CVS Breaks Apart, PBM Reform Moves Forward & the Future of Pharmacy Care | TWIRx

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1:22Welcome to This Week in Pharmacy. Twerks is the weekly pulse of the pharmacy profession. And now, here's Pittsburgh native, bleeding black and gold, pharmacy's first podcaster and founder of the Pharmacy Podcast Network, the RxPodfather, our host, Todd Urie.

1:43Hey there, hey there, hey there. Welcome to This Week in Pharmacy. I am your host, the RxPodfather, Todd Urie from the Pharmacy Podcast. Network. And this week in pharmacy, pretty excited about what's happening. And we have three people on our panel discussion today, returning podcast host, Greg Reibold from the PBM Reform Podcast. Greg, welcome back. Thank you, Todd. Appreciate being here. One of my favorite writers in pharmacy, Alec Ginsberg. He's the cowboy out there wrangling the data and helping us to understand what's going on. Excellent resource. If you don't listen, Alec Ginsberg will have links to your blog in the show notes, but welcome.

2:31Thanks for having me. And one of my favorite independent community pharmacies, Dr. Chi Chi Moma, who runs Springfield Pharmacies and her dedication to patient care. So excited that you're here and getting your feedback and some big news today. Thank you, Todd. All right. So we all know what's happened this week in pharmacy. And if you haven't, you must be on vacation. But CVS Health plans to break up itself and clap and clap and hands that they've made that decision. And I can't wait to dig into this. But their insurance company, their PBMs and their 9000 pharmacies will become two separate publicly traded companies.

3:17And we are surprised, kind of excited about the news. But I kind of want to shake this down and start with Greg, just you knowing everything that you've tracked through PBM reform. Tell us what you thought of the news and set us up to dig deeper into the concept of Aetna and CBS splitting up? Yeah. Yeah. So look, first of all, I think fascinating news, right? There's no question about it from my perspective. I thought it was very interesting. I'm going to make, I think, a positive statement, but couch that and offer some context. But I do think that it is reflective and indicative of some of the policy work that has been done in the space, drawing attention to vertical integration.

4:06Much credit to Arkansas and Tennessee in that regard. Also, Senators Warren and Hawley and Representatives Auchincloss, Harshbarger in terms of advancing legislation that would break up the vertical integration between pharmacies and pharmacy benefit managers and in some case insurers. So I do think this is an indication of policy affecting sort of the business plans of you know what's one of the largest companies on earth right if you're looking at the fortune 500. so i i think i think it's significant i don't think that should be discounted right that said setting that aside acknowledging that i think that you know if you look into the details there's you know there's there's a lot to be suspect about right first of all it doesn't involve specialty you know there you know the PBM is still going to be vertically integrated with the specialty pharmacies, is still going to be vertically integrated with the insurers.

5:06So, you know, from that perspective, you know, there's a lot of profits in the relationship between the vertical integration, between the insurer and the PBM. And then, of course, all the massive, massive steering and markups that we see in the specialty market space. And I'm going to say specialty with air quotes, because oftentimes what they say is specialty isn't specialty. So I think there's, you know, there's a lot to pay attention to. In addition, some of the devil being the details. And lastly, and this is going to be more from an advocacy perspective, but I think it also very much goes to show that lawmakers at the federal and state level should be, I would say, incredulous of statements that some of these large PBMs make when they're trying to undermine policy and legislative positions, because a lot of sort of the vibe and I think the press releases and the conversations with news media centered around, hey, this legislation will necessitate pharmacy closures and reduce access.

6:01And there was sort of no acknowledgement that, hey, there can be restructuring, there can be sales, there are ways for these retail pharmacies to sort of stay in these states. So again, I think this step very much undermines a lot of their past advocacy in terms of what the impact would be to breaking up these vertically integrated entities. That was a lot, sorry. oh thank you for that as a pharmacy owner chi chi what what was your first say of this and and then dig into the speculation of of what you think what you think could happen uh based on the breakup so what makes this conversation so important to me is that we're experiencing these industry challenges firsthand right as a pharmacy owner not just from a business perspective But from the patient care side, we care for medically complex patients, including individuals with intellectual and developmental disabilities who rely on us for much more than dispensing prescriptions.

