Speaker 1: 0:00

President Trump's recent executive order on drug pricing tried to answer some questions a lot of us have been asking for a long time, but it also raised a bunch of new questions. So what does it all mean? We'll find out on this episode of Shift Shapers.

Speaker 2: 0:17

Change either energizes or paralyzes. The choice is yours. Paralyzes the choice is yours. This is the Shift Shapers podcast, bringing the employee benefits industry interviews with individuals and companies who are shaping the industry's shifts. And now here's your host, david Saltzman.

Speaker 1: 0:39

And to help us discuss the executive order and the issue of drug prices, we've invited our friend and emergency medicine physician assistant, tiffany Ryder, who also hosts the awesome Healthcare Liberty Lab podcast and writes long form on Substack at Red Flag Hero. Welcome, tiffany, how are you today?

Speaker 3: 0:56

Hey, I'm great. How are you?

Speaker 1: 0:59

I am awesome. I'm better now having you on the podcast.

Speaker 3: 1:01

I'm so excited to be here.

Speaker 1: 1:04

We're going to have fun and we're going to try to bring some sense to all of this craziness. But first we typically ask guests a little bit about your background, because your background is more unique than pretty much anybody. I know from how you got to what you were doing and what you're doing today. Give us a quick summary of your background and how you came to be doing what you're doing.

Speaker 3: 1:23

Sure, yeah, I used to be a little embarrassed of my nonlinear path and now it's, I think, one of the greatest gifts that I've had the pleasure of having. But basically, you know, I actually grew up in rural Louisiana in a poor community no health care, no health insurance or access to those sorts of things, and that was just sort of part of the background. When I was first starting out as an adult, I moved to Maryland and found myself in a position where, as a young mother in college you know, just trying to figure out life was looking for something big and ended up becoming a professional dancer and really having all of this exposure to these big people in DC doing cool stuff, especially in the health care space. And so when I finally retired from dance, I was living in the EU and decided it was time to sort of go back to my roots and figure out how to have an impact on people who were growing up in similar situations to the way that I had been, was enrolled in medical school, moved overseas, finished up here and found myself in rural ERs as a PA, and that I thought thought was my path to fixing the healthcare system and really having the impact that I dreamed about and really it was all. It was all a nice fantasy but was not playing out. So I started getting involved.

Speaker 3: 2:59

I read Marty McCary's book now the FDA commissioner. He was a surgeon at Hopkins when I read the book and really changed the way that I thought about healthcare and that I understood some of the health policy and business aspects, and so I've spent a little time helping out in compliance and marketing and all of these different spaces. But where I see myself now is moving the message forward, trying to use some of those skills of being plain spoken, from Louisiana and and also being in the emergency department, you know, sitting with people with varying degrees of health literacy and being able to take more complex messaging and actually help people understand it, because I think that's where we all need to be looking to in health care in general.

Speaker 1: 3:53

And that's a great jumping off point. So let's talk about this. What were your key takeaways from the executive order?

Speaker 3: 4:00

Yeah. So you know it was a little scary at first because I, you know, initially read the initial headlines that came out and the big talking points that were just quickly thrown out into the universe and it sort of looked like price controls to me, just because in my experience, in my reading and experience in life, you see price controls come up and immediately you think of things like shortages and really the cessation of development of new ideas and new solutions. And in healthcare that is absolutely a devastating concept. Right, it's got a huge impact. But the more that I have looked into it, to be fair, there aren't a ton of details on exactly how the nuts and bolts of all of this are envisioned to work.

Speaker 3: 5:00

But through watching the press conferences that again Marty McCary has given and President Trump gave officially the day he signed the order, and reading through the White House information that they've put out, it looks a lot less like price controls and a lot more like almost like we see things playing out in the normal marketplace. My husband owns a just started a coffee company of all things. It's a product-based company and when I look at the distributors that he buys from or the stores that he sells to, every bit of pricing works with this sort of understanding and formula that the larger the order is, the more favorable the pricing is. And given that Americans represent only 4 percent of the global population but we are actually providing 75 percent of pharma profits, I think that does speak somewhat to the fact that we're sort of not operating in the same way that every other industry is operating, and this executive order seems to be an attempt to rectify and sort, of course, correct some of that.

Speaker 1: 6:17

Yeah, I mean, even if you make the argument that there might be a drag on development of new drugs and whatnot, the question is, why would you require one country to subsidize all of the other stuff? Why wouldn't you spread your development costs over your entire marketplace rather than just one? I mean, it's kind of a rhetorical question, but then again it's not. So I digress the bill. The bill, the executive order, seeks to set up what they call most favored nation pricing. What does that mean and what do you think the impact might be on us mere mortals here in the United States?

Speaker 3: 6:54

Yeah, there's a spectrum to look at impact and you know I've attempted to really find diverging viewpoints on this and basically the spectrum at the moment, from what I've seen, runs from you know, it's actually not going to do much. It's a big nothing burger. It's a PR stunt which, as far as worst case scenarios go, that is not the worst one I could imagine. Right To this, could you know if it works? The way that talks about creating a direct-to-consumer path. It's not clear what that is. The order provides for HHS, the Department of Health and Human Services, to come up with some sort of structure for a direct-to-consumer area. It also alludes to some power to source drugs from other countries, which, for those of us in this little corner of the healthcare disruptors, we know that this is already happening. But something that I think is particularly interesting about that as far as outcomes go is, you know, when you think about other industries again, like maybe a new parent who needs to buy a car seat or a crib and has never done that before, you have no idea sort of what the pricing is going to be for those things. Like what to expect, what's available in the marketplace. You go to Amazon or whatever you type in the search term and then you get an idea.

Speaker 3: 8:54

In healthcare, if I have never really paid attention, I've never had a chronic disease before and my doctor prescribes metformin I have really no idea what to expect. Why is the CVS metformin a different price than maybe Walgreens, than maybe my independent pharmacy? I have no way to shop and I think some of the unintended consequences certainly might be not advantageous to different stakeholders in the marketplace. But one of the unintended consequences that I think could result from this is really that consumers have a place where they can go and start to inform themselves on what's possible and what to expect in regards to drug pricing. You don't have to buy it through this direct-to-consumer area, but you at least start to get a transparent overview of how healthcare works, and that's something that I kind of love.

Speaker 1: 9:56

Well, it's kind of hard to imagine that it won't have a significant impact, assuming it gets implemented. And there's a long way. As everybody knows, there's a long way between an executive order and actual implementation, especially around things like drugs where there's efficacy and safety issues and all of that kind of stuff. But an example yesterday I went to Walgreens. I picked up a medicine after Medicare, after my Part D supplement, which is healthy. It covers a lot. My out-of-pocket was $144. If I call up my buddy at the Canadian med store who's been doing this importation stuff direct from factories for years, and I get the same drug, my price is $140. Which means that someplace between $140 and the retail, the quoted retail price of the drug, which was $1,600, there's a whole bunch of people making a whole lot of money. And do you think that's part of the reason for trying to go down this path?

Speaker 3: 10:54

I mean, I absolutely think it is, and you know that's not just speculation, that's something that they certainly brought up in the press conference in a comedic way. If I say so myself, it was a little bit like I don't know. We're not going to name all of these middlemen, but certainly middlemen are involved in every step of the process. Pbms comes to mind, clearly. But I want to go back to something that you said about research and development, because I think that you know bipartisan discussion and efforts and promises, quite frankly, to reform and address the escalating cost of prescription drugs have been going on for years and every time you know this really comes up.

Speaker 3: 11:43

The one of the big arguments against doing any sort of reform is look, we believe in, you know, capitalism to whatever degree, we believe in free markets to whatever degree.

Speaker 3: 11:56

And if you take a, a company that exists, pharma right, whether it's Pfizer or whoever it is, and you tell them, well, we're going to take away your ability to make profit, then obviously that has an impact on how much they're willing to invest, because the return on investment has now decreased.

Speaker 3: 12:17

What I thought was really interesting about this approach is that the goal of this order and of the way that it's structured isn't to decrease the profits of pharma whatsoever, right. But if 75% of the profits are only coming from 4% of the population, then what if everyone just pays a little more? What if the deals are just structured a little differently? And you know, and it makes this equalization effect. And I love that right, because I feel like that argument and that concern which, as a clinician, is concerning to me, I, I want pharmaceutical companies making, um, drugs that are impacting lives. Not a lot of those. Those products don't have a large effect, but some of them do and, um, and, and I think that this order does uh, is has the potential to lower prices without having those negative effects.

Speaker 1: 13:27

And now a word from our sponsor. You're not just an advisor, you're a game changer. Forget cookie cutter, off-the-shelf solutions. That's yesterday's news, it's 2025, and it's all about delivering bold, custom-crafted plans that truly make a difference. At the core is a razor-sharp self-insured framework, but the real magic that's in the high-impact point solutions. You strategically layer in to slash costs and supercharge member outcomes. But let's be real, that's where the headaches start Hours wasted sifting through endless options, wrestling with integration issues and fighting data-sharing roadblocks. It's a time suck and it's holding you back Not anymore. Meet Benapower, the AI-powered game changer that builds killer plans in minutes, not hours. Benapower doesn't just curate the best point solutions. It makes them work together seamlessly, streamlining communication and driving collaboration like never before. With BenePower, you're armed with an end-to-end AI-enabled solution that makes you unstoppable. Spend less time piecing together a patchwork plan and more time selling. And now back to our conversation. One of the things that you said a moment ago as the predicate to your answer is in a free market.

Speaker 3: 15:13

Yep.

Speaker 1: 15:14

This is not a free market. No, what we have today is probably the furthest thing from a free market that you can possibly imagine. So to a point you made earlier, if we start getting transparency and if consumers get information and if there are multiple pathways to be able to buy a drug, where I don't have to go to A, I can go to B or C or D, then we're approaching a free market and that logic might hold. Then we're approaching a free market and you know that logic might hold. Today you used the T word so I'll bring it up again. We have no transparency.

Speaker 1: 15:49

If I didn't know the folks at the Canadian med store and know the owners for the last 25, 30 years, it would never have occurred to me to call them up and go hey, you know this drug, I'm taking this Eloquist stuff. What does a 90-day supply of 5-milligram Eloquist you know cost if I take it twice a day? And I would never have known that. It was almost exactly the same as the co-pay I'm paying after two different kinds of insurance, which it turns out is 10% of the retail price of the drug in the United States. Tell me in what universe this makes sense.

Speaker 3: 16:25

David, I don't know if I should be happy or sad that that was the example that you brought up, but my heart is racing out of my chest. I mean, this is the perfect example. So let me give you an example from the emergency department. You know, we have young people who show up and have no idea that they have a genetic predisposition to clotting or have no idea that, you know, for whatever reason they have developed this blood clot. And you know our answer to them in the emergency department is we do all of these expensive tests, we do the ultrasound, we find the things and then we say, okay, whether it's something that you know was caused by an outside situation, or something that is just you're predisposed to, either way we're going to go ahead and put you on this blood thinning medication that will, you know, reduce the likelihood of really terrible things happening in the future because of this problem. And it's infuriating because it's such an important thing to happen. It's such an important treatment that we believe actually changes clinical outcomes that we are unwilling to allow a patient to leave the hospital until we are certain beyond the shadow of a doubt that the patient is going to be able to pick up this medicine and the reason that I have spent many shifts that you know thousands of clinicians, I'm certain, have spent, you know, hours past their shift like on the phone with social work figuring all of this out. It isn't because this drug is some sort of like special unicorn that we can't find somewhere. It's because it's so darn expensive that we know the patients are not likely to be able to pick it up when they get to the pharmacy, and so, anyway, it creates all of these barriers to care for pricing.

Speaker 3: 18:35

And maybe you say, oh okay, well, this comes from this very special plant or animal or whatever and it costs us this much to make it. But that's not the case. If it's not the case in Canada, then how is that the case in the U? S? And I think, like we're not talking, we're not playing games. This is a political game. You know. I brought up the thing about free markets because because the talking points from pharma right, like, for example, one of their largest lobbying organizations. Their talking points were well, we oppose price controls at any level, in any way. And that's not what this is about. It's not about finding the contrary opinion that isn't really congruent with reality. It's about figuring out how can we help the patient in front of us, and as clinicians we don't really have the power to necessarily change all of these things systemically, and we need our health policy leaders and organizations and our you know, president and other other people in power Congress to actually step in there and intervene and help us do this, and I hope that is what is happening.

Speaker 1: 19:46

Well, you know, you raised the rock and let the critters scurry out, so I'll follow it out into the hopefully out into the sunshine. There isn't an organization on earth that spends more money lobbying than Big Pharma. They were the first people in the White House when ACA was being considered. They're headed by a guy who's a former congressman from Louisiana who certainly knows his way around. They spread loads of money around on Capitol Hill. So do you think that we're at a tipping point now, where I know the four guys who are at HHS are unicorns? They're unique, you know you've got Marty McCary, who you mentioned earlier, and Jay Bhattacharya and Mehmet Oz and Bobby Kennedy, who is certainly the outlier. Do you think that they will maybe be able to rally their friends in Congress to maybe take a different path than just sucking up funds from big pharma and doing their bidding?

Speaker 3: 20:45

I would say that that is probably my primary concern. When I look at all of this, when I see an initiative like this and I get really excited about the world that this could create, uh, the reason that I tell myself to just calm down and not get, not get too worked up too soon, is, uh is because I'm not. I'm not sure about that, but I am forever an optimist. Uh, thankfully, I think, but the way that I look at it is, um, the chore. The story, at least, that I choose to tell myself, is that we really do have more power than we think, and some examples of that that I bring up all the time are if patients asked more questions, there would be less over-testing. If patients asked a question about the CT scan that they find on their medical bill that never happened, they would do that less right. And the same is true of doctors and clinicians. We all are up in arms and complaining about Epic and declining reimbursements and all of these issues everybody wants to be upset about. But if we just opted out and said, no, I'm not doing that, I'm actually not going to treat diabetes and heart failure and this wound that won't heal in my 76-year-old patient in seven minutes. I'm not doing it, and I think that the tipping point for that is likely smaller than we think. Right, so if 10% of people saw the light and said, yeah, we're not doing that anymore, I think that real change could happen.

Speaker 3: 22:24

And I think my hope in this situation in particular is if we can get some traction on these things. If we have seniors and kids with rare diseases and we have populations who were rationing their insulin and experiencing life-threatening complications from doing so all of a sudden have access to medication, they have access to medical treatment, then that has the power to change. We won't stand for it anymore. I think that Congress and politicians, after we've reached that tipping point, aren't going to be able to hide behind oh well, it can't be done.

Speaker 3: 23:08

Oh well, we can't possibly do this. The implications are going to be horrific, because we're going to already see it happening, we're going to already see it working and we're not going to want to to give that up. And so that is, I think, the the silver lining that at least I'm clinging to, and it's part of the reason that I'm on this show and I'm, like you know, talking about things as much as I am. It's not because I'm committed to any particular political party or political ideology or what have you. It's because I am 100 percent committed to transparency and accountability and patients getting what they need without being exploited by third parties who produce minimal if any value and and are destroying the health care system.

Speaker 1: 24:00

So here's a question on something you said, because you're in the trenches and you're out there practicing clinically a good portion of your time, when you're not doing insightful articles and kind of interesting YouTubes and all that stuff. I mean, I've told you this before Years ago. One of my very first clients in the insurance business Dinosaurs I mean, I've told you this before Years ago one of my very first clients in the insurance business dinosaurs, I think had just left the earth at that point was a hemoncologist who said to me that doctors will get off their pedestals when patients get off their knees.

Speaker 3: 24:31

Yes.

Speaker 1: 24:32

In your clinical practice? You just said you know patients need to ask more questions. In your clinical practice, are you seeing a generational shift away from this blind white coat authority in patients and patients asking more questions, or is it not happening yet?

Speaker 3: 24:47

So I'm seeing a generational shift, but and I wish that I could say that it is what you just described I wish that I could say that young people are now showing up and they're saying no, I don't have to do that. Actually, why don't you explain to me how this test is going to change your treatment, and then you know, and then we can talk about if it's something that I'm willing to do. But honestly, at least in my end of one my personal experience, I am seeing a generational change, but it's more of apathy. I think that young people are just beaten down right. They don't believe, like the older generations I would say you know my generation and maybe before. They don't think oh, doctor knows best, of course, doctor, I'm happy to listen. They think well, you're likely an idiot and some sort of pharma shill, but I'm going to do what you say anyway, because I have no power. And essentially I mean that's heartbreaking, that's devastating to think that there is a generation of young people that are growing up and and continuing to follow the same patterns of just doing what they're told In a.

Speaker 3: 26:06

In a lot of ways it reminds me of taxes. So you know, there've been many years that people are like, oh, you should ask your CPA about this or that or whatever. And I'm like I'm not paying a CPA. And they're like, well, why you could save thousands of dollars because you're just throwing money away by not following these, taking exemptions, that, whatever I could or whatever the terminology is. That I don't understand. And my answer has all like it doesn't make any sense. And when I sat down and I reflected and realized, like why am I doing this really stupid thing? I'm like a smart person and the answer is well, because I feel like I have no power. I feel like I'm going to get screwed no matter what I do, so I might as well not try. And it's. It's really. That's what I'm seeing from patients.

Speaker 1: 26:59

A wise man, not all that many years ago, said power is never given, it's always taken. What's it going to take? Or are we so far around the bend that we're going to have to blow up what's here today in order to get to patients saying, hey, I'm in charge here?

Speaker 3: 27:14

Hmm, you know, I hope that's not true, but I will say that one of the positive things that I have noticed in the financial crisis essentially that we have in healthcare is that the trajectory that we're on is not sustainable. And I don't mean it's not sustainable for poor people or for people who make minimum wage or for factory workers. I mean it is not sustainable for anyone I routinely talk about when I walk out through the waiting room at the emergency department and I look at the people who are waiting there. The people that are waiting for eight, 10 hours aren't just people who are experiencing homelessness or who perhaps are uninsured or whatever the case may be. They're people with Mercedes key fobs on their key chains. They're all of us key fobs on their key chains. They're all of us.

Speaker 3: 28:25

Every class, every patient group in America is being affected by the prices in one way or another of healthcare, and what I think could happen is that, as these prices increase and people get more and more desperate, they are going to be willing to accept things that go against the status quo, things that go against the narrative, like maybe they're willing to go to the pharmacy and ask the pharmacist hey, I usually use my insurance, but could you tell me what the cash price is for this medicine? Maybe they wouldn't have done that before, but when your medicine's $10,000 a month, you're willing to ask that question a lot easier, right? So my hope is that, as the industry stakeholders continue to be more greedy and things continue to go up, is that patients slowly come to the realization. And then, you know, they realize that one alternative model works and is true and provides great care, and then they're willing to try some, a new one, and a new one, and a new one.

Speaker 3: 29:21

Um, but either way, I think that's where we're going. Whether it's that you know we aren't willing to try anything new and then, uh, the whole thing blows up and then we have to. Or if it's that, you know, incrementally, more and more and more of us are us are willing to try things like direct pay or direct primary care, and you know all of these alternative models. I don't know, but I certainly hope that it will be a soft landing.

Speaker 1: 29:45

In the meantime, folks should check out your YouTube channel, healthcare Liberty Lab, and also, you know, your longer form stuff that you write on Substack at Red Flag Hero, tiffany Ryder. Thank you so much for being our guest today. It's been a pleasure having you on the podcast and I can't believe I waited this long. But thanks for being here.

Speaker 3: 30:03

Thanks so much for having me, David. I hope we talk soon.

Speaker 1: 30:12

I want to give a quick shout out to our sponsor and our producer, hatcher Media. Hey, if you need podcast production or professional graphic design, josh Hatcher is the expert to contact For more information. Visit him at hatchermedianet. That's H-A-T-C-H-E-R medianet.

Speaker 2: 30:30

This Shift Chapers podcast is copyrighted content and may not be reproduced in whole or in part without the express written permission of ShiftChaper Solutions LLC. Copyright 2024.