Navigating the Future of Healthcare Policy

Welcome back to "The Only Healthcare Podcast." This episode delves deep into the evolving landscape of healthcare policy in 2025. Hosted by Randy Vogenberg, PhD we are joined by special guest Jayson Slotnik, a seasoned health policy expert from Health Policy Strategies, LLC.

Jayson Slotnik is a prominent figure in health policy consultation, with over 15 years of experience at Health Policy Strategies, LLC. He works with government agencies, manufacturers, patient advocacy groups, and healthcare providers to navigate and influence significant policy changes. His expertise includes advocating for better patient access and developing commercial strategies. Jayson's approach combines his legal background with a deep understanding of healthcare operations and policy impacts.

Key Insights:

• Understanding New Policies: Jayson provides an in-depth look at how upcoming policy changes, particularly concerning PBMs and Medicare, could reshape the industry.
• Forecasting Commercial Insurance Trends: Discussion on how commercial insurance may adapt to regulatory changes and what businesses might expect in terms of cost management and policy impacts.
• Future Outlooks: Speculation on major healthcare topics like chronic disease management, Medicare negotiations, and the implications of AI on healthcare services.

Hosted by:
Michael Navin & Dr. Randy Vogenberg

Michael's LinkedIn

Randy's LinkedIn

Sponsored by:
Peek: A game-changing prescription shopping solution that allows its members to view all their prescription cost options across cash discount programs and their insurance in one easy-to-use platform. Peek is currently being offered to organizations to help both employees and plan sponsors save money on their prescription spend. https://peekmeds.com/.

Institute for Integrated Health (IIH): Health care benefits, insurance coverage regulations, and doing business in the healthcare industry can be complicated. At IIH, Dr. Randy Vogenberg and his team understand these unique challenges and provides strategic guidance customized to every client. To help overcome your unique challenges, IIH delivers education, planning and advisory on market trends, and U.S. health care market intelligence. The firm’s decades of proven success are due to strategic collaboration with associates from the business, clinical, and scientific communities. https://iih-online.com/.

Music by:
Hanu Dixit, https://www.youtube.com/hanudixit

Transcript

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You are listening to the only health care podcast created to inform you on the white House and budget of health care, hosted by industry leaders Michael Needed and Doctor Randy discussing why cost and risk are so high and who should be held accountable. How will technological advancements merge with quality of care and when does with public ease access to advanced medical treatments? 

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Listen in as Michael and Randy answer industry concerns with the public and all stakeholders involved. 

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Welcome back to the Only Health Care podcast, where we dive deep into the dynamics shaping the health care landscape. I'm your host, Randy Valkenburg, 

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and today we're joined by Jayson Slotnick from Health Policy Strategies, LLC, 

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where Jason works closely with government agencies, manufacturers, patient advocacy groups and health care providers to influence and Understand policy changes. 

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Jason, it's great to have you with us. 

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Thank you very much, Randy. Really appreciate the opportunity, for this to do this podcast and look forward to an exciting, discussion. 

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Unknown 

Why don't you just briefly introduce yourself to our audience, and then I'll do a, brief introduction before we start the questions. My pleasure. Randy. As you mentioned, I am the principal at a health policy consulting firm called Health Policy Strategies. I've been running this, consultancy for about the last 15 years. I love the practice of law, 

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Unknown 

to run this company and my clients are drug companies, device manufacturers, some diagnostic companies. 

00;01;44;27 - 00;02;04;13 

Unknown 

I used to practice law, and so I represent them. And advocacy point of view, help them understand what is going on in the Congress, but more so, what's going on at the center from the centers for Medicare and Medicaid Services CMS. I take that information and work with my clients to understand the commercial impact, 

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Unknown 

helping them develop commercial strategies, patient access 

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Unknown 

strategies, and then also do advocacy work to have the business drive the policy. 

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Unknown 

In other words, have, conduct meetings with CMS, 

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Unknown 

to educate the agency and hopefully partner with CMS to provide appropriate access to innovative technologies that my manufacturers bring to market. 

00;02;25;28 - 00;02;51;27  

Unknown 

So let me start off by, kind of setting the stage very briefly. 2025 brings disruptive forces to health care, a new government administration, increases in all health care costs, particularly for employer plan sponsors, a growing burden of chronic diseases, and frustration with both legacy players and innovators. 

00;02;51;29 - 00;03;26;06 

Unknown 

Ultimately, what happens in health care in 2025 and beyond will be driven by some key questions, such as how do we determine tradeoffs between access, quality and cost? What is or drives or delivers health? And whose job is it to make decisions? Fundamentally, US health care is struggling on policy and strategy across cost, quality and access, leading to widespread frustration by all of the stakeholders. 

00;03;26;14 - 00;03;44;10 

Unknown 

So with that background and your experience, Jason, let's start with a general sense. Of recapping 2024. Can you give us a general sense of where U.S. health care stood at the end of the year? 

00;03;44;10 - 00;03;53;14 

Unknown 

well, I mean, ready way to hit the ground running. It's such a, a great philosophical question filled with, a lot of possible details. 

00;03;53;15 - 00;04;06;20 

Unknown 

I think the best way to answer that, perhaps, is by sector. I'll start with the sector. I know the best. Which is the drug company, the drug sector where we ended in 24 was, 

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Unknown 

better than where we ended in 23. Not from necessarily from a policy point of view, but from a certainty on the business point of view. 

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Unknown 

Specifically the industry. Now, the drug industry has a much better understanding of 

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Unknown 

most of the fundamental principles of the Inflation Reduction Act that was passed in August of 2022 and can now make much better assessments of their business. Specifically, we have greater information related to how the Medicare Part D is. And David, redesign works out of the patient, out of pocket of $2,000 will be calculated how those dollars can be smooth as part of the Medicare prescription payment plan. 

00;04;48;14 - 00;04;53;07 

Unknown 

Working understanding of how the CPI penalty. And then lastly, a 

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Unknown 

very good working understanding of how the Medicare negotiation programs will work. So for the drug company, although some of that is bad news, at least there is some certainty 

00;05;04;15 - 00;05;13;16 

Unknown 

for some of the other sectors. Specifically, the health plans slash PBMs. Now they are entering into a level of uncertainty. 

00;05;13;18 - 00;05;29;16 

Unknown 

They don't know what the part D redesign will do for their drug exposure. How many more patients will will go through the benefit? Will the abandonment rate for some of the high cost drugs now actually hit their bottom line? How many patients will choose to smooth. 

00;05;29;16 - 00;05;37;06 

Unknown 

And so they're having some issues about doing actuarial values of, of their benefits on how to price it. 

00;05;37;06 - 00;05;50;01 

Unknown 

They are weighing their level of uncertainty. And you combine that with continuing growth on the medical side because, just sort of more patients still recovering from Covid, 

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Unknown 

related to, 

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Unknown 

their model and the PBMs, which service the health plans. 

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Unknown 

As you know, on the pharmacy side, are entering into an even higher level of uncertainty because the Congress is seriously considering changing some of their business model, because of some of the behaviors that the Congress doesn't like that are being perceived as anti-competitive and anti patient. So we can get into a little bit more detail, 

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Unknown 

but the PBMs are entering into a higher level of uncertainty. 

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Unknown 

On the provider side I mentioned the hospitals. Their costs continue to rise. Physician payments are going down in 2025 from a 

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Unknown 

Medicare point of view. And the commercials are tightening up their reimbursement rates, because of what we just mentioned before. On their dollars. 

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Unknown 

Mergers and acquisitions are continuing. 

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Unknown 

So that's putting some downward pressure on contracting and pricing. 

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Unknown 

So 2024 ended with some sectors having a better sense of their commercial fortunes going forward, some with somewhat of a better sense, and some others, as we mentioned, with a lot a lot of uncertainty. 

00;07;01;09 - 00;07;18;11 

Unknown 

Thank you for that. So let me just do a, very brief follow up, to that, nice landscape from 2024. What were your thoughts on, 1 or 2 key significant challenges or successes 

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Unknown 

from last year for which industry? Randy, 

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Unknown 

from, any of them? 

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Unknown 

think, 

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Unknown 

of the successes for, 

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Unknown 

the drug industry. 

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Unknown 

Right. 

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Unknown 

it goes back to what I said before, which is the certainty they gain some level of certainty on, 

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Unknown 

the part D redesign the Medicare program. I think one of the other successes for the industry may be has to do with the 340 B program, which we really didn't discuss, and that is a program that Congress established that allows, 

00;07;49;19 - 00;08;05;12 

Unknown 

certain providers, hospitals, really, that serve underserved patients the ability to buy drugs at a cheaper price and sell it at market price to use those dollars to compensate it for uncompensated care, to serve the under and uninsured. 

00;08;05;14 - 00;08;18;14 

Unknown 

That 340 B program has grown tremendously, and we can cover that a separate time. But some of the value of the manufacturers are trying to get a better handle on the growth of that program, either through litigation or policy changes. 

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Unknown 

I think they might be some successes there. We've had some victories in the courts around the 340 B program, so that 

00;08;25;21 - 00;08;27;17 

Unknown 

is one of the positives. 

00;08;27;19 - 00;08;33;24 

Unknown 

And I think for now, what I mentioned on the PBM side, while I mentioned that the Congress is coming forward 

00;08;33;24 - 00;08;49;03 

Unknown 

with some reforms, it didn't occur last year. So the PBMs get to live to fight for another day and try to avoid that. I personally think it's going to happen, but the PBMs, you, one could argue, got a victory by not having any reform last year. 

00;08;49;03 - 00;09;07;00 

Unknown 

other words, that there weren't any other major victories by any of the other sectors because there weren't any other major pieces of legislation or regulatory changes that occurred in 23 or 24, unlike 22 that had the Inflation Reduction Act. 

00;09;07;00 - 00;09;17;16 

Unknown 

That's their victory where nothing else happened to disrupt any of the other verticals in the health care sector, like site neutrality or PBM reform, like I mentioned. 

00;09;17;18 - 00;09;24;01 

Unknown 

So I think the victories are what didn't happen as compared to something that might have happened. 

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Unknown 

But that's a great perspective. I appreciate that. 

00;09;27;16 - 00;09;40;01 

Unknown 

So as we sit here at the beginning of 2025 and, we just gone through a inauguration for Trump as the 47th president. 

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Unknown 

We have a lot of changes already underway, some that are being proposed. 

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Unknown 

We have a, acting, Department of Health and Human Services secretary right now. 

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Unknown 

As we wait, see what happens with the Senate, 

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Unknown 

the executive orders, 

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Unknown 

Trump has begun to sign and put into play. Which may impact some of the items that you mentioned from 24. They may be, caught up in 25. 

00;10;04;18 - 00;10;10;18 

Unknown 

Including, you know, what will be happening around, cost saving measures. 

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Unknown 

Now that, 

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Unknown 

Trump has signed a new executive order taking away what, 

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Unknown 

President Biden had put into place such things as $2 generics and Medicaid innovation for selling gene therapies around financial, 

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Unknown 

affordability? 

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Unknown 

That would have started in 2027 through some innovation efforts. 

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Unknown 

And then, some other really broad based things, 

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Unknown 

such as W.H.O., the Paris Accord and so forth. So the question now is for you, Jason, 

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Unknown 

looking at 

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Unknown 

2025 and trying to project what's going to be happening, in our world on health care, 

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Unknown 

what would be the key changes or shifts that are being discussed in the Beltway? 

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Unknown 

Okay, so 

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Unknown 

what's 

00;10;56;03 - 00;11;20;27 

Unknown 

entertaining, if you will, you use that word in air quotes about having a Trump 2.0 administration is that change is the only constant at least to talk about change is oh, is the real constant. So there's a lot of just that right talk. And so what's hard to understand or hard to really know here inside the Beltway is what is real and what isn't real. 

00;11;20;27 - 00;11;25;07 

Unknown 

And I hate to use a Trumpism what is fake news and what's real news. Right, right. 

00;11;25;07 - 00;11;42;17 

Unknown 

I'm going to try to sort of piece that out part set out a little bit. Right. The PBM reform is real as a concern to what could happen in 2025. What is also real is that the Trump administration won't reduce Medicare benefits or Social Security. 

00;11;42;17 - 00;12;06;26 

Unknown 

They're not going to focus on those federal programs as a source of of dollars to offset some of the other monies they want to spend, rather. So starting at the big picture, you could look for significant changes in Medicaid and how Medicaid is structured. Some specific idea is being tossed about. Is our work requirement policies. 

00;12;06;26 - 00;12;11;09 

Unknown 

Maybe block grants, in other words, giving the states a fixed amount of money. 

00;12;11;09 - 00;12;20;11 

Unknown 

Right now, Medicaid is a fee for service. So the more the states do, the more money they get. Now it's not a dollar for dollar, but still it is perceived 

00;12;20;11 - 00;12;31;18 

Unknown 

as a lack of an incentive to manage costs. So I think you're going to see a lot of talk about how to, using their words, modernize the Medicaid program. 

00;12;31;20 - 00;12;40;28 

Unknown 

That'll be a big source of possible savings. I mentioned something before in the hospital community about site neutrality, trying to, 

00;12;40;28 - 00;12;52;15 

Unknown 

pay hospitals that have purchased physicians offices the same rate that they would have paid the physician's office had they not been owned by the hospital. So, in other words, 

00;12;52;15 - 00;12;57;26 

Unknown 

have a physician's office across the street from the hospital, the physician's office performs a procedure. 

00;12;57;26 - 00;13;23;06 

Unknown 

They build the government, they get paid X dollars, the hospital comes buys that physician's office. Same procedure. The way our system works, the hospital gets reimbursed X plus. And so there's been some talk over the last couple of years about trying to neutralize make that payment the same, regardless of whether it was in the physician's office or in the hospital outpatient department. 

00;13;23;08 - 00;13;29;21 

Unknown 

That generates a lot of savings for the federal government. So that's a big policy that the Congress may look 

00;13;29;21 - 00;13;43;13 

Unknown 

to implement, to take those savings so we can do tax cuts or other kinds of policies. Those are the big healthcare issues, and there's a lot of sort of tweaks around the edges that the drug companies want. 

00;13;43;13 - 00;13;51;28 

Unknown 

That may or may not happen. And then the other big issues, speaking of providers, is what do you do and how do you pay physicians, 

00;13;51;28 - 00;14;14;14 

Unknown 

the MIPs and, and those kind of programs that pay for quality of sort of run their course, physicians are still subject to a conversion factor and, can explain. But what has resulted is physician payments have gone down not only in real dollars, but certainly inflation adjusted dollars significantly. 

00;14;14;16 - 00;14;20;07 

Unknown 

So the Congress has a lot of health care issues on its plate that it could address. But ironically, Randy, 

00;14;20;07 - 00;14;34;28 

Unknown 

they're not the top issues for the Congress. So I don't expect anything that I just mentioned to hit the Congress's desk in any way until the second half of this year. Rather, what will be focused on is what we've already seen here. 

00;14;34;28 - 00;14;40;29 

Unknown 

Is, immigration policy. And then slowly now we'll get into tax reform. 

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Unknown 

Those are some great points. 

00;14;42;26 - 00;15;00;25 

Unknown 

Can you share any insights on some of the talk and upcoming policy changes that might happen around chronic disease prevention and treatment as priorities as part of this Make America Healthy Again agenda? Yeah. No, that's 

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Unknown 

probably a 17. 

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Unknown 

Our podcast in in of itself. Randy. 

00;15;04;23 - 00;15;12;28 

Unknown 

So as you mentioned, the Make America Healthy Again initiative is being driven by the secretary of Health and Human Services nominee, 

00;15;12;28 - 00;15;18;01 

Unknown 

Robert Kennedy Jr. He's been talking for years about 

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Unknown 

his, 

00;15;18;13 - 00;15;26;23 

Unknown 

displeasure with the health care system that seems to be motivated to keep patients chronically ill and, 

00;15;26;23 - 00;15;38;28 

Unknown 

wants to reevaluate the entire, really, health care system to focus more on prevention and to avoid this sort of chronic disease state. 

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Unknown 

And what he specifically means about that is not really clear. 

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Unknown 

What he can do about it is also not really clear, because, as I mentioned before, that Congress is the one that writes the rules. CMS, which is the agency under his, jurisdiction, implements those rules. So specifically, there are specific rules about how physicians get paid, how hospitals get paid, what services are covered, what drugs are covered. 

00;16;09;25 - 00;16;36;14 

Unknown 

So he, in and of himself doesn't have a lot of autonomy to change those rules, because they're very prescriptive from the Congress. But what he could do around the edges is do some demonstration programs with two sided risk to physicians and hospitals that focus more on prevention and longitudinal health improvements by measures along those lines. So we shall see what those details are. 

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Unknown 

But I caution a lot of people just to remember that we have a significant infrastructure here, that he's going to run up against that would prevent any dramatic swings in, the way the health care services are delivered. 

00;16;52;28 - 00;16;54;01 

Unknown 

So, 

00;16;54;01 - 00;17;00;07 

Unknown 

switching gears a little bit, but kind of, looking at it from a couple different perspectives, 

00;17;00;07 - 00;17;15;17 

Unknown 

looking at some of the unfinished business around health policy in the commercial sector, some of the hot topics that I run into with, with other consultants or brokers, includes three, three, major areas. 

00;17;15;17 - 00;17;47;10 

Unknown 

One is affordability or new funding models, for health care, either products or services. Secondly, leveraging carrier or integrated innovations, into the care delivery model and then simplifying benefits delivery is anything along those three lines entering into the congressional discussions that you're talking about, or is that more of a potentially a regulatory or just commercial market's going to drive its own thing? 

00;17;47;13 - 00;17;58;25 

Unknown 

No question. The commercials are going to drive it. Right? Because they have greater flexibility. They can move faster, which is an amazing statement in and of itself, given the largesse of the commercial payers. But yes, 

00;17;58;25 - 00;18;06;01 

Unknown 

you'll see the innovation and those different types of initiatives coming from commercial. First, I don't think the Congress is going to legislate 

00;18;06;01 - 00;18;15;03 

Unknown 

to that level of prescriptive ness, maybe, but I'm very skeptical that this Congress will get into that level of detail, to drive that kind 

00;18;15;03 - 00;18;16;29 

Unknown 

level of change it. 

00;18;16;29 - 00;18;31;22 

Unknown 

So from an infrastructure point of view now where I argue against myself about to do that is, like I mentioned, changing physician payments. That's where maybe the Congress will get involved and try to do what you're mentioning, Randy. 

00;18;31;22 - 00;18;38;15 

Unknown 

I'm skeptical that that's actually what's going to happen. Now. You mentioned demonstration programs, regulatory point of view. 

00;18;38;15 - 00;18;54;22 

Unknown 

If this was not the Trump administration, I would say, yes, you have a better chance of that happening through what's known as the center for Medicare and Medicaid Innovation. But as you mentioned it, heading into the beginning of this call about some executive orders that have, 

00;18;54;22 - 00;19;18;09 

Unknown 

stalled some of the currency, my initiatives, the Trump administration is not a big supporter, proponent of CME, and I don't think will drive some of those other kinds of care models that you mentioned, Randy, through CME for Medicare or Medicaid patients, which is why I led off with my conclusion that it's going to be the commercial that leads the way. 

00;19;18;16 - 00;19;27;13 

Unknown 

Okay. So is it safe to say that when we reflect back on the past five years and some of the major trends, 

00;19;27;13 - 00;19;27;26 

Unknown 

that you've 

00;19;27;26 - 00;19;30;08 

Unknown 

talked about or I mentioned, 

00;19;30;08 - 00;19;45;25 

Unknown 

both government and commercial, how do these trends inform what we can expect not only from 2025, but even looking out further and towards the end of this decade, particularly concerning commercial insurance. 

00;19;46;07 - 00;19;47;15 

Unknown 

Well, that's a good question. 

00;19;47;15 - 00;19;48;22 

Unknown 

so 

00;19;48;22 - 00;19;58;14 

Unknown 

hear my thoughts. Commercial insurance is going to continue to receive a lot of populist pressure. That's already started as a result of the, 

00;19;58;14 - 00;19;59;09 

Unknown 

tragic, 

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Unknown 

murder of, 

00;20;00;12 - 00;20;02;10 

Unknown 

United CEO 

00;20;02;10 - 00;20;10;27 

Unknown 

You saw on social media this undertone of populist angst and anger regarding the way insurers behave. 

00;20;10;27 - 00;20;14;25 

Unknown 

I think this administration is going to pick up on that 

00;20;14;25 - 00;20;21;25 

Unknown 

They don't have to pick up far on that, because even the Biden administration was putting forward and implementing policies 

00;20;21;25 - 00;20;29;07 

Unknown 

that were providing greater oversight on the way commercial plans, conduct prior authorizations, 

00;20;29;07 - 00;20;38;21 

Unknown 

scheduling network design. So the government was already sticking more of its camel's nose under the payers tent. 

00;20;38;23 - 00;20;58;01 

Unknown 

And so I think that will continue. There'll be greater scrutiny on commercial. Will they be forced to diversify and break up? No, I don't think so. They may wind up doing that on their own as a result of a what I just said. And b the PBM reform that's requiring greater transparency, 

00;20;58;01 - 00;21;00;29 

Unknown 

between the PBM and their customers. 

00;21;01;01 - 00;21;11;04 

Unknown 

So towards the end of the decade, we'll have a lot more information about these business practices. A greater groundswell will continue regarding payer, 

00;21;11;04 - 00;21;29;21 

Unknown 

denials, delays. Why are they so profitable? I think all of that will continue. But all of that having been said, Randy, almost everything that we've talked about for the last 20 minutes and this is my opinion, could all be dramatically altered depending on how artificial intelligence and LMS, 

00;21;29;21 - 00;21;37;20 

Unknown 

are being used in healthcare in ways that we can sort of think of and ways that we even can think of going forward. 

00;21;37;23 - 00;21;49;29 

Unknown 

And so we could be here five years from now, and we could have a completely different health care experience as a result of those, you know, I know, changing away healthcare 

00;21;49;29 - 00;21;58;17 

Unknown 

is distributed and disseminated and provided in this country. If you're going to use a five year window. 

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Unknown 

Good point. 

00;21;59;20 - 00;22;06;12 

Unknown 

Kind of along that line as we start to dig down into some of the, areas of legislation and reports, 

00;22;06;12 - 00;22;07;21 

Unknown 

recently, 

00;22;07;21 - 00;22;13;03 

Unknown 

there was an ITV report about, what's indicators of progress, 

00;22;13;03 - 00;22;20;20 

Unknown 

looking at 2025 and you hit on a lot of those things such as trust, in companies, whether they're, 

00;22;20;20 - 00;22;27;04 

Unknown 

third parties or life sciences companies, reduction in out-of-pocket costs for patients, 

00;22;27;04 - 00;22;28;23 

Unknown 

part of the changes, 

00;22;28;23 - 00;22;32;20 

Unknown 

along with better patient access, so forth, all that. 

00;22;32;22 - 00;22;33;27 

Unknown 

So let's 

00;22;33;27 - 00;22;37;02 

Unknown 

start with, with PBMs. 

00;22;37;10 - 00;22;38;18 

Unknown 

could you mentioned legislation, 

00;22;38;18 - 00;22;45;04 

Unknown 

on the PBMs that didn't really make it this year, but will be a major target for 2025? 

00;22;45;04 - 00;23;05;16 

Unknown 

Can you just, elucidate a little bit more about the impact that you foresee that those changes would have on the industry? Not only in the PBM industry, but just health care in general because of the overflow effect on to patients, providers and so forth. 

00;23;05;16 - 00;23;13;27 

Unknown 

I will be clarify what that reform is going to be above and beyond some of the transparency that I mentioned, because that will, 

00;23;13;27 - 00;23;17;25 

Unknown 

help, give a greater understanding of, 

00;23;17;25 - 00;23;28;17 

Unknown 

the impact. Right. So right now, Randy, if you are running a PBM or a GPO and I'm a manufacturer, you come to me and you say, hey, Jason, you're the manufacturer. 

00;23;28;17 - 00;23;55;02 

Unknown 

I'm going to provide access to your drug. You're going to give me a rebate dollars. And if you want data, I'm happy to sell you the data. And I'm going to say, great, how much is the data? And you're going to charge me a fee for the data that is directly linked to the price of the drug. And the Congress is not happy about that, because now you and I are incentivized to increase the price of the drug. 

00;23;55;02 - 00;24;12;12 

Unknown 

Right. Because you make more money. If I'm paying you 2% or 3% of the drug cost when my when I raise my drug price, you make more money even though you're doing the same work. So the PBM reform is going to require a de linking of. 

00;24;12;12 - 00;24;18;08 

Unknown 

The price of data and portal fees and other fees off from the drug price. 

00;24;18;11 - 00;24;26;09 

Unknown 

You can no longer charge me a percent of my drug price. You must charge me a dollar. Figure. 

00;24;26;09 - 00;24;44;20 

Unknown 

So in other words, everything that I pay you for, like the data or to enter the portal or other kinds of services must be a bonafide service fee at fair market value. And that's what's in the law. That's going to be a significant transition of the business model 

00;24;44;20 - 00;24;51;02 

Unknown 

for the Gpos and PBMs, and how they then contract with manufacturers. 

00;24;51;04 - 00;24;58;12 

Unknown 

Those are hard habits to break. You're introducing new legal and regulatory 

00;24;58;12 - 00;25;18;14 

Unknown 

concepts that not so much new because it exists on the medical side, but certainly breaking a lot of old ways of doing contracting and introducing new, you know, bonafide service fees in the how they are valued. And that's going to take some time to implement and then to settle out as, 

00;25;18;14 - 00;25;23;19 

Unknown 

what the market can bear and not bear and how these entities behave and not behave. 

00;25;23;21 - 00;25;26;14 

Unknown 

That is going to be one of the significant issues for 

00;25;26;14 - 00;25;29;23 

Unknown 

next five years. Should the legislation go through. 

00;25;29;23 - 00;25;45;04 

Unknown 

Yeah. And you bring up a good point about one of these approaches to better managing, information. And the money flow exists on the medical side, but have not on the pharmacy benefit side. So a lot of these, 

00;25;45;04 - 00;25;48;06 

Unknown 

changes are going to be focused on the pharmacy benefit 

00;25;48;06 - 00;25;49;06 

Unknown 

that is relatively new. 

00;25;49;06 - 00;25;50;29 

Unknown 

As you pointed out. 

00;25;50;29 - 00;26;15;18 

Unknown 

There's some other information that's come out from both the Office of Inspector General and from CMS. Different reports, publications, that have been critical, on PBMs. So how have those reports shaped our understanding of their role in health care, or did we already know what those reports say? Right. So that's a great 

00;26;15;18 - 00;26;16;22 

Unknown 

follow up question there, Randy. 

00;26;16;22 - 00;26;18;24 

Unknown 

So there are a couple of government entities like 

00;26;18;24 - 00;26;21;16 

Unknown 

Gao and there's OIG and there's Medpac. 

00;26;21;16 - 00;26;32;14 

Unknown 

There is no shortage of entities that are either government entities or quasi that issue reports on what's good and what's bad and how to fix it in the health care sector. 

00;26;32;14 - 00;26;41;09 

Unknown 

So those couple of reports have come out over the years regarding PBM, regarding side neutrality, regarding physician payments, regarding hospital costs, 

00;26;41;09 - 00;26;45;18 

Unknown 

regarding overpayments to Medicare Advantage, all that information is out there. 

00;26;45;18 - 00;26;49;12 

Unknown 

just a matter of when the Congress wants to get around to use that information and 

00;26;49;12 - 00;26;51;11 

Unknown 

when it's in their favor, 

00;26;51;11 - 00;27;06;27 

Unknown 

to issue and try to implement reforms. None of the information that's published by those entities is surprising to those of us who follow whatever sector the report is reporting on. If the like, the Federal Trade Commission came out of that report regarding the 

00;27;06;27 - 00;27;15;18 

Unknown 

some of the negatives, with the vertical integration of the PBM model, nobody who was in the drug industry or otherwise was surprised by the FTC findings. 

00;27;16;01 - 00;27;33;13 

Unknown 

But, you know, you still need to go through that exercise because that's what serves as the backbone for change. Right? So when the Congress and or regulatory agency wants to change something, they get more credibility in that change. If there's an FTC or other kind of government report that validates 

00;27;33;13 - 00;27;42;04 

Unknown 

and supports the change as compared to a pharma or a hospital or even an Iqvia report, that is going to be paid for by somebody else. 

00;27;42;07 - 00;27;44;21 

Unknown 

So you need these reports. It's part of the 

00;27;44;21 - 00;27;51;23 

Unknown 

legislative sausage making process. And that's how it works. Okay. So there were a couple other reports, 

00;27;51;23 - 00;28;01;02 

Unknown 

kind of along that line, the Congressional Budget Office focused on sickle cell and the Office of Management and Budget on Medicare and health care costs. 

00;28;01;02 - 00;28;02;20 

Unknown 

What did we get out of that? 

00;28;02;21 - 00;28;06;22 

Unknown 

What was the key takeaway that our listeners should be aware of? 

00;28;06;22 - 00;28;08;08 

Unknown 

I think the key message that 

00;28;08;08 - 00;28;15;28 

Unknown 

our listeners should understand is that I'm going to make it a very big picture message that when the Congress 

00;28;15;28 - 00;28;17;29 

Unknown 

implements law or makes a legal change. 

00;28;18;00 - 00;28;48;18 

Unknown 

Right. There are a lot of those reports that support the policy change, at least in health care. Going back to, you know, the Medicare Modernization Act in 2003 that put out stood up a party pharmacy benefit. There were lots of reports about how patients didn't have pharmaceutical drug coverage and how bad that was. And starting from there and even before that, going forward, there usually are a lot of Medpac and GOP courts that support a legislative change. 

00;28;48;20 - 00;29;17;21 

Unknown 

Now, what that legislative change ultimately becomes is usually a political negotiation. So, for example, the $2,000 out of pocket, everybody sort of knew that it was bad policy not to have an out of pocket on the Medicare Part D side. So that was well supported by reports where the Congress drew the dollar figure 5000, 2000, 3000. That became a worse training political message and a costing for the government to try to fit in the benefit. 

00;29;17;29 - 00;29;18;10 

Unknown 

But 

00;29;18;10 - 00;29;25;11 

Unknown 

the policy changes are usually supported, and then some of the details are traded for based on politics. 

00;29;25;11 - 00;29;39;04 

Unknown 

building off of, some of these reports, particularly, in a Health Affairs article that came out at the end of last year that CMS, provided looking at overall health care costs. 

00;29;39;07 - 00;30;03;22 

Unknown 

There were a lot of implications on the commercial marketplace, and it could affect the commercial trends going forward. Particularly, we talk about the price negotiations for Medicare as just one example. So there's a lot of implications from the government sector on the private sector commercial insurance. Right. By some of these things that that do come out. So my question is, 

00;30;03;22 - 00;30;11;26 

Unknown 

what's your take on how are commercial trends likely to be impacted by what may come out? 

00;30;11;26 - 00;30;16;22 

Unknown 

Is new regulation or legislative change? 

00;30;16;22 - 00;30;20;16 

Unknown 

Using history as a guide. And take that for what it's worth, commercial is 

00;30;20;16 - 00;30;24;26 

Unknown 

always been influenced by Medicare when it benefits the commercial marketplace. 

00;30;24;26 - 00;30;43;08 

Unknown 

So for practical purposes, the ten drugs that are now at a much lower price, you would anticipate as we get rolling here into commercial contracting for 2026, the commercial payer will come to the table with the maximum fair price, negotiate a price for those drugs, 

00;30;43;08 - 00;30;48;13 

Unknown 

you know, in their pocket to try to get more money from those manufacturers. 

00;30;48;15 - 00;30;50;16 

Unknown 

There's no question in my mind. 

00;30;50;16 - 00;30;55;10 

Unknown 

What would you say are some of the specific cost shifts that we should be aware of 

00;30;55;10 - 00;31;02;11 

Unknown 

either good for commercial or bad for commercial, as we look forward over the next year or two. Oh, I think, 

00;31;02;11 - 00;31;17;16 

Unknown 

the trends have always been there and probably will be accelerated, of cost shifting to cheaper sites of care from the commercial point of view, inpatient, outpatient, outpatient, a physician physician to the home that will continue to, 

00;31;17;16 - 00;31;21;04 

Unknown 

And that'll be could be better for commercial. It could be, 

00;31;21;04 - 00;31;24;05 

Unknown 

better for the patients right from a convenience point of view. 

00;31;24;05 - 00;31;28;09 

Unknown 

I usually don't oppose that. Those kinds of initiatives, 

00;31;28;09 - 00;31;38;15 

Unknown 

the providers usually get hurt, but if it's better for the patient, then that's the way it should be. On the Medicare side, you're going to see that much more aggressively because of the way the party benefit works. 

00;31;38;17 - 00;31;44;11 

Unknown 

I guessing that you'll see a lot more medical benefit drugs being pushed to the pharmacy benefit side. 

00;31;44;11 - 00;31;45;29 

Unknown 

So is it safe to, 

00;31;45;29 - 00;32;02;11 

Unknown 

say that we may actually see more of an integrated benefit emerging in the next question? No question. Mandy, I think you're going to see a lot more of the medical and pharmacy benefit drugs merging into one of more of a global formulary. 

00;32;02;13 - 00;32;05;11 

Unknown 

Many more of the medical benefit drugs will be managed, 

00;32;05;11 - 00;32;13;11 

Unknown 

by the Medicare side because of that significant cost differentiation between B and D, and that'll bleed over into commercial. 

00;32;13;11 - 00;32;14;29 

Unknown 

Interesting. 

00;32;14;29 - 00;32;19;20 

Unknown 

And that's something we've definitely been talking about for a while. Yeah. Really interesting to see that 

00;32;19;20 - 00;32;24;06 

Unknown 

moves faster than we think after all these years. See. 

00;32;24;08 - 00;32;34;06 

Unknown 

Yeah, we will see. This is the year because of the way the 25 redesign, this is where it's going to start a little bit. And then by the end of the decade, it could be significant. 

00;32;34;06 - 00;32;37;23 

Unknown 

Okay, great. So, 

00;32;37;23 - 00;32;48;00 

Unknown 

want to wrap up and, leave, some, tidbits for our listeners. Based on, the discussion, a brief one, albeit, 

00;32;48;00 - 00;33;02;09 

Unknown 

that we had today on some of the health policy areas, what would you say are the key points our listeners should take away about the future of health care policy and the impact on their lives. 

00;33;02;09 - 00;33;12;25 

Unknown 

two things, right. I'm going to start from the big picture. I'm going to go back to the artificial intelligence. I would monitor what and how this government will regulate AI. 

00;33;12;25 - 00;33;23;01 

Unknown 

because it can be so disruptive starting from diagnosis to treatment, the way it can change healthcare. What this government does on AI 

00;33;23;01 - 00;33;25;16 

Unknown 

is something that everybody should be following. 

00;33;25;19 - 00;33;36;03 

Unknown 

And then number two, what is this populist government? Because this is a technology government that in that way that's why. And then secondly is as a populist government, 

00;33;36;03 - 00;33;50;17 

Unknown 

how do they leverage that sentiment, that quote unquote support to try to really drive down prices across the board, hospital, drug physician, health plan, insurance, whatever it may be? 

00;33;50;19 - 00;33;56;00 

Unknown 

Those big pictures are on the table and can impact day to day lives. 

00;33;56;00 - 00;34;13;04 

Unknown 

terms of cost and access to health care services. And that's what I would sort of focus on. Whatever catches your fancy, then you can double click and try to get more information on it. But those are going to be the two big, you know, philosophical issues that this government is going to try to push. 

00;34;13;08 - 00;34;36;27 

Unknown 

Yeah. For those that haven't been paying attention to strategy in their in their plans or their operations, they better buckle up and get ready because, well, I'm seeing the same thing with some very strategic changes are being started that will have very important implications whether you're a plan sponsor or provider or manufacturer, etc.. 

00;34;36;27 - 00;34;47;03 

Unknown 

that's a great way to summarize things so that that very high level with technology in particular, for those looking to stay informed and engage. 

00;34;47;03 - 00;34;54;21 

Unknown 

Jason, what resources or any specific actions would you recommend for our listeners? 

00;34;54;21 - 00;34;59;09 

Unknown 

starting in a high level, right. Any kind of, you know, national newspaper, 

00;34;59;09 - 00;35;04;20 

Unknown 

just Google smart briefs and there's all kinds of topics there. And then there's all kinds of, 

00;35;04;20 - 00;35;06;13 

Unknown 

health care focused, 

00;35;06;13 - 00;35;13;01 

Unknown 

trade, newspapers, you know, they can reach out to you, Randy or me, and we can help them do that. 

00;35;13;01 - 00;35;16;26 

Unknown 

The Congress and all the different committees have daily emails, 

00;35;16;26 - 00;35;29;27 

Unknown 

on that. And there are other kinds of specific podcasts that that also can do it. But we know the big issues that we just talked about are going to be covered by the big newspapers and the big news. And then from there, you can, 

00;35;29;27 - 00;35;33;10 

Unknown 

like we said before, just drill down into any specific issue. 

00;35;33;13 - 00;35;44;29 

Unknown 

I mean, because all of it depends on your politics and your time. So I'm not going to give anything very specific. But, you know, people figure out how to get there right? As always, 

00;35;44;29 - 00;35;58;02 

Unknown 

things are constantly changing, particularly in health care, in our extremely complicated environment that we both work in. Well, Jason, I want to thank you for sharing your insights and expertise with us today. 

00;35;58;04 - 00;36;04;21 

Unknown 

It's been very insightful having you on with us today, and I appreciate your time. 

00;36;04;21 - 00;36;07;01 

Unknown 

My pleasure. Thank you very much. And 

00;36;07;01 - 00;36;08;16 

Unknown 

look forward to many more. 

00;36;08;16 - 00;36;15;22 

Unknown 

Absolutely. And so to our listeners, thank you for tuning in. Keep engaging with us through our website. 

00;36;15;22 - 00;36;38;28 

Unknown 

Only health care podcast, dot com and social media, almost all the platforms that are out there to stay updated on the latest in health care, please share this episode with your colleagues or friends that you think could benefit from this discussion, and we look forward to seeing you in the next episode of the Only Health Care Podcast. 

00;36;38;28 - 00;37;01;25 

Unknown 

Thank you for tuning in to the Only Health Care podcast. We hope you found today's episode insightful and informative. Remember, our mission is to provide actionable and inspirational insights on how we can improve health care, cost, care, and accessibility for all. If you enjoy this episode, please subscribe, rate and share with your friends and family. For more resources and updates, visit us at Only Health Care podcast.com. 

00;37;01;27 - 00;37;10;18 

Unknown 

We'd love to hear from you! Let us know what topics you'd like us to discuss in future episodes. Until next time, stay informed and together, let's navigate the journey to better health care.