7:04So when I look at the CVS separation, I'm cautiously optimistic, right? Separating companies doesn't necessarily change the incentives that drive the reimbursement. It doesn't change the network access. It doesn't change patient choice. So my question is whether this would lead to meaningful changes for the pharmacies, delivering care like us, and more importantly, the patients that are dependent on us. How does it affect them? Because access to medication is not always the same as access to coordinated medication care, right? So I think we have to be careful not to celebrate this announcement prematurely because they're a business, right?

7:45A CVS pharmacy becoming a separate company is significant, but CVS Caremark and CVS specialty, a pharmacy still remaining together. So what does that actually change in economic relationship between the PBM, the pharmacy, and the patient? Will reimbursement become more transparent? Will pharmacies have more equitable opportunities to participate in networks? I don't know. Will patients have more meaningful choices? I would love to be put in a room where all the CVS people are. so we can have conversations. I don't think we can answer these questions simply because the corporate structure is changing.

8:22The real measure of success will be what happens after the separation, not just what happens on Wall Street. Alec, you're up. And I want to say, you know, Tennessee, Arkansas, like Greg referenced, Tennessee says, hey, if you own a PBM, you can't own pharmacies. And now they're going to come right back to Tennessee and say, hey, that's fine. We don't own the insurance company and the pharmacies together anymore. But then all of a sudden, who the heck knows is going to go on behind the scenes for reimbursement for their pharmacies versus, let's say, independents. So what say you on this news? Yeah, so I think I had, you know, I agree with everything both of you guys said.

9:04You know, my initial thought, I actually saw mirrored in the comments on your post on LinkedIn, Todd, when Mark Cuban chimed in and basically said, like, I'm not going to say this is a bad thing, but I don't think that it actually changes anything in the grand scheme of things. You know, they're still going to be intertwined together. You know, they're going to own a bunch of each other's stock. And I don't think, you know, the most important part of the vertical integration they have is still preserved in the same company. To me, as I've thought about it over the last two days, what's really more interesting is, And I'm just predicting here, but I think I wouldn't be surprised if eventually the CVS pharmacies are sort of sold off to a private company in the same way that we saw with some of the other chains in the past.

9:52and basically it indicates to me that the bigger CVS company, Caremark and Aetna, they don't really view that as a profitable business worth holding on to anymore, which is similar to what I've been saying about the future of independent pharmacy as a whole and that the money now is no longer in dispensing. Not that we're going to abandon dispensing prescriptions, but CVS is just a dispenser. They don't, I mean, sure they vaccinate and stuff, but they're not providing clinical services or other services in the same way that my pharmacy or Chi Chi's pharmacy is doing. Their business is dispensing and there's no money in it anymore.

10:30So they're fine getting rid of this. And I think it just shows you what they're thinking about the future is that they don't view that as part of the future of their business anymore. And I think that anybody who owns an independent pharmacy should take that as validation into what they're thinking about for the next few years of their pharmacy. Because I think any independent pharmacy that's still around has realized that already and started getting, you know, focusing on profitable prescriptions and figuring out other ways to bring in revenue besides just putting pills in a bottle and giving them to people.

11:02Yep. Yep. And Mark Cuban did have something to say in the post. He said just spinning out the pharmacies is smart, but for the cost of care, it's a non-event. They will have contracts. They probably will retain stock in the spinoff. He says, I don't see anything changing for anyone. What changes is that they avoid the legal hassles of being forced to divest. What will be fascinating is whether and how much of the spinoff they own. And that's exactly it. We don't know what we don't know. But what we do know is that the profit is going to stay out front and they're going to try to squeeze out of their pharmacies whatever they can get out of the 9 ,000 fast food pharmacy locations that they have.

11:52And we have read that they're going to maybe put in some more clinic style into their communities where they have maybe quick clinics. but to think that this was a, hey, let's do this for the best of public health is just not the case. Yeah, Todd, and I think obviously there's a lot of agreement amongst all of us on here. You know, I would know two things. One is this move doesn't even necessarily bring them into compliance with Arkansas and Tennessee, right, with regard to from the specialty perspective, assuming those laws ultimately do go into effect. And listen, I don't know what the deal is going to look like.

12:35Will there be cross ownership of shares? Won't there be? Will there be cross referrals? Will there be preferential? Like, there's a lot of answers we don't know. And I would say, look, like, this is why good laws need to be written well is also right, like the definition of affiliate, a good definition of affiliate in certain state laws or the federal level could absolutely still contemplate cross share ownership, right? So, look, this is significant. I think it's caught everybody's attention. I think everybody really is center punching this and going into this with eyes wide open. Certainly, I think PBMs will try to leverage this as, hey, look, look, we're divesting.

13:17There's not a vertical integration concern, but there's so many vertical integration concerns, right? Particularly the steering to the specialty, the targeting the sickest patients, the disruption of care, the marking up of drugs. There's a lot of action in vertical integration on the specialty pharmacy side. And then again, with the PBM and the insurer as well. So I'll give you an example. This is probably a little bit of digression. But even if you look at the federal level of the federal delinking law, right, that became law this year that says, hey, PBM can't profit off of the price of a drug, including a rebate.

13:52Well, there's a rule of construction that says that nothing prohibits them from passing that rebate back to the prescription drug plan. Well, in so many cases, the prescription drug plan is vertically integrated with the insurer and the PBM. So essentially, you're going in a big circle and you're passing it back right to yourself. So again, I do think that there's positives and it shows that policy can shape business decisions. I do think this is probably some attempt to get out in front of some of this, but I really don't think it alleviates the pressure. And my hope is that this draws even more scrutiny and pushes policy further in terms of tackling vertical integration, not just between PBMs and retail pharmacies, but PBMs and specialty pharmacies, and in particular, PBMs and insurers as well.

14:37So I'm hoping that this just becomes more of a catalyst to continue to see policy work advance that really attacks vertical integration that at certain periods where efficiencies were claimed. But I think the jury's kind of out on that. And we see that this vertical integration is being used to leverage higher drug prices. Pittsburgh pharmacy owner, shout out to Brandon Antonopoulos, who runs ForwardRx, commented today on LinkedIn. He said, the current and future market conditions of running a community pharmacy that does not sign any below-cost reimbursement contracts is becoming more and more sustainable.

15:15Choose your contracts wisely. Chi-Chi, let's talk about that. Does this opportunity give us more access to the employers out there in your communities to pay more attention to what kind of contracts that they are signing and in turn, what kind of contracts you're going to be signing as a pharmacy owner in 2027? I mean, if you're giving me a magic wand to answer that question, it will be like, I hope so, right? I hope that my definition of transparency is CVS's definition of transparency because they might have to be using a different kind of dictionary, right? So in a perfect world, that's what we want.

16:01And like when Greg was talking, I thought about a group of patients that I serve, right? Our pharmacy coordinates all their medication services beyond dispensing, right? We work with their caregivers. We manage the packaging, the delivery, the coordination of prescription changes, supporting this group's medication administration process. And then one of the patients or two CVS is like, you can't fill it at these, this pharmacy, this type of pharmacy. It has to be pharmacy that has CVS in it, whether it's CVS retail pharmacy, CVS mail order pharmacy, it has to be CVS. Now think about what that actually means, right?

16:44Who makes sure the medication arrives to the, these patients one time who communicates with those nurses that will make sure it's reconciled, who is coordinating care. Now flip it to an employer side, right? I have an employer that wants a certain kind of medication or therapeutic medication for their members. But then the PBM that we're talking about here is restricting certain things because of X, Y, and Z and their third. Let's not even talk about prescribers wanting to prescribe certain medication and then the PBNs which goes to the same pharmacy. So it's a whole lot of mess out there in the streets, right?

17:25So I'm hoping that this split gives power back to help patients, to help employers make the right choices for their members and empowers us pharmacies to do the right thing by the patient that's my wish will it happen i don't know i'm here for it and i mean it's not happening in the next few months so we'll see what happens i like uh the drugstore cowboy i want to hear kind of like you're in the next phase of being a pharmacy owner. And obviously, it's not all dispensing revenue. We can't have the growth that we want. It's other things. And I think that we still have an opportunity to outpace the services that are being offered to the communities that you serve, contraception services, specialty medication counseling services where you can recommend a specialty pharmacy that works with independent community pharmacies unless you're doing it yourself, compounding services, remote patient monitoring, what other things are you looking at in being able to expand services and once again, really being a full service healthcare disease state treatment provider versus fast food pharmacy?

18:49Yeah, I think about this a lot. And I think the answer I keep coming back to is that it depends where you are in the country. I think every area has an ability to, you know, support a pharmacy that's very specific to the needs of that community. That's what community pharmacy is about. It's like, I'm in downtown New York City, what works for me is going to be very different from where Chi Chi is in Pennsylvania, or somebody in like Mobile, Alabama, or a very rural area. It depends what else is around you, how specialized you want to get. I do think that overall we're heading towards this future where people probably don't get their medications from the same source for everything.

19:35Maybe they get their cheap generics from Mark Cuban or Amazon. They get their GLP direct from Lilly Direct or Novo, you know, DTC, and then they get their antibiotics and stuff from the local pharmacy. But in that world, people are already confused about their insurance and where to get things. So maybe there's an opportunity there for the pharmacist to, you know, take a fee or be paid to kind of manage medications, which is what we're trained to do. But to help people navigate this new healthcare world, that's just one of the things that comes into my head. In New York City, I have lots of older people who probably should be in a home, but they have been in the same apartment for 20, 30 years.

20:20They won't let their kids take them out. And those people don't want to live in help, but maybe they're okay with a pharmacist coming once a week to their apartment and helping them manage their medications for the week. That works for me in New York City. in other areas like rural areas where doctors are much further away maybe they you know can serve as sort of like urgent care centers if pharmacists get prescribing power there's a lot of different ways for pharmacies to be successful the one thing that I keep saying to students when I've been when they've been reaching out to me lately students who are interested in opening their own pharmacies is that it does seem like right now pharmacy is in like one of the most turbulent changing times that it's ever been in.

21:01But the history of pharmacy has been riddled with crazy stuff happening all the time. Like Medicare Part D is only 20 years old. Insurance was only created in the 60s. Modern medicine, like penicillin, was only during World War II. It's not even 100 years old. Smart pharmacists have always figured it out. And there will be plenty that do it now. You just have to get creative and try some things. And none of us, anybody who says they know what it's going to look like a few years from now I was lying, but all the best, my pharmacy has been around for 188 years. It's because we're nimble. We always change with the changing times.

21:37The right ones will do the same thing and figure it out.

21:45Greg, at this point, we can't slow down with the state-to-state reforms. I want to see more states still putting legislation in place that says, hey, you're an insurance provider, you're a PBM, you can't own pharmacies. Also, if you are an affiliate or an associated organization, the reimbursement pricing of what you're pitching to your affiliate pharmacy network, you have to open that up to all pharmacies, that same reimbursement, And then steering. How do we know that a letter is going to go out from Aetna to every covered live and that they have and saying, hey, you know, use CVS pharmacies for this, this or this reason.

22:37So what say you on kind of the ideas of continuing to press on on PBM reform from state to state? Yeah, look, I think when you look at the evolution of PBM reform at the state level for over the last 10 or 11 years, it's amazing, right? It's really almost unprecedented in terms of the amount of legislation that has been introduced in states and passed in certain states. And I think certainly, you know, we saw the first steering law in 2019 pass that was out of Georgia and that's proliferated right in multiple, multiple states. There's massive issues with enforcement on the steering and PBMs very much like to kind of hide behind preemption arguments in connection with steering and arguing that that wasn't within the purview of Rutledge v.

23:24PCMA. Obviously, we have this vertical integration legislation that's being introduced in other states and has been passed into. i'd certainly i think i think like to see more of that i do think you know that pbms are using some of this uh you know state litigation you know as an attempt to try to chill other states from introducing that um obviously they've got preemption arguments in those lawsuits they're also arguing dormant commerce clause which i personally think is is is really not a strong argument it doesn't you know these laws aren't tackling where a pbm is located you know so it's not favoring in-state versus out-of-state rather it's targeting how corporations are structured and targeting that vertical integration and then of course we're seeing different types of state legislation kind of proliferate in terms of ensuring that there's transparent and you know fair and sustainable reimbursement trying to stop the markups at the pbm affiliated pharmacies and i think states are having some you know some degree of success on that so i think there's a lot to be optimistic with at the state level i would say you know work needs to continue to be done in that regard and then you know very excited about some of the things that are at the federal level including patients before monopolies act pharmacists fight back act you know particularly we saw hr 6610 and the federal employee health benefits plan uh get marked up overwhelmingly in support and oversight so i think there's you know from an advocacy perspective there's a lot to be optimistic about, but the work is nowhere close to done.

24:58Well, we're excited about the announcement today. We're apprehensive. I don't trust it, but nonetheless, I still think it's good news. I also think that it gives an opportunity for all of our independent community pharmacies to communicate with their patients, with their communities about other services that you're providing, as well as delivery, as well as some of the exterior services that are now coming out of technology. And just steadfast, always keep in touch. I do want to say thank you to my panel today. Chi Chi, it's wonderful to see you and talk with you. Alec, the drugstorked cowboy, like I said, one of my favorite blogs out there.

25:40If you don't subscribe to his blog, please do so. You'll have a link in the show notes. And then tune in to PBM Reform Podcast with Greg Reibold, one of my favorite podcasts and educating me on what's happening in pbm reform hey shout out to our entire pharmacy market um on a on an international scale the 50 most influential people in pharmacy 2026 voting is now open so if there's someone if there's a technician if there's a pharmacist if there's someone in wholesale who you think is special that has made difference to pharmacy care and the business of pharmacy care, please go to pharmacy50.us.

26:22Once again, that's pharmacy50.us. This has been This Week in Pharmacy. Chi-Chi, Alec, Greg, thank you so much. Thanks, Todd. Thanks. Thank you so much, Todd. And I say go nominate Chi-Chi and Alec. Thank you.

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27:38Hey, welcome back to This Week in Pharmacy. What an amazing interview that we had with pharmacy owners digging into This Week in Pharmacy, specifically around CVS Health's news. Part of that news comes back to what is happening in our nation around PBM reform. And the Consolidated Appropriations Act of 2026 was a sledgehammer that we desperately needed on a federal level, a major federal reform for pharmacy benefit managers. And I have with us a legend in PBM reform, Representative Buddy Carter of Georgia. Welcome back to twerks, buddy. Oh, thank you for having me. It's always a pleasure with you.

28:27And someone I go to a right hand of government relations with our relationships with independent pharmacy cooperative, John Covello, who recently accepted the leadership of their division in government relations as VP of that division. Welcome back to twerks, John. Thank you, Todd. It's always great to be on your program, and I am thrilled to be with the best champion pharmacy has ever had in Representative Buddy Carter. I agree. Buddy, take us down this complex road. Talk to us about the outcome. We all like outcomes in pharmacy care about the Consolidated Appropriations Act of 2026. Well, the Consolidated Appropriations Act of 2026 was arguably, and I think certainly, the most significant PBM reform we've ever seen.

29:22And it was a culmination of a lot of years of work, to be quite honest with you. And it resulted in three major things that had happened. One is that we now have more transparency so that the PBMs will now have to show the discounts that they are getting with the pharmaceutical manufacturers. And of course, the result of that will be that as the plan sponsors and as the employers see the discounts that the PBM are getting they're going to demand that they share in them whether it be at you know at the corporate level or whether it be at at the point of sale but they're going to demand that they share in those in those rebates the other thing it did was to de-link the compensation of the PBMs from a percentage of the drug to just a flat fee and that was significant because some of these percentages that the the PBMs were making on some of these drugs were just outrageous I mean in the 2000, 3000%.

30:21And, and by going to just a flat fee, that's going to be significant. The third thing that it did, and something that has just been implemented here recently is that, or something that is being implemented, I should say, is that it called for, for relevant and reasonable comp on contracts between CMS and, and between independent retail pharmacies. And that was, that's very significant now we got a situation now where where CMS is taking comments until until November the 23rd about what is exactly reasonable and relevant and and in contracts and negotiations and that certainly is an opportunity for us to to be involved and and and to make sure that that we are we are helping CMS to understand what is reasonable and relevant, because I will tell you, there's been a little bit of pushback from them about this.

31:21And that is them saying, well, you know, what's reasonable to one person might not be reasonable to another person. And I get it and I understand that, but that's where the public comments that come in are so vitally important. So the consolidated appropriations act, that was three of the major things that was in it, that were in it. One thing that was left out was spread pricing. And, you know, it's just ridiculous that CBO has now gone from saying it was going to save millions of dollars to saying it was going to cost billions of dollars. So still haven't figured out exactly how CBO came up with that scoring, but nevertheless, they did.

32:01it. I think the public connection, that public is also our pharmacy operators and owners in our microchains and our independent pharmacies in businesses that are still privately owned that are non-biased to federal programs that give them reimbursement, fair reimbursement to take care of patients who in many cases need constant touch with a pharmacist to manage their medications because it it might be eight it might be 12 um and buddy you understand that as a as a pharmacist and pharmacy owner absolutely you're absolutely right and and that's why you know i tell people all the time when whenever you talk about health care whether you're republican or democrat or independent we all want the same thing we want accessible affordable quality health care and accessibility is so vitally important and that's why retail pharmacies particularly independent retail pharmacies in rural areas are so vitally important you know over 80 percent of all Americans live within five miles of a pharmacy and pharmacists are some of the most accessible health care professionals in America and that's one thing we need to keep in mind because as more of these independent retail pharmacies close, then you're impacting accessibility to healthcare.

33:24John, I like the perspectives that you bring to us because now you're collecting so many people's feedbacks throughout the nation. What's the outcomes from your perspective of the Consolidated Appropriations Act of 2026? Well, as Congressman Carter said, I mean, This has been the most significant single enactment of PBM reform we've ever seen federally. Certainly, I would say it's going to rank up there with what the Rutledge decision did from the United States Supreme Court to sanction and protect the rights of states to regulate PBM activities within their states. The two of these are really going to go hand in hand.

34:10And, you know, I have got to compliment Congressman Carter. I mean, I first met him when I was in this industry, when he was still in the Georgia state legislature, and he had gotten significant reforms passed. And he did what was really important as a public servant, but also somebody who believed in his profession. He stepped up and ran for Congress when it wasn't a clear path. And he worked hard and diligently to get to Congress so that what he was able to do as a pharmacist legislator for Georgia, he's been able to do nationally. So, you know, Congressman, I want to thank you on behalf of all the IPC members and every pharmacist and pharmacy owner out there and every patient out there.

34:51And I think even plan sponsors for the sometimes lonely work you did for a lot of years that now is in fashion. That is a part of the center part of this whole national debate about drug and health care affordability. So I think, you know, it's a difficult job. I know, Congressman, of leading and championing an issue, but finally seeing the fruition of it. But to your question, Ty, you know, with Consolidated Appropriation Act, it was twofold. In the self-reg, basically the self-funded market of both labor plans and ERISA plans, it finally set some parameters that the Department of Labor had been talking about going back to 2012, you know, three administrations ago.

35:39And it basically is requiring a fiduciary responsibility now on PBMs that operate, that are offering these benefits that the Department of Labor and, more importantly, plan sponsors can hold them accountable to. I mean, during that process that got into this bill, major employers, Princeton University, John Deere, went and talked about how we can't get from these PBMs information we want or what we think is our right to audit, because they said we weren't entitled to it. And these are the entities paying them for this drug benefit services. I mean, it sounds farcical on its face, but this puts an end to that.

36:21It also does make it very clear, as the congressman said, they now have to de-link their compensation from what they're doing in these roles. And it does provide some pathways for ending in that space, spread pricing of where they are charging higher amounts to the plans than what they're actually paying for the services to pharmacies. A very important thing it does, it eliminates just arbitrary clawbacks of the PBMs taking back money without plan sponsors knowing it or even patients. And it has real penalties to it that would allow both the Department of Labor and the IRS. Remember, private sector health plans are a tax-deferred benefit, so there's a tax consequence in them offering this.

37:13So ultimately, any profiteering that's been going on is basically being subsidized by taxpayers without knowing about it. So this is really significant rules to the road. And, you know, Todd, for everybody's edification out there that's listening, I mean, just last week, the administration finalized these regulations. They now go into effect. I've seen a lot of literature in Congress. I'm sure you've heard from people in preparation for this in the last six months. Plan sponsors, PBMs, pharmacies, unions are all getting prepared for what these rules of the road are going to mean. So, you know, Congressman, I know they always talk about, you know, health care is a sixth of the U.S.

37:55economy and what we spend. This was a part that was always ignored of what was happening in this field. And, Todd, very quickly as to Part D. Part D has been around 20 years. It's been an important benefit to vulnerable seniors, including those that are dually Medicaid and Medicare eligible. people think about that are in nursing homes, our most vulnerable patients that Congressman Carter knows well, this affects the quality of their life. This is the first major change since we got prom pay in 2008. But having lived through the wars of all the clawbacks of DIRs and the take it or leave it provisions and all the things about where if you didn't sign a Part D contract, you would lose all of their contracts.

38:40This is what we've been working for probably since the start of Part D, where it was always about it had a requirement for non-interference, what was in the legislation. Well, thanks to Congressman Carter and all Congresswoman Harshbarger and all our other pharmacists in Congress and our pharmacy-aligned champions in Congress, they said, we need an actual statutory exemption from that. We need to protect the recipients, the federal government, who remember, pays a lot of the cost of Part D, and those pharmacist providers they all depend on to make this system work. So they created this thing of reasonable and relevant.

39:24And it's finally setting some rules to the game. Basically, I would say, you know, the four corners of the page, what's going to be in these contract terms of what pharmacies get so they can effectively and properly be able to serve their Part D patients. And it goes beyond just how much pharmacies get paid. I mean, that's a large part of what our interest is. You have to pay them fully for the full cost of the service to be able to carry these drugs and pay these services so that, you know, we're avoiding, Congressman, as sure as you would want to avoid more expensive, more intensive health care by not letting these seniors have all of their services.

40:02But it goes beyond that. It's about all the other terms that we find that are nebulous, that are one-way terms that benefit the PBMs, that allow them to discretion to decide things, to determine whether they even tell pharmacies why appeal got denied or why they're being audited. And it creates a third thing that's very important. And I know Congressman Carter and his whole allies of the pharmacy caucuses in Congress made this clear. It's going to set a standard for what's an essential pharmacy. You know, there's been a lot of talk about pharmacy deserts and other healthcare deserts, Todd. This helps define what are those critical pharmacies?

40:39What are those keystone pharmacies helping hold up this healthcare system? And it gives CMS the tools to define those, not the PBMs, and set the parameters about what's reasonable or relevant around the one word that I know Congressman Carter always talks about, patient access. This is designed to fix a system that went far too long with any rules to the road to make sure it really is benefiting everyone, because so far it's really only benefited the PBMs. Well, that leads me to what happened this week in pharmacy, and that was a major announcement from CVS Health to break up and split their 9 ,000 community pharmacies from their PBM.

41:23And I want to ask both of you what you think of this announcement. And of course, my conspiracy theory mind is they knew exactly what the writing on the wall was with many states not allowing a PBM to own pharmacies anyway. and was the writing on the wall there for them to make this decision themselves before they were forced to make this decision? What say you, Representative Carter, on this news? Well, first of all, keep in mind that this is what we've been working for since the very beginning, and this is what we pointed out to everyone in the legislature. This is what we pointed out to all the committees we've been before, is that the vertical integration is the problem.

42:09That is where the insurance company owns the PBM, that owns the group purchasing organization, that owns the pharmacy, that owns the doctor. You know, the largest employer of physicians in America is UnitedHealthcare. An insurance company is the largest employer of physicians in America. And what CVS is doing, and you are accurately describing this here because they see the writing on the wall, and that is they're going to go ahead and bust it up their cell. Two things I want to mention here. First of all, I was in a meeting. It wasn't a hearing. It was a meeting of the Energy and Commerce Committee and the CBO, the Congressional Budget Office, the economists that tell us how much legislation is going to cost or how much it's going to save.

42:52I asked them, there was the director there as well as about 20 staff members. I asked them directly, give me one example, one example of where consolidation in health care has saved money. They couldn't give me one example. And this is an example of what I'm talking about, this consolidation, this vertical integration that existed that we've been calling to get busted up for years now. Finally, CBS, as you say, they see the writing on the wall, so they're going to separate it. And one of the things, one of the major things that has contributed to this has been the ruling in Arkansas and in Tennessee where they've said that an insurance company cannot own its own pharmacy and a pbm can't own its own pharmacy well that has led them to to see the writing on the wall and see that hey we we can wait for them to bust it up or we can go ahead and bust it up ourselves and they've decided to go ahead themselves so this is a major major win for pharmacy john what do you think of the news i i think uh it's like letting things it's uh I guess, Congressman, I would go back to what President Reagan said, trust but verify.

44:07I mean, you have to really start to dig into part of what they're saying. One thing, if you notice, they said they are splitting them up into two separate companies. I don't know if they're going to go the full level of divesting the bricks and mortars, but what I think this is an effort for them is to try and get all the dogs off their trail in both the state houses and in Congress on divestiture. what it may be that they're trying to create a legal avenue where they will say, well, the law really doesn't apply to us. It's the PBM corporate entity is not owning these bricks and mortar stores.

44:43But I think the more important thing that gets to what Congressman Carter is talking about, that I still think has a very salient need for the federal legislation. And, you know, Congressman, I know you always talk about, you know, there's one, this seems to be the one area where Democrats and Republicans can agree upon. I just saw an article written this past week that says that point. Republicans and Democrats can agree on one thing. They all hate PBM. So this in many ways is the culmination to all your career's work on this. But what was very interesting in their announcement was saying they are not divesting from the corporate ownership with Aetna, their specialty pharmacy operations.

45:23And what's really clear where the money is. I always talk about follow the PBM money. It's not really in them owning a bricks and mortar store. You know, there's the other PBMs are still involved in challenging these laws in the states. It's about their mail house orders and their specialty closed network mail house pharmacies. And it's an interesting development. I think we'll see if it's mainly for public relations benefit, but I think it will give a lot of appetite in this next year as to more of these bills coming up because whatever they think they may have gotten to the benefit of this, they've almost conceded a very important debating point about jobs in this, of what they were arguing.

46:05But I still think we have to keep our eye on what Congressman Carter says. They own the healthcare system, which gives the admitting rights to their own employee doctors that are writing the scripts that go to their pharmacy. Think about it. They're taking other people's monies, deciding how much to pay providers, including how much to pay themselves and their competitors. And I think you're right, Congressman, it took a lot of years to get a 180 on the attitude of the Federal Trade Commission on this. When you take other people's monies and decide how much to pay yourself and competitors, I don't know how the consumers ever went in that kind of a setup.

46:44So I think this is more to come, Todd. Let's keep following this story to see where the path leads to on this, but it is a very positive development. I will tell you, John, I don't trust them any further. I can pick them up and throw them. So, you know, I've always described it like because of that vertical integration, it's like squeezing a balloon. When you squeeze it in one area, it comes out in another area. So if their profits go down in one area, they're just going to make up for it in another area. Yep. Yeah. If standalone CVS pharmacy has to negotiate with multiple PBMs, demonstrate their competitive dispensing economics, improve the value of their clinical pharmacy services, which is part of their plan for immunizations and disease state management, everything that independents have been doing for the last 20 years.

47:33If America's largest pharmacy chain needs to separate from its PBM to unlock its future, what does that tell us about the economic pressures facing thousands of our independent pharