, audits, GPOs or rebate aggregators, prior authorizations, specialty drugs

125
00:45:42.000 --> 00:45:58.400
andarmacies, predatory contracts, closed networks, and below reimbursements. In a world that is unfortunately bitterly divided, there is a real opportunity in PBM reform. It is truly a bipartisan issue that affects every demographic in every community in America. If we really

126
00:45:58.400 --> 00:46:14.480
want to address a skyrocketing cost of health care, we must address the runaway trains that some of the PBMs have become. We should demand a free and fair market where costs go down and quality goes up. Breaking up their vertically integrated monopolies and dellinking their compensation from the cost of the

127
00:46:14.480 --> 00:46:30.400
medication are two things that would show immediate results. I'm happy to answer any questions and provide any specific examples. I represent myself and nearly 20,000 other independentarmacies in America that are in real danger of being driven out of business by a few but very powerful bad

128
00:46:30.400 --> 00:46:45.839
actor PBMs. We are begging you for help. We're simply asking for a level playing field and a chance to run our small businesses and take care of our communities. Thank you. >> So, um

129
00:46:45.839 --> 00:47:02.880
thank you all. Now this is a little bit of a different sort of a committee hearing in the sense that normally the committee members sit on the dis and those who are testifying testify to the dis. We're all in we're all here on the dis. So, I'm going to,

130
00:47:02.880 --> 00:47:19.760
if you will, kind of set the stage and allow more free flowing conversation because, as TJ said, Kathy set them up beautifully. But I think as TJ is speaking about addressing the high cost of insurance and the component of the drugs play, you two would certainly

131
00:47:19.760 --> 00:47:34.880
feature into that. So, if you will, I'm going to integrate this. But that said, after saying I'm going to integrate it, now I'm going to separate it. You two spoke about prescription drugs and um and specifically those things that would inflate the cost of the prescription

132
00:47:34.880 --> 00:47:49.040
drugs over and above that which the manufacturer would be charging. Whatever they're charging, you're both acknowledging that there is a premium we're paying way above that sometimes because of artificial policies, if you

133
00:47:49.040 --> 00:48:07.280
will. uh um I think I I think it summarized what you say almost uh collusion or or antitrust activities. Now, Rell and Debbie are speaking though of the health policy kind of in total. Uh, and uh, and I think Rell, I think I

134
00:48:07.280 --> 00:48:24.720
can safely say that you're about how do you allow the consumer to have access to the most information by which she can make the best choice and the key role that a uh, agent would play in that. I get that. I once tried to pick a Medicare Advantage program for my wife.

135
00:48:24.720 --> 00:48:39.680
Not to say that she's eligible. It was just a theoretical exercise. Uh, and uh, and you know, I think about this all the time. Finally, I said, "Baby, call a broker." You know what I'm saying? Uh, for your theoretical exercise because, you know, I'm just not I just can't figure this out. And that's on a

136
00:48:39.680 --> 00:48:54.319
dashboard specifically made theoretically to be um, consumer friendly. And and and Debbie, you spoke about the real life experience. So, let me start with you. Your credit catastrophic policy only paid 5,300. >> Correct.

137
00:48:54.319 --> 00:49:09.839
>> Now, how did that happen? catastrophic is supposed to pay everything above a certain point. >> Yes. Um that is the insurance that is what I chose that when it was all said and done that is what they paid. I went

138
00:49:09.839 --> 00:49:27.520
back and forth. I talked to them. I submitted um medical medical records upon medical records. I talked I I called I did everything I could and that is all they paid. Now, that was after the Affordable Care Act

139
00:49:27.520 --> 00:49:43.280
passed. And so, theoretically in the Affordable Care Act, policies that you know were fig leaf policies were banned, but nonetheless, you ended up with a fig leaf policy, unbeknownst to you. Is that >> Oh, absolutely. Yes.

140
00:49:43.280 --> 00:49:59.599
>> Okay. So, that aspect of the Affordable Care Act either poorly enforced or didn't work. Now, I will say that we now I don't know if one of the reasons they didn't pay was because your hospital was not in network. Was that one of the issues? >> Um, no, sir. The hospital was in

141
00:49:59.599 --> 00:50:17.760
network. Um, and this is what I went back and forth about um was at first they wanted to say it wasn't, you know, life life-threatening because there was no blockage. There was a the records stated, but there it was a heart

142
00:50:17.760 --> 00:50:34.240
attack and so they argued back and forth and back and forth and you know but it was a network. >> It was a network. I'm I'm pleased to say that signed into law I think in 2020

143
00:50:34.240 --> 00:50:52.000
um was the No Surprises Act which which I negotiated which now says that if the patient goes to a hospital whether in network or not was something that a reasonable person would deem an emergency that it would be covered as if

144
00:50:52.000 --> 00:51:09.440
an in-et network expense. Mhm. >> And it was precisely because of human stories like yours where someone would go to an in-et network hospital but a piece of machinery would be out of network >> or they were contracting for EKG services and that was out of network and

145
00:51:09.440 --> 00:51:26.319
they were getting these huge bills. >> Yes. >> I remember being in um press conference with President Trump and a fellow from Austin, Texas. He had gone into the hospital, came out with a $100,000 bill. Um, and and but he thought he had an MI

146
00:51:26.319 --> 00:51:43.920
cardio infuction, a heart attack. >> It's just crazy. >> So, the No Surprises Act ends that. So, so I'm I'm I'm pleased to say for one aspect of what you're speaking of that they were disputing that this was something they should pay for, that has

147
00:51:43.920 --> 00:51:58.559
been addressed. >> Good. And there are phone numbers which we can get on both the federal and state level that if someone has a no surprises if someone has a surprise medical bill that they can call one of these numbers

148
00:51:58.559 --> 00:52:14.800
and have an arms budsman intervene on their behalf. I'm told that this prevents a million surprise medical bills per month. >> That's wonderful. >> So so we're making progress on that even if we still don't have coffee. You assume someone say this but but I also

149
00:52:14.800 --> 00:52:29.440
applaud you for being for saying what you were saying about being intentional in terms of how you live your life in order to improve your health. >> Yes, that is a must. >> It is a must. >> I I I that changed my whole outlook on

150
00:52:29.440 --> 00:52:45.839
everything is to be intentional about everything I consume. um the drugs that are prescribed uh to me. Um I I'm very intentional about that. Um

151
00:52:45.839 --> 00:53:02.559
and and it shows in my coffee shop, in my restaurant, in my my coffee, in my roast, everything I do. Um you know, it does show that uh >> well, you know, >> very intentional. >> That's a nice >> education is everything. >> Education is everything. And and so that

152
00:53:02.559 --> 00:53:18.880
kind of goes into Miss Nolan because Rell, I once had two people I contacted when I was still practicing medicine and one called me up and she said, "Um, I have a health savings account. My cardiologist just ordered a

153
00:53:18.880 --> 00:53:36.160
liver scan. You're my liver doctor. Do I need the liver scan? If I do, I'll pay for it, but if not, I won't." And I said, "You do not need the liver scan." And she saved the money. She was quite intentional. There was another person with not my patient but someone who who was just wealthy just you know wealthy

154
00:53:36.160 --> 00:53:53.680
and she goes I just pay for the goldplated insurance policy and I don't ask questions whatever is ordered I get now that's fine that's a choice she had the money so I'm not at all criticizing that but for most people they don't have that luxury so what's in there is

155
00:53:53.680 --> 00:54:11.040
empowering the patients intentionality to be effective does that make sense Now, as a agent, how can we do that? >> I think one thing that's very important and gets misconstrued on every level is

156
00:54:11.040 --> 00:54:28.160
that every American is different. And you just described that everybody needs something different. And that's kind of where we play a role is knowing, you know, the family. What drugs are you on? What doctors do you have? What is your income? you know, everything that you

157
00:54:28.160 --> 00:54:43.520
need to help them find those plans that are best for them. And I think that's important, especially when Congress starts deciding what Americans need because I don't think Congress knows what we need. I think Americans know what they need. And I think that's

158
00:54:43.520 --> 00:55:00.240
important that the lady with a lot of money, if she wants to do her thing, she need she can do her thing, but the person who really doesn't have the money can ask the questions and they she knew where to go. Sometimes they ask their agents. Many times I send them to your office um because you guys have a staff

159
00:55:00.240 --> 00:55:16.319
that that helps them or whatever state that they're in. So it's important that we have options. >> So a couple things as I'm asking questions, y'all think of a question that you would ask each other because the insights each of you bring to the table. And I was interesting how all this fit together. Uh so Kathy's going

160
00:55:16.319 --> 00:55:30.960
to have a question for somebody for example. Uh and so just to brag on her. Um, the other thing saying how people are different. We we were we were recently I was speaking to some of my Democratic senator C colleagues and I and I was

161
00:55:30.960 --> 00:55:47.520
telling them, you're thinking that somebody getting a policy with a $4,000 deductible is going to meet their need. Most people don't have $500 in their checking account to pay for needed health care. Debbie, I see you're not in your head. I think that sounds like it

162
00:55:47.520 --> 00:56:02.480
was your experience. >> Yeah. Not to mention $100,000. >> Yes. >> So, Rell, the agent needs to do a screening, if you will. How much can you afford? But think about the total cost of being insured,

163
00:56:02.480 --> 00:56:20.480
not just the cost of insurance. Because if your deductible is here, you're not going to be able to afford that insurance. The money is going to the insurance company. It helps them a lot, but most likely you'll never use it unless you get in a car wreck or have cancer or get a heart attack because so

164
00:56:20.480 --> 00:56:35.520
what is your idea? >> It's a very complex decision because you take the premium and then compare it to different deductibles and you talk about you know what do you foresee? We don't know foresee everything but what do you

165
00:56:35.520 --> 00:56:50.720
foresee? Do you go to the doctor a lot? Do you have a lot of you know medication? Is it worth you paying a little bit more for a lower deductible or when you all when you spread it out on an Excel spreadsheet, it's better to get a higher deductible because you're never going to touch it.

166
00:56:50.720 --> 00:57:06.559
>> Okay. So, under my MVP plan, money in your pocket for your out of pocket coupled with tools on your phone to give you a sense of of where you can get the better deal.

167
00:57:06.559 --> 00:57:22.640
Um, imagine a family of four of $2,000 upfront in their pocket. What? Tell me in my mind, but you confirm that they could then buy a higher deductible policy, which would be significantly cheaper. Is that true?

168
00:57:22.640 --> 00:57:38.559
>> Right. If if they had the money set aside, and I'm assuming you're talking about like an HSA, something like that, if they had the money set aside, absolutely. That plays a whole um part of the decision that the agent has the conversation with them. here's this $200, here's, you know, you have this,

169
00:57:38.559 --> 00:57:52.000
and here's all your the things that are going to happen to you throughout the year that we know of. How does that play a role? And how does that help you save money on the premium or save money on a deductible? >> So, let's assume, let me just ask you, you may not be able to tell me this.

170
00:57:52.000 --> 00:58:10.240
Let's take um a family of four, the parents are 40 years old, everybody's normal health, and you give them 2,000 bucks into an health savings account. And so now they go from maybe a $2,000 deductible to a $6,000 deductible. How

171
00:58:10.240 --> 00:58:25.839
much would that on average, could you tell me, decrease their premium? >> I don't really know exactly two two to six is going to be significant. >> Like significant meaning $500 a year or $2,000 a year.

172
00:58:25.839 --> 00:58:42.319
>> Maybe half. Maybe cut it in half. >> Now wait a second. A family of four I just described could have a premium of 15,000 a year. Exactly. >> So, you're saying that that would cut their premium down to 7,500. >> It could. It could. Yes. Depending on all the factors because remember you're picking a PL you're not

173
00:58:42.319 --> 00:58:58.640
>> you're you're talking about a plane plan $1,000 uh $6,000 deductible 50/50 whatever. But it could have some bells and whistles. What if it has um you know co-pays in it? I mean, you can't really give a blank answer when there's all

174
00:58:58.640 --> 00:59:14.319
plans are complex and all plans are different and there's bells and whistles in each one. >> But but but but my estimate frankly from my chief economist chat GPT was that there >> was there be there' be about a 10% decrease. But that seems very reasonable to you. >> Yeah, absolutely.

175
00:59:14.319 --> 00:59:31.440
>> And so a 10% decrease and I would I'm guessing a family of four would pay about 1,500 15,000 a year for a policy or more than that. >> Definitely. I mean, like I said, the two people were 3,000. So, family four, you're going to hit 610,000.

176
00:59:31.440 --> 00:59:47.920
>> So, so first they're taking care of their out of pocket because they have money in their pocket to pay for the out of pocket, >> right? >> And then they're going to decrease their premium by 10%, in this case, a,000 bucks. So, they could be saving 3,000 a year just off the top, >> right? But the concern is, do they have

177
00:59:47.920 --> 01:00:04.720
the 3,000 to pay it to upfront? Well, that would be the health savings account preunded, >> right? But can they use premiums for that? Because you can give me 2,000 all day long, but if I can't afford to buy that premium to use that 2,000, I don't have the plan and I don't have the

178
01:00:04.720 --> 01:00:21.040
2,000. >> Now, right now, federal law does not allow HSA money to be used to pay for a premium, but at least the premium would be less expensive, >> right? So Kathy, your husband, as my wife says, she's from Alabama, your husband. Um, your husband, uh, y'all

179
01:00:21.040 --> 01:00:38.079
treat cancer patients. So, we've been talking in the kind of theoretical about patients being concerned about cost. >> By the way, y'all be thinking of questions ask each other. Okay. Uh so how often does somebody come into your

180
01:00:38.079 --> 01:00:55.280
office and the cost of treatment, the cost of medications is an issue to be dealt with? >> You were going to ask me that. So I actually did that research this week because at Ponta Train Cancer sorry um

181
01:00:55.280 --> 01:01:11.520
the way we the way we do things when people come into our office and need you know treatment is you know you contact their insurer you get their benefits plan and then we develop their treatment plan and it's what the insurance company

182
01:01:11.520 --> 01:01:26.720
will pay and what that patient out of pocket will look like based on their individual plan. And when we started doing this over a decade ago, if it was more than, you know, 25 or $30, we would look for assistance for them. So whether

183
01:01:26.720 --> 01:01:42.480
that was manufacturer co-pays, foundation, free drug, or anything in the PAP programs. Well, we quickly learned that $25 to all of us sitting at this table and in the room looked very different than for the majority of the

184
01:01:42.480 --> 01:01:59.760
patients that we saw. So we lowered that to $10. that's been our benchmark for probably eight years. So, I had a feeling you were going to ask me that and so I spoke to our financial counselors this week and as and just to give you a a sense of the magnitude, we

185
01:01:59.760 --> 01:02:17.520
treat about 1,200 unique patients a year through our infusion center. 43% of those people need some type of financial assistance to afford their care. 43%. And that's after theoretically they've

186
01:02:17.520 --> 01:02:34.000
probably exhausted their deductible because by the time they get to you with a cancer diagnosis they've seen lots of doctors and had lots of x-rays. >> Yes sir. >> And there's still an ongoing need for financial assistance. >> Yes. And then you know keep in mind you know January 1st and 2nd when that plan

187
01:02:34.000 --> 01:02:50.000
year rolls over we start all over again. Now, now we are speaking about the individual, the employer. >> Um, but let me ask you, you said something in your testimony about how

188
01:02:50.000 --> 01:03:07.280
the independent doctor's practice is less expensive than that which is owned by an institution. Uh, can you elaborate on that? Um, please. >> Sure. Well, I think quite

189
01:03:07.280 --> 01:03:23.599
>> less expensive for who? I guess less expensive for >> Well, less expensive for the for the patient. You we don't have the overhead that a large hospital system would. We we don't put people

190
01:03:23.599 --> 01:03:40.000
>> Let me stop you. Let me stop you. >> Go ahead. >> So, so let's imagine Debbie has to see somebody whose practice is owned by a hospital versus someone who's independent. Are you telling me and let's um this is not true of Debbie. Let's go back to my theoretical wife. Let's assume let's assume she's on

191
01:03:40.000 --> 01:03:55.119
Medicare or Laura. >> She's she's been moved into the theoretical realm. >> Let's assume somebody who's on Medicare. Yeah. >> So, I think you're telling me I think you're telling me that someone on Medicare who goes to a practice owned by

192
01:03:55.119 --> 01:04:12.240
a hospital will pay more out of pocket than that same Medicare patient who goes to a practice which is independent. >> That's true. >> That has been my anecdotal experience because remember, you know, an EOB from the hospital looks very different than

193
01:04:12.240 --> 01:04:27.680
one that we might >> EOB explanation of benefit. >> Yes. Um it's not just a pharmacist who like abbreviations. Uh and so going to that I I your your sight neutral concern >> that if someone is paying a

194
01:04:27.680 --> 01:04:43.440
hospital-based practice, they're going to pay a hospital part A type bill, which is significantly more than a hospital part B. >> So if your co-pay is 10% of something that's bigger is more than a copay of 10% of something

195
01:04:43.440 --> 01:04:59.119
which is smaller. So this actually means something to the patient. Um everything you're speaking of to their pocket, to their wallet, it means something for them. >> Well, also keep in mind that those bills from the hospital, you know, even if you're

196
01:04:59.119 --> 01:05:12.559
moving towards your part B and you're receiving your infusion in the hospital outpatient setting. I kind of liken it to buying a car. you know, you buy you enter into that payment term over, you

197
01:05:12.559 --> 01:05:29.520
know, $5,000 over 60 months in a hospital setting, you're moving towards satisfying that bigger car payment at a much faster clip than if you know they're treated in an in a community

198
01:05:29.520 --> 01:05:45.119
oncology setting. You know, additionally, and again, it's, you know, it's anecdotal because remember, I'm not also treating an infused patient at a hospital and my facility. So, I can't marry those EOBS together, although I'd

199
01:05:45.119 --> 01:06:00.480
love to. Um but we do hear of patients who have come to us after receiving treatment in a hospital and you know the level of support financial assistance

200
01:06:00.480 --> 01:06:18.559
support is what we hear is you know a value ad which I deem as a required service not a value ad in cancer care but also that they're moving to that ultimate dedu deductable in a much slower clip.

201
01:06:18.559 --> 01:06:39.039
>> So, um the um let me see here. Um got it. Um yes. Okay. So, um um TJ Kathy mentioned she has limited insight

202
01:06:39.039 --> 01:06:55.599
into what the explanation of benefits would be from a hospital-based practice. I was struck. You knew that Express Grips for Triricare charges $3,000 for a drug which is only $20.

203
01:06:55.599 --> 01:07:12.480
>> Yeah. And that was uh >> like how do you know that, man? Well, I I don't personally know it, but um that was actually kind of a a surprise insight when a pharmacist colleague was helping her mother uh fill a prescription via Triricare and tried

204
01:07:12.480 --> 01:07:29.680
to fill it at her own pharmacy and she got her mother's explanation of benefits from what they had been paying Triricare compared to what they then paid her pharmacy for the one-time fill. So, so what Kathy said she would like to do, you were able to actually do by by

205
01:07:29.680 --> 01:07:45.839
getting you were able to do. >> I'll give you a more extreme example. A a colleague mentor of mine called the plan himself from his pharmacy to compare to see why his explanation of benefits and his remittance advice,

206
01:07:45.839 --> 01:08:00.880
which is what we get at the pharmacy level, why they didn't match. Why there was more on the explanation of benefits. He was charged more than his pharmacy was remitted in payment and was actually told by the plan that that he was not

207
01:08:00.880 --> 01:08:18.799
supposed to know that information and was not supposed to discuss it and he could be kicked out of the network as the pharmacist. Shocking that he was both the patient and the and pharmacist. But it's so egregious that you know much like the gag clause that you helped uh pass on a federal level. We we for a

208
01:08:18.799 --> 01:08:34.960
point in time there, we literally couldn't tell the patient that they could get the medication off of their insurance for cheaper thanks to Senator Cassidy. That's been fixed at the federal level. But these things are so egregious, they almost seem unreal, but they are absolutely real. And they're huge numbers that, you know, those of us

209
01:08:34.960 --> 01:08:51.120
that just get stuck with a $100,000 hospital bill, you're you're stuck in the ether. What What do you do? >> Who do who do you call? Um to to Miss Ub's point of I had the same experience with an MRI I needed. It was

210
01:08:51.120 --> 01:09:06.640
significantly cheaper to pay out of pocket than what I was going to be build. And I went to a local independent uh provider of care and they were more than happy to do it for a third of the cost that it was going to cost uh through my insurance. So, you know, those of us that somewhat know how to

211
01:09:06.640 --> 01:09:22.640
navigate this world, uh there are opportunities. There are an awful lot of people that have nobody. Uh, so I I regularly refer people to brokers. My own mother when she's trying to select a a Medicare plan. I I live and breathe

212
01:09:22.640 --> 01:09:38.560
this world, but I don't know, especially an advantage plan that affects your doctor's uh she really likes her her physicians that she's had for years. She didn't want it to change. So, I referred her to a friend of mine who's a pharmacist and a a licensed broker so that he could guide her through it. Uh

213
01:09:38.560 --> 01:09:56.480
so let me ask you um again giving us insight into things. Um I understand you may have an example about a pharmacy benefit manager requiring a mail order for a prescription but it's not necessarily in

214
01:09:56.480 --> 01:10:09.679
the patient's best interest. Can you elaborate? >> Absolutely. Uh, I mean, I had one just this week when a patient was prescribed an inhaler that has a generic equivalent that's very effective. The plan would

215
01:10:09.679 --> 01:10:27.280
not cover the generic. The the plan required the use of the brandame drug. That's quite obviously because there's a rebate involved there. Um, the generic medication was exactly half the cost of the brandame drug. the patient had a

216
01:10:27.280 --> 01:10:43.040
higher co-pay because it was a brand name drug. I was reimbursed 25% below my cost if I dispense that medication. I told her to reach out to the insurance company and she could get it for no charge if she used the plans mail order to pharmacy to

217
01:10:43.040 --> 01:10:58.560
get the brandame drug. I mean, that's how that's that defies logic for for anyone that knows anything about economics. There's quite simply a perverse incentive there and the patient is kind of stuck between use a chain

218
01:10:58.560 --> 01:11:15.040
pharmacy or mail order pharmacy to get this medication that your doctor says you need, but they won't cover the generic equivalent that's very effective. So, let me just say this. Each of you has been an advocate. Debbie, you and I have not interacted before, but the other three of you, you have been. And people wonder how, wait,

219
01:11:15.040 --> 01:11:32.320
I'm I'm Jane or John Q public. How do I interact public policy in Washington? Each of you have just a couple examples. TJ mentioned the no gag clause bill when a pharmacist from Louisiana came from the Northshore came up and said,

220
01:11:32.320 --> 01:11:48.960
"Listen, Bill, I am being if I tell a patient it's cheaper to pay cash than paying their co-pay, my contract with a PBM will be cancelled." Mhm. >> We signed we we wrote a bill, got it signed into law by President Trump

221
01:11:48.960 --> 01:12:04.880
forbidding gag clauses. And so now there's no gag clauses because a pharmacist from Louisiana came to DC. Uh Miss Hub is such an advocate uh and has recently got access to a database, I'm

222
01:12:04.880 --> 01:12:20.480
not sure how, in which she can look at the impact of 340B in each state. And I sent her a list of states. please give this to me so I can share it with the senators who are on the health committee. Uh Renell has been such an advocate for how do we have um you know

223
01:12:20.480 --> 01:12:35.600
access for an individual to the sort of specialized care that she or he needs in order to understand the policy they need because it's all very nice to say put it on the internet and let people figure it out until my theoretical wife and her dumb husband can't figure it out if you

224
01:12:35.600 --> 01:12:50.719
follow what I'm saying. Uh and lastly, Debbie, you may not have been involved, but it was clearly cases like yours that led to the uh negotiation and the passage of the No Surprises Act. So, real life stories makes a difference. Let me continue on that. And some good

225
01:12:50.719 --> 01:13:09.040
news. We have passed a PBM reform bill that in the Medicare Part D and I think Medicaid bans spread pricing. I'm looking at my team to see if it includes Medicaid. Uh they're saying no, only Medicare. And then in the commercial space, it

226
01:13:09.040 --> 01:13:24.880
doesn't ban spread pricing, but I think it does about the same thing in the sense that it requires a 100% pass through of all rebates. And so if you are charging $2,000 for a $1,000 drug, but then you got to give

227
01:13:24.880 --> 01:13:42.480
the whole $1,000 to the employer, it's no longer to the PBM's advantage to be charging a rebate. It's just not. And we think what that will do is migrate people to a feebased, okay, we're going to charge this amount of money per prescription. We also have other things

228
01:13:42.480 --> 01:13:58.640
of transparency in there so an employer can look and say, "Whoa, I'm paying way too much for this drug >> uh when I compare it to what it should cost." So, so you know, I've been saying we're going to have an informal conversation. That informal conversation will become more formal when all of a

229
01:13:58.640 --> 01:14:15.600
sudden employers have access to the true price of a medication versus that which they're paying. I can tell you there's going to be somebody scraping what pharmacies are being reimbursed, what employers are being charged, and they're going to start kind of making those two look a lot more alike. Does that make

230
01:14:15.600 --> 01:14:30.480
sense? Mhm. >> Um, by the way, there was a pharmacy a PBM out of Nacadesh, uh, at that time called Southern Scripts, now called the Quinty, which was the one that acquainted me with the idea. And so, going back to Steve and his wife, uh,

231
01:14:30.480 --> 01:14:47.040
speak and speaking of individuals advocating, they really informed my understanding. So, so I, so before we go further, I'm just thanking y'all for your involvement. For those watching by live stream, absolutely, you can impact federal policy in our country. Uh, and and

232
01:14:47.040 --> 01:15:02.560
I somebody mentioned my staff. They are fantastic and they're going to take your input and pass it to me and we'll get it done. Let me pause. I don't know if any of you have a question for the other, uh, because you kind of represent different aspects of what we're speaking of, which is kind of why you were

233
01:15:02.560 --> 01:15:18.560
chosen. So, uh, Kathy, >> you asked me to, so I did write questions. So my first question actually is um for you TJ. How many of your you know your patients that come into your pharmacy are even aware of the gag clause? And I'm going to do the weave

234
01:15:18.560 --> 01:15:33.600
because I have a point. >> Uh I I don't probably a very small percentage. I I don't know that I always followed that uh requirement in my contract anyway because I can't morally or ethically. >> Well, now it's outlawed. Now it's

235
01:15:33.600 --> 01:15:50.159
outlawed. And you know, so I I kind of probably dance in the gray area some on that, but um a very very few, but very regularly we we we try to catch it constantly, but if there's an option for a patient to pay less. Now, we do give them the option because some

236
01:15:50.159 --> 01:16:06.000
surprisingly choose to pay more to get to the deductible faster, but it it should be the patient's choice, but if they can get it off of their insurance cheaper, they should have that option. It's it's oddly, I guess, a perverse incentive for us because sometimes we

237
01:16:06.000 --> 01:16:21.920
actually would be paid more if we charge that, but every independent pharmacy owner I know can't ethically or morally do that. So, very few know about it, but it's it's becoming more and more common, especially with uh Trump RX and Good RX and different things like that. Our our

238
01:16:21.920 --> 01:16:38.400
in-house plan is often not only competitive, but less than their co-ay would be. And then Miss Row, so you know, like I said, I'm I'm going to do the weave on something like the No Surprises Act.

239
01:16:38.400 --> 01:16:54.400
>> Was that something you were aware of >> um after the fact? This was in 2017 and this uh happened in 2020. Correct. >> Yes, I am aware of it as you know now. >> But then

240
01:16:54.400 --> 01:17:10.400
>> all I could think about was living, >> right? So it was very um >> well you said so and the reason I'm I ask is you said something earlier about education is everything and that is extremely true and that is yes

241
01:17:10.400 --> 01:17:24.800
>> where I'm trying to get at Senator Cassidy is you know with the no surprises act and the repeal of the gag clause you've really championed some very patient forward policy I worry that

242
01:17:24.800 --> 01:17:41.040
there's a lack of awareness and you the No Surprises Act. I'm aware of it because I remember exactly when it passed as well as the gag clause, but my parents were not. And my mother recently had an event and they sent her a full

243
01:17:41.040 --> 01:17:57.199
freight bill. And my father called and he's like, "What are we going to do? It's, you know, it's $11,000." And I said, "Well, Senator Cassidy passed this." And I sent him the I sent him the email and the law and everything. and I said, "You call

244
01:17:57.199 --> 01:18:15.120
that hospital back and you you send them that email." And it did go away. But that's only because my father had me. And so what happens to all of those millions of Americans that are unaware of some of these very patient forward

245
01:18:15.120 --> 01:18:31.920
policies that you you pass? So, so sometimes this way this transpires is that the insurance company or the provider will spend send the bill.

246
01:18:31.920 --> 01:18:49.679
The patient doesn't pay and so the provider then takes the insurance company. But if the patient doesn't realize that she should have her episode covered by the insurance, you're absolutely right. She may be paying when

247
01:18:49.679 --> 01:19:04.960
she otherwise wouldn't because it would be covered by insurance. And that's a great point, which is why we have these sorts of hearings because staff put it on the agenda. How do we kind of get out there that you have that protection

248
01:19:04.960 --> 01:19:20.880
because someone may feel obligated to pay $95,000 without recognizing no stop this has been fixed. >> Well, that that is my point is you know my parents have always been taxpaying law-abiding people and they thought they

249
01:19:20.880 --> 01:19:36.640
were just supposed to pay it but they didn't exactly have the funds at that immediate time to pay it. And so they called me because they were scared. And so how many Americans do we, you know, family, friends that are caught in these

250
01:19:36.640 --> 01:19:52.480
in these issues due just due to lack of awareness and I worry about that. >> Yes, Debbie. >> No, that's very good. Great point. I I totally agree with that. >> I think that's exactly where the agent or brokers come in. >> Yes. >> And if you have >> Say that again, please.

251
01:19:52.480 --> 01:20:07.440
>> It's exactly where the agents and brokers come in. If you have an agent or broker, the person's going to call and say, "I got this bill." and what should I do? And that's the point where we're going to educate them on um exactly what the laws are and do not ever pay. We always tell people do not ever pay that

252
01:20:07.440 --> 01:20:24.320
bill until you allow us to help you and it goes through the insurance and it you know goes through the process. So it's important education is I mean powerful. >> Yes, it is. >> And we all need to play a role but as an agent that's something that we do you know we bleed for our clients. We love

253
01:20:24.320 --> 01:20:39.920
our clients. We want to make sure that they're not caught in those situations where they think they owe money that they don't. >> If I may, I think that's a great there's a an example and and again in our pharmacy world that that comes up and I think you can make an economic argument

254
01:20:39.920 --> 01:20:55.440
for it. We see regularly patients on a fixed income that if it's the beginning of the year and there's they're in the deductible phase, they simply can't afford, let's use an expensive uh blood thinner that's very effective that someone may need after a stroke or a

255
01:20:55.440 --> 01:21:11.840
heart attack. Uh they simply can't afford the copay. Of course, we try to work with them and and find copay cards and things like that, but a lot of times what we see is either rationing where they try to make it last 3 months or they just simply don't take it or they self-medicate with aspirin over the

256
01:21:11.840 --> 01:21:29.760
counter, something like that. It's the ounce of prevention argument. What are we then paying? I I think we have an idea what we're then paying if that patient has a heart attack and goes into the hospital. So, I think there's an econ economic argument to be made and it's again it's education. We try to

257
01:21:29.760 --> 01:21:45.280
fight for our patients and let them know that there are opportunities and this is I'm a terrible businessman at times and sometimes we just give it away because uh they they truly need this medication and don't have another option. So it's it is the education. There are an awful

258
01:21:45.280 --> 01:22:01.280
lot of people that don't have folks that can help them or a broker that they trust and they do the best they can and they take a guess and and sometimes it's catastrophic. >> Yeah. We we shouldn't have to look for manufacturing coupons and all the things that we're doing to help them, but we

259
01:22:01.280 --> 01:22:16.400
have to because if they're not going to take it, they're not going to survive and we have to figure it out. And bless you for giving it when when they need it because some people just don't have the money. And honestly, as an agent, if I could pay for everybody's medicine and

260
01:22:16.400 --> 01:22:32.560
everybody's premiums, I would. But because it's heartbreaking, but we just can't. And and I'd like to ask the question, Senator Cassy, is and I and I we've talked about this forever, so I know you know, but why in the world can we search for the price of anything in

261
01:22:32.560 --> 01:22:48.719
America except for health care and medication? >> So, a couple things about that. Um, we are right now working on a piece of legislation. One, the No Surprises Act begin to put in price transparency. Uh, I'm a gastroenterenterologist, so this

262
01:22:48.719 --> 01:23:04.400
image comes vividly to mind. Um sometimes you would only tell p the person that they were going to be responsible for the cost of the care not covered by insurance when they're about to have a colonoscopy. They're sitting under a a thin sheet with shall we say

263
01:23:04.400 --> 01:23:20.560
dressed prepared for a colonoscopy or undressed prepared for a colonoscopy and you'd give 18 pieces of paper to sign one of which said you're responsible for anything the insurance doesn't pay. uh under the no surprises act, we changed that and so that the

264
01:23:20.560 --> 01:23:35.840
kind of estimated cost had to be presented to the patient prior to the procedure, not when they're in their, you know, um birthday suit, but when they're like wearing a suit. Uh and by the way, this is what we think it would cost you. So that's number one. Secondly, there's another piece of

265
01:23:35.840 --> 01:23:50.080
legislation we're working on right now called the Price Tag Act. Roger Marshall, Dr. Senator from Kansas and and uh John Hickinlooper from from Colorado are co-sponsors in which

266
01:23:50.080 --> 01:24:07.440
um in a more readable usable form hospitals would put forward that which they would charge for certain procedures and that which they're getting paid. What appears to be happening and there's a Wall Street Journal article about

267
01:24:07.440 --> 01:24:24.480
this. A patient comes to a doctor who's out of network, and I'm just going to make up numbers to illustrate the point, has emergency surgery, and the doctor charges the insurance company $100,000.

268
01:24:24.480 --> 01:24:40.400
The insurance company um negotiates with the doctor and pays them $30,000, but bills the employer $60,000 and tells the employer, "We saved you

269
01:24:40.400 --> 01:24:57.199
$70,000." No, they did not because they both knew the final price was going to be closer to 30, but they build the employer that much more. Now, this was an article in the Wall Street Journal. The question is

270
01:24:57.199 --> 01:25:12.719
whether or not it continues. If we're able to get not just what is being charged, but which is being paid, I can tell you there's going to be an industry which is going to aggregate this information, bring it to the

271
01:25:12.719 --> 01:25:27.679
employer, and say, "Wait a second. For your out of network charges, this insurer is padding their cost. this one is not. So, you may think that you're getting a better deal here, but on your

272
01:25:27.679 --> 01:25:45.760
out of network, you're paying far more. There's at least some suspicion that insurance companies are keeping providers out of network, deliberately, not contracting for them. And it begs the question whether this would be an activity so that they cannot indeed do

273
01:25:45.760 --> 01:26:03.360
exactly what I just described. um pad the cost of what they're passing on to the employer. So how did I launch into that? We are working on price transparency. Now secondly, um I got a great job and my job is I get to

274
01:26:03.360 --> 01:26:18.800
go speak to folks like you and speak to those who are entrepreneurial. But already there are people who are developing apps in which they have a large language model AI scraping all these EOBs that

275
01:26:18.800 --> 01:26:35.199
are public to find out if you go here for this procedure to see this doctor this is how much you get build. And so already you can say to your phone, where is the cheapest place to get an routine visit for my daughter's ear ache? That's

276
01:26:35.199 --> 01:26:52.639
already before we've even begun to to require the full publication of this information. And so when we say money in your pocket or MVP plan, money in your pocket, the value for the patient is going to come from the private sector using this information which is being put out

277
01:26:52.639 --> 01:27:09.840
there. So if, as Miss points out, if you go to a hospital-based practice and your co-pay as a Medicare patient is 10% of whatever your charge is, but your charge is higher over here and less over there, then you'll know my out of pocket will be less over here than it is over there,

278
01:27:09.840 --> 01:27:28.400
if that makes sense. So we think that these tools will work for the commercially insured patient and also for the Medicare uh patient. Uh you bring up an interesting point about triricare and so we have to think about that too. Um so so um all that to say

279
01:27:28.400 --> 01:27:44.639
the price transparency by itself is not helpful. The price transparency with the tools to use it is gamechanging. And you don't have to be uber sophisticated. You can be like my wife and me. We know how to use an app. My wife really knows how to use the Amazon app. I've learned. You

280
01:27:44.639 --> 01:28:00.560
see what I'm saying? And so that's the sort of thing that'll get you theoretically the best value. So yes ma'am push back on that. >> Yes ma'am. >> In the commercial space if that is the lowest you know site of care to get an MRI but does that mean then that the

281
01:28:00.560 --> 01:28:16.719
commercial insurer will authorize that site? >> So there's two things about that. Uh and Kathy of course is bringing kind of real life experience to this. uh if if you're paying for it with the money that is

282
01:28:16.719 --> 01:28:31.280
preunded into your health savings account, you control that money. You see what I'm saying? And so, um you control it. And so it isn't whether or not they are going to steer you to a more expensive

283
01:28:31.280 --> 01:28:47.840
drug or a more expensive facility. You control it. I was once on the Northshore going north on 90. Uh, I think that's 90. And there's a big billboard. Open MRI $200. Now, that could have been two to three

284
01:28:47.840 --> 01:29:03.600
to $4,000. But they were advertising open MRI 200 bucks. If you had the money in your pocket for your out of pocket, you would say the heck with the deductible. I'm going to go pay for this open MRI. So, uh, I took a picture of it at the

285
01:29:03.600 --> 01:29:19.920
time and there used to be signs for like eye surgery, you know, $200 per eye. Uh, so that said, you would control it. You bring up a good point. Do, you know, if you got a $6,000 deductible and you're paying out of pocket with this mechanism, does that count towards your

286
01:29:19.920 --> 01:29:36.639
deductible? And that would be one of our reforms. Yes, if you're paying for it. One more thing I should say, we should all be concerned about fraud. The people who are doing these tools also have a mechanism by which

287
01:29:36.639 --> 01:29:54.320
wait a second this guy's on the up and up. This guy's on the up and up. This person's a crook. And so they only will let people into their system who they know are on the up and up. If that makes sense. >> Lastly, because I can tell you that some of TJ and some of your um money that you

288
01:29:54.320 --> 01:30:10.639
get goes to overhead. The nice thing about it is Apple Pay or something similar where you would immediately pay and so instead of some of that money going to processing your claim, it's just going to be deducted from your account and so you

289
01:30:10.639 --> 01:30:26.239
get greater efficiency on the account as well. So, so we're just and by the way, I've learned people are doing this. All we're doing is catching up with what the private sector is doing. So, and so you would get of they pay you a h 100red bucks instead of 15 bucks of that being

290
01:30:26.239 --> 01:30:41.199
for your office overhead or probably more like $35 now it would be like $98 will be going to your support your practice and only $2 for overhead. So anyway, that's all good. So Debbie, do you pay for

291
01:30:41.199 --> 01:30:57.040
do you buy insurance for your employees? The only thing I offer them um at this time is um a supplemental, a life insurance or an accidental policy. >> So you have fewer so few employees you're not required. >> Correct.

292
01:30:57.040 --> 01:31:13.679
>> I have nine employees. >> Yeah, I'm sure you'd like to, but it's just hard. >> Yes. >> Now they can go on the exchange right now. Correct. >> I believe so. >> Yes. >> I was going to say we need an agent for you to come in and take care of those people and drink some coffee. >> There we go. See, trip to Ditter. There

293
01:31:13.679 --> 01:31:29.600
we go. >> And I can promise you there's a good insurance company in Ditter. >> And yeah, there there are many. Um, but we're getting ready to open another um coffee shop inside Borgard Memorial Hospital in Der. So, that will be the

294
01:31:29.600 --> 01:31:45.760
the second location. Then we're building our third. So, the employees, they're they're growing. And so I would really love to talk to see what I can offer to someone, you know, >> we can find you some. >> Yeah. >> And so just let me just say let me just back up from healthcare for just a

295
01:31:45.760 --> 01:32:01.199
second. >> Sure. >> And let me say on healthcare um the reason that among the reasons it's important to make it affordable for the employer is because you're growing. You're creating jobs. Um Southwest

296
01:32:01.199 --> 01:32:17.840
Ditter Ditter's lumber mill is closed. You need somebody like you creating jobs for other people. And every contribution someone like you makes helps the overall economy. If you're crushed by health care cost, you cannot create those jobs. So, it needs

297
01:32:17.840 --> 01:32:32.719
to be affordable for the patient, if you will, the consumer. It needs to be affordable for the employer because once you get to 50 employees, you're going to be required, >> correct, >> to provide insurance. So, so we've got to make it affordable for the employer

298
01:32:32.719 --> 01:32:50.239
to keep our economy moving. Uh, so, so thank you for being an employer. >> Thank you, sir. >> I I like the way that you decrease the stress in your life after your heart attack. You become an employer who's continually trying to expand your operations. Seemed like a real easy way to decrease your Hey TJ, that lowers

299
01:32:50.239 --> 01:33:06.880
your stress, doesn't it? I would have threeies compound compounding. >> Yeah. Right. I would have threearmacies if I didn't want to be married any anymore. But so yeah, I can attest to how how diff and we do we provide uh insurance to our

300
01:33:06.880 --> 01:33:24.320
employees. I really I not only do I want to, I need to to be competitive. Uh but it's a tremendous expense and and I wish I could do more. Uh but I I think we all hit on something including you, Senator Cassidy, on on transparency and we preach that all the time. That's the

301
01:33:24.320 --> 01:33:39.760
enemy of the the big bad insurance people is transparency because it exposes the true cost of these things. And you know to your point about saving the $70,000 that's the same thing they do with with the rebates and they have all these employers and HR departments

302
01:33:39.760 --> 01:33:55.760
and honestly state governments convinced that they're somehow saving them money and it's a it's a completely fictitious savings on what they wouldn't spend anyway. Uh, so transparency is always the answer. And I love the idea of putting money and decision-making power

303
01:33:55.760 --> 01:34:13.199
back in the patients hands so they can make the best decision for them for themselves. Um, they can often spend a little more on on premium to lower deductible like that or pay out of pocket for something and save money. >> Um, yes, I I smile. Um it's I've been

304
01:34:13.199 --> 01:34:27.360
told that it's always the husband who gets the last word in a typical marriage and the last words are always yes dear. And so I'm assuming that that's apparently in your case TJ. So um um >> may I jump in? >> Yes. Yes, dear.

305
01:34:27.360 --> 01:34:42.480
>> Because we are also an employer. So I I looked at this on the way here too in prepping for today. So, you know, we're a small employer, 25 employees, and in the last eight years, our, you know, at

306
01:34:42.480 --> 01:35:00.560
Pont Train, we offer a no deductible co-pay only plan for our employees. >> Oh, you do. You're generous. >> We try. I mean, it it really is important to our employees. We think it's a it's also allows us to remain competitive in the space. But also I I

307
01:35:00.560 --> 01:35:17.120
did go back and look and over the last eight years the premiums for an individual over that eight years have have gone up $500. So we have 24 patient I mean employees participating in the

308
01:35:17.120 --> 01:35:34.639
plan. And right now, as you know, I'm paying $1,700 a month per individual. >> Per individual. >> Yes, sir. >> Does that cover their family, too? >> No. >> That's a lot. >> I know.

309
01:35:34.639 --> 01:35:52.320
>> Now, can I ask are there people, for example, we know that um women who can have children probably I think it's illegal to charge them more, but it's going to increase the cost for your whole group. So because obviously pregnancy is is expensive. >> So I don't know if it's illegal now, but

310
01:35:52.320 --> 01:36:08.480
a year ago it wasn't. And so yes, we we have a majority of women in our plan that are of childbearing age. So yes, we opted into the maternity coverage. >> So So 1700 that is 17 that's $20,000 a year. Mhm.

311
01:36:08.480 --> 01:36:25.440
>> So, going back to what we were speaking, if you're able to give a $2,000 upfront to a family of four and now you have a $2,000 deductible instead of a 10,000 and Reell said at least it would save you 10%. It might save you more, then that would be $2,000 a year that you

312
01:36:25.440 --> 01:36:42.880
would be saving. Um, and and you said you have 24 employees, so that's $48,000 a year just run that. um which allows you to take another full-time or or halftime FTE. >> Yes. And you know grow my program add

313
01:36:42.880 --> 01:36:57.280
you know add more research you know trials to our to Ponta train or do do a lot of things with it. But I do want to also mention you know it was kind of interesting. I was talking to my 28-year-old yesterday and telling him

314
01:36:57.280 --> 01:37:13.679
about this. He is a budding actuary who works for a you know a very large insurer n in in the nation and he is he came clean yesterday. He's functionally uninsured.

315
01:37:13.679 --> 01:37:31.360
He has a high deductible plan. He has a health care need that he was talking to me about and he can't afford his medication >> and he didn't want to tell me. Now, we're going to deal with that, of course. But he was telling me about

316
01:37:31.360 --> 01:37:47.520
another friend in his pod, so they're all actuaries. And that particular friend had a car accident recently, went to the emergency room, and not out of network or anything, but he has he has to pay

317
01:37:47.520 --> 01:38:04.159
$4,000. So he is putting instead of saving for his home that particular ch you know I call them child they're young men is now paying off his hospital bill >> now theoretically he saved enough money in premiums if he had put it to the side

318
01:38:04.159 --> 01:38:20.080
he could have paid off that bill right but most people are not that even actuated >> right they're young and I mean I wasn't saving like that >> yeah and and that that's the flip you either have a high deductible and a low premium or a high premium and a low deductible And people make that choice

319
01:38:20.080 --> 01:38:37.040
and especially young. I'm invincible. I'm good. I'll just get the lower premium, the higher um deductible. But I I want to back up a little bit. Didn't the ACA add Medicare for everybody? Even men? Did that change? >> No. No. No. No. Medicare for everybody.

320
01:38:37.040 --> 01:38:53.280
>> Not Medicare. I'm sorry. Maternity. It was the other M. So young men pay more relative to the what other otherwise would to cross subsidize, if you will, the premium for the female. That's on the ACA. I thought they did that on the commercial insurance. You're you're

321
01:38:53.280 --> 01:39:09.840
implying to me that they don't. >> No, I I thought when the ACA was passed, because I remember doing presentations everywhere that it said maternity is the premiums included for men, women, women that are too old, didn't matter. That premium was factored in there. And I

322
01:39:09.840 --> 01:39:24.239
didn't know if anything had been changed, but that does affect the bottom line. >> It does. Um Um Yes. Yes. So, but yeah. >> Um anyone have anything else?

323
01:39:24.239 --> 01:39:40.480
>> Can I ask a question of of you your thoughts on the 340B program because that's kind of a hot topic now certainly in the pharmacy world. Uh, it's hyper complicated obviously, but it >> you obviously think there needs to be some reform.

324
01:39:40.480 --> 01:39:55.199
>> I do. >> What would you like to know? >> Well, I mean, are you are you a fan of the overall program? >> Yes. Yes. It Yes. You know, please don't misunderstand me. It is, you know, a vital I'm sorry. I'm always going to do

325
01:39:55.199 --> 01:40:11.199
that. You know, it is a vital program in its original intent, but it has been it is my opinion that that program has grown without, you know, lack of transparency

326
01:40:11.199 --> 01:40:27.119
and guard rails. And I don't see tremendous benefit to the patient at the end of the day. You know, we've been doing this for 20 years, >> and I have seen community oncologists

327
01:40:27.119 --> 01:40:44.560
and other specialties consolidate into the hospitals over time. You know, the AMA did a study, gosh, it was probably 10 years ago, that when a a 340B covered entity can bring in a prescribing

328
01:40:44.560 --> 01:41:00.800
oncologist within their four walls, it'll generate revenue of about a million dollars annually. >> Well, that was my point that I I think it's become a closed system and a significant revenue generator, especially for these consolidated hospital systems. Um just to give some

329
01:41:00.800 --> 01:41:16.320
brief background, 340B is a federal program that essentially if a patient qualifies that the manufacturer uh provides that medication at often a a much much lower cost than it would be commercially available. In our world it kind of started in rural hospitals so

330
01:41:16.320 --> 01:41:32.239
that they could you know a way for them to survive. And I don't participate, not because I I don't want to, but a lot of times these closed, especially big hospital systems, it's a they don't they won't allow you in their network. Um, their 340B network. So, not only are

331
01:41:32.239 --> 01:41:48.320
they the prescriber, they're the health care facility, the covered entity, and the pharmacy. It generates an awful lot of revenue. Uh, and it's kind of heartbreaking for us because that same patient that I was paid 25% below cost, that same entity would make an awful lot

332
01:41:48.320 --> 01:42:05.760
of money off of that. So, I think it goes back to fairness and transparency and uh it's it's it's becoming a bigger issue, the 340B program. Well, as I mentioned, you know, we've been doing this a while, so we've seen our, you know, our our areas contract

333
01:42:05.760 --> 01:42:22.159
>> and there aren't as many as independent physicians as there used to be 20 years ago. >> But, you know, in addition to that, you you mentioned the manufacturer needs to sell those drugs at discounts, >> but there's no reporting requirement on who they're administering those drugs

334
01:42:22.159 --> 01:42:40.000
to. And so, you know, simple math, if you're buying that drug at a 40% discount and you get to give administer it to a Blue Cross patient and get that spread, I mean, that's significant >> and that's, you know, if you look more

335
01:42:40.000 --> 01:42:54.960
broadly across the nation, you know, we're seeing that with hospital systems like Bons Secors and I'm sorry, you you know, I so they are a large health system in Virginia

336
01:42:54.960 --> 01:43:10.800
>> and they acquired a historically black hospital, Richmond community. And what they did over time is they drained Richmond community of its resources and essentially moved the the pharmacy,

337
01:43:10.800 --> 01:43:26.080
the infusion, everything into wealthier zip codes. And why would you of course do that? Well, that's where your more well-insured patients are. it it makes sense on paper. It is not appropriate patient care. It is not that is not a

338
01:43:26.080 --> 01:43:43.040
patient focused way of doing business. And so what it did is it stripped Richmond community of physicians and resources. Now you mentioned something about a closed system and that's something we're seeing also.

339
01:43:43.040 --> 01:43:58.880
um we are seeing certain 340B entities pass by laws that will no longer allow um hospital privileges to non 340B physicians and so that's I have several

340
01:43:58.880 --> 01:44:15.040
friends in other states that are now subject to that and that is stifling their ability to continue to deliver care and bring on new partners. Um there is a covered entity in this state that

341
01:44:15.040 --> 01:44:31.600
is starting to do that. They have not done it for oncology yet, but two years ago they went they did pass that into their bylaws for five specialties. Mhm. And so your concern is I think the concern is just for people who may not be uh as well verssed in the ins and

342
01:44:31.600 --> 01:44:47.760
outs of 340B is that there's academic data that when 340B is accessible, the there's an incentive to prescribe the more expensive medications. And TJ, you you referenced that a little bit. And so the person paying 8% as a co-pay would

343
01:44:47.760 --> 01:45:03.440
pay more out of pocket and the insurer would pay more out of pocket because there's an incentive to use the more expensive medicine. >> If there is a infusion drug of $100,000 and you're getting u some percent say 6%

344
01:45:03.440 --> 01:45:18.719
of that versus an alternative which is $20,000 and you're getting 6% of that. Um, that's one incentive, but the other is that you get the rebate of the $80,000 if you're with me. And so there's a lot of incentives to encourage people to use the more expensive

345
01:45:18.719 --> 01:45:35.840
medication even though the people paying are going to pay more. >> Rell, let me um this might be the last question for me, but others are welcome if they have another. During the debate of whether or not to continue the enhanced premium tax credits for the ACA, there a lot of concern about ghost

346
01:45:35.840 --> 01:45:51.280
patients that people were getting signed up that didn't know they were getting signed up and uh the agent was taking a commission. Uh by the way, I always say in every group there's 5% you want to take out back and shoot. I'm just

347
01:45:51.280 --> 01:46:07.760
kidding. Okay, I'm just kidding. But the point being there's 5% of every group that is just that that doesn't, you know, that the reputation ruins everybody else. In Congress, they say it's more like 15%, but I'll leave that there. Uh, but there's there was some unscrupulous agents that were signing

348
01:46:07.760 --> 01:46:22.639
people up who didn't know they were being signed up. The agent was pocketing the premium. There was a multiund million dollar type of penalty uh placed upon an agent from either Texas or Florida for doing this. So now we don't have zero premium

349
01:46:22.639 --> 01:46:37.840
policies, but I was told recently by someone, an agent, that she was still seeing these fraudulent policies being issued. And of course, I told her to let me know if she has some specific examples, but any thought on

350
01:46:37.840 --> 01:46:54.000
that? Because if you have a good program that the federal tax dollar is using to help a fellow American, there's no way to undermine support for that good program if there's widespread fraud. and then the good program is thrown out the window because of the fraud. >> I'm so glad you asked me this. I love

351
01:46:54.000 --> 01:47:10.719
this question. Um, what we first of all, I don't call them agents. I call them bad entities because they're I don't even like to put them in our industry. Um, but CMS has known forever that there's a hole in their system. It allows you to go into their system and

352
01:47:10.719 --> 01:47:26.880
put in name, date of birth, and state, which could be anybody. So if you have access to all these people, Jane Smith, whatever, you can go in there and change their plan. So that's there. That's why I was calling for a two-factor authentication. That's happening now.

353
01:47:26.880 --> 01:47:42.159
The fraud has slowed down some. They have I mean, we have to do two two separate two-factor just to get into our systems. But they have refused to close that hole. They eventually they have originally had >> Stop for a second. >> Yeah. >> We've met the enemy and he is us.

354
01:47:42.159 --> 01:47:58.639
>> Yeah. the federal taxpayers being ripped off because the federal agency will not close a loophole that allows people to conduct fraud. >> Right. >> Staff, are you taking notes? They're not in their head. Yes, for the record. Okay, that's great. >> So, you have these bad entities that are using this hole and you we talk about them getting commissions. They're

355
01:47:58.639 --> 01:48:14.320
getting $20 a month. So, we're not talking about a huge amount of dollars. Now, if you get bots involved and offshore accounts that we know that are happening that are are turning these people over and over again, then you can make some money. But the average person that you say goes in there and they do

356
01:48:14.320 --> 01:48:31.040
it and they made $20. That was not worth their time. But we do know and we feel that that little hole would solve a lot of the fraud. I mean, there's fraud, rampant fraud everywhere. But that is too easy. And I've said on on Capitol Hill so many times, "Let me put your

357
01:48:31.040 --> 01:48:46.800
name, your date of birth, and your state in and I'm going to show you." And I can't remember what senator was like, "No, don't do that. Don't put my name in there." Nobody wanted to see it. But it's true. it and it still is true >> and it's there. So, the fraud is happening. It's not happening as

358
01:48:46.800 --> 01:49:03.360
rampant. Um, >> but if it's not zero premium, meaning that, okay, I now have a place, >> right? If >> it's not zero premiums, it's harder um to move those people, those bad entities. So, it slowed them down. But I I personally had one that I sat down

359
01:49:03.360 --> 01:49:18.639
with, it was a clean one of my cleaning a cleaning lady. I sat down with her. She was Hispanic, barely spoke English. we changed her plan and somehow the marketplace switched her to United Healthcare and her plan got cancelled and she didn't have coverage for her family.

360
01:49:18.639 --> 01:49:35.119
>> So, there's still things happening. It's happening within the system and they just need to be addressed and and I talk to CMS daily. So, I do work with them and they're my friends, but we just need to figure out how to get them to take action. >> Okay. >> And that help? >> It does. >> Okay.

361
01:49:35.119 --> 01:50:01.679
>> Now, again, this is very informal. Is there anything anybody in the audience would like to ask one of our panelists? Yes, ma'am. >> Tell everybody who you are. >> Oh, sorry. I am really excited

362
01:50:01.679 --> 01:51:02.159
people. subscribers $10. I guess my question. I tell people to get loud. You see something, say something. You don't understand, ask. And I I've said it and I'll say it again. If you don't have an

363
01:51:02.159 --> 01:51:18.960
agent, call Senator Cassy's staff. He has everyone that will help you in a millisecond. I've never had anybody call me back and say, "They didn't answer the phone. They wouldn't help me." That's not true. They might refer them to an agent or a doctor or a cancer center.

364
01:51:18.960 --> 01:51:36.800
But yeah, just get loud. Don't keep don't assume that you have to take whatever you get from the doctor or hospital or from a bill. I mean, I'll add add to that from the pharmacy side and uh there are certainly good chain pharmacists out there. I'm

365
01:51:36.800 --> 01:51:53.599
obviously partial to independentarmacies. Um I would say establish a relationship with whoever that is, wherever that is. And if we don't know, which we often don't certainly on insurance products, we can generally steer you in the right direction. So don't ever assume it's

366
01:51:53.599 --> 01:52:09.920
it's okay to not know what you don't know. Um, and it's it's hyper complicated, I think, on purpose, but even from the prescribers side, they don't often know what they're sending us, what the patient's copay is going to be, or if it's covered or requires a priorization. So, we can certainly help

367
01:52:09.920 --> 01:52:25.520
most people navigate these things, but it's it's important to have that relationship so that you can go and ask. So when I talk to patient groups, I always encourage them to engage engage with their state and federal officials.

368
01:52:25.520 --> 01:52:42.800
Identify the problem clearly, but be solutionoriented. You know, communicating with your legislators is not meant to be a complaint fest. You know, we get that enough at home from our kids. you know, but they really, you know, Senator Cassidy and, you know, the people that I

369
01:52:42.800 --> 01:53:00.560
meet at the state legislature and on the Hill, they do want to help, but very often, what does that look like? And then what does that look like not only for that one patient, but across a broad spectrum? And how do you, you know,

370
01:53:00.560 --> 01:53:16.159
effectively legislate? But I always tell them engage, be solutionoriented, identify the problem and follow up. And then ultimately try to grow that relationship to be a resource. And that way you're

371
01:53:16.159 --> 01:53:34.639
always you're continuing that relationship not just for you and your family, but you know for the broader the broader ecosystem. >> Do your research. >> Good. >> Do your research. It's there. We just have to do it.

372
01:53:34.639 --> 01:53:50.960
>> Uh I will say summarizing, lean in. If you're going to go someplace, if you ask for the price, you get a much better price. There's a doc on the Northshore, a physician, and his wife is

373
01:53:50.960 --> 01:54:07.599
going for the mammogram. His deductible for the mammogram for his wife's mammogram was 150 bucks. He said, "How much he'll pay cash?" $98. I mean all but if you hadn't asked you would have paid 150 >> and so um so the key thing is um be

374
01:54:07.599 --> 01:54:24.400
forwardleaning um and and it used to be that you had to ask for generic equivalent. Now the pharmacist many years ago the legislature made it so that unless you say no give the name brand or prescribe as written the pharmacist can sub substitute. So your

375
01:54:24.400 --> 01:54:39.599
good pharmacist is going to try and save you money. Sometimes it's built into the system to save money. Not always. And and um u and you can say is there a generic for this? Because once I did go out of town, I was in DC and they or prescription for me and I said, "No,

376
01:54:39.599 --> 01:54:56.239
this is expensive. This is I think it was I think it was name brand." Uh and I said, "You can't give me a Oh, yeah. We can give you a we can give you a generic which cuts the price. I don't know what what's trrami >> pennies." >> Not much. Yeah. >> Yeah. Not much. So, so lean into it and

377
01:54:56.239 --> 01:55:12.800
you can save a lot of money. Uh, like the woman, the woman from Texas who stopped me to say, um, oh, I asked and now I was paying 600 than less than that because I was asking as opposed to just whatever it would have charged me. But thanks for being healthcare researcher

378
01:55:12.800 --> 01:56:01.480
and the gentleman sitting right in front of you and the woman right next to him helped run my healthare team and you can check with them to see if they're looking for help. Does anyone else have a question? Yes, ma'am. I don't know. years ago.

379
01:56:11.119 --> 01:58:50.880
He did one So going back to the innovation that I've seen in the private sector, once they've scraped and they found what is the likely price, the doctor then agrees to take that price if you're a member of this network. And so it won't be that they come back in and oh by the way

380
01:58:50.880 --> 01:59:05.119
we're going to charge you more after all. Now it's no you're part of this plan and you swipe your card or you do your face view and that is the payment paid and it's instantly settled. Now the doc likes it because the doc is

381
01:59:05.119 --> 01:59:22.000
instantly paid as opposed to not getting paid for six months and the billing is cut out so they're not doing 20% overhead for all their billing staff. It is like that. there may be a 3% credit card fee period in the story and if that's all the oops paid in their

382
01:59:22.000 --> 01:59:38.400
practice was a 3% credit card fee she'll be very happy on that. So so I do think we're rapidly progressing to that point. I you know my gosh if you made 24 phone calls uh whoa um that's pretty impressive. I I will

383
01:59:38.400 --> 01:59:54.560
say that it's never too late to ask though. So I say that because it may have been the person speaking to you was not the person equipped to give you the cash price. Uh there's a woman who's very active in this space called her name is Cynthia Fischer and she busted

384
01:59:54.560 --> 02:00:10.960
her ankle and so she went to a hospital in Boston and she goes in and she just is all about price transparency. And so she said, "How much is this going to cost me uh as a deductible?" And they said, "Your deductible is $3,000." And she goes, "What if I pay you cash right now?" Oh, you pay me cash right now? you

385
02:00:10.960 --> 02:00:27.520
write me a check, it's 800 bucks. And so you can even at the last minute, you can say, "Stop. I want to pay you cash right now." And they'll give you the cash price. Now, if you wait, they're going to charge you 3,000 bucks. But if you do it on the front end, if you're the kind

386
02:00:27.520 --> 02:01:04.040
of pushy broad that asks 24 questions before she says no, somehow I think you had it in you to ask one more time. Uh because you're impressive. Yeah, that happens. >> Staff, please take a note. Okay.

387
02:01:04.480 --> 02:01:20.639
>> Yeah, believe me, Stacy. you just sound like the kind of person who like Ronell uh who just is going to download a lot of information for us from a practical experience. So, thank you for that. Uh anyone else? Um Mark, you're the youngest guy in the room, but on the other hand, you're a guy, so guys typically know nothing

388
02:01:20.639 --> 02:01:48.800
about healthcare. Um but I'll open it up to anyone else who may want to ask who just has a real life experience, Mark, or anyone else as regards um how is this impacting you? my family and uh thank you. I mean, I'm my whole

389
02:01:48.800 --> 02:02:02.320
family's from Wisconsin, so I don't know the uh the the interstate applicability here. Um, one of the largest things, and this may be off topic, but it's it's non-feasence and malfeasants. Something that very personally affects

390
02:02:02.320 --> 02:02:20.239
me and my family is uh that how on the committee do you kind of balance ch you know creating I don't know what the the the word would be accountability and being able to hold

391
02:02:20.239 --> 02:02:37.920
you know in this case maybe for uh uh hospitals pharmaceut uh pharmacies for nonfeasants and malfeasants and but also not pushing the envelope and creating a a costic environment to to

392
02:02:37.920 --> 02:02:55.119
deal business and as you were getting at allowing the the private sector to flourish. So h how do you kind of in particular with with nonfeasants because where I'm from in the state of Wisconsin you can't sue for non-feasence. It's it's just untenable. No one will will take that case.

393
02:02:55.119 --> 02:03:11.760
How do you how do you cut that line? >> And how are you defining malfeasants? Uh well malfeasants non feas nonfeasants in in the case with my family it was a physician not taking action. >> A malpractice

394
02:03:11.760 --> 02:03:26.239
>> sorry >> malpractice. >> Not in their eyes. They uh my father was uh undergoing a medical event. They weren't fully aware of what was going on despite what we were telling them and they chose not to act. Um

395
02:03:26.239 --> 02:03:42.000
>> got it for 20 I think 24 hours. So, there's a couple ways to answer that. First, um um the mal malpractice typically is a um to the degree that would be malpractice. It's typically, in fact, it's almost always a state issue.

396
02:03:42.000 --> 02:03:59.280
Um and um you could argue that the federal government could step in because the federal government is the principal payer of health care now directly or indirectly in the United States. But there's Republicans who would say, "Wait a second. The 10th amendment of our constitution says that unless

397
02:03:59.280 --> 02:04:13.440
something is specifically delegated to the federal government, then that shall be that right shall be reserved to the state to regulate." And so, so the reason that you you rightly point out, Mark, what's the interstate applicability between Wisconsin and Louisiana? Because each state has the

398
02:04:13.440 --> 02:04:31.280
right to regulate its own everything that's not covered by the Bill of Rights. And so they would argue that that's a 10th amendment issue. So it may be that federal malpractice with very limited exceptions like good Samaritan laws uh will remain a state issue. But

399
02:04:31.280 --> 02:04:48.639
you also bring up another tension. How do we attempt to regulate without interfering in the free market? Uh and and and that's and that's a tension. But the way I look at it, when we buy stocks, the Security Exchange Commission has consumer protections.

400
02:04:48.639 --> 02:05:04.000
And those consumer protections keep me from being uh what was the term you used? You don't call them agents, you call them >> bad entities. >> Bad entities. That keeps me from being ripped off by a bad entity. Why do we do that? Because at some time

401
02:05:04.000 --> 02:05:20.239
in the past, there were bad entities that ripped off a lot of people. When there is someone like a Bernie maid off that attempts to do a Ponzi scheme, we now have federal protections against that. So when it comes to health care expenditures, we can say, "Wait a second, uh, we're going to pass the No

402
02:05:20.239 --> 02:05:35.760
Surprises Act, which takes the patient out of the middle and allows the provider and the insurance company to kind of sort it out on their own because this is a federal protection of a consumer. Similarly, when we talk about pharmaceutical cost and we can put in something which effectively is going to

403
02:05:35.760 --> 02:05:51.440
get rid of spread pricing by saying that all rebates need to be passed to the payor which would be the business owner and or the business owner's employees. That is not interfering with the free market as much as putting guard rails to make sure that one party which has all

404
02:05:51.440 --> 02:06:08.639
the information doesn't exploit another party which does not have that information. Does that make sense? So, uh, so there's a tension there. As a conservative, I want to make sure that we don't tie our society up in knots over regulations. And I also want to make sure that my the people whom I

405
02:06:08.639 --> 02:06:24.560
represent are not being exploited because one side has all the information on both sides of a transaction and they can demand any price they want, any price they want, and I don't know enough to say stop. That's why I think price transparency is getting there. I think

406
02:06:24.560 --> 02:06:41.280
it was Rell that said, "Every other aspect of our society, gasoline and groceries, you can shop for your best price. A house, you can shop for your best price. The one place you cannot is healthcare." And that's why we've seen cost explode at a rate of inflation far

407
02:06:41.280 --> 02:06:57.280
greater than almost anything else. Um, and so, uh, so, but you put your finger on that tension. Um, did you listen to what Debbie said from a personal experience? it has changed her experience of how she addresses that. I don't know. But I suspect Debbie just

408
02:06:57.280 --> 02:07:11.760
you know just thinking about this probably tends to be conservative. I don't know that. But when healthc care touches you and all of a sudden you realize the fix is in and you're getting ripped off because somebody can exploit laws that you as much as you try and

409
02:07:11.760 --> 02:07:29.840
Stacy as much as she tried. 24 calls 24 calls and still at the end they gave her the wrong price. That's when you say, "Wait a second. The system has broke down." That's when we need to have guard rails. And I thank them both for sharing their personal experience. I now let me uh just finish with some Usually

410
02:07:29.840 --> 02:07:45.440
they give me closing remarks. Did y'all this time or did I am I am I on the wing? >> They're shaking their head. No. Okay. Um so, um >> wing it. >> Memo to self.

411
02:07:45.440 --> 02:08:02.719
Uh thank you all for participating. Uh and thank you for the people who are live streaming, for the people who have been watching. Um this has informed what we are going to do when we go back to DC to write laws and it is our mutual

412
02:08:02.719 --> 02:08:18.880
responsibility to serve our country. So, thank you for taking that seriously because as I you as I said earlier, each of you has given me things in the past uh three of you because I've never previously met Debbie uh but someone like Debbie gave us something on

413
02:08:18.880 --> 02:08:33.840
surprise medical billing that has informed us. Today, we have more things that are going to inform what we do in the future and there will be a better future when it comes to price transparency in terms of the guarantee of the ability to get a cash price because of that because of things that

414
02:08:33.840 --> 02:08:49.960
were set here. So for any senator who wishes to submit a question for the record, you have until close of business >> in 10 days uh 10 days from now. Uh um seeing that there's no more questions, with that we adjourn. Thank you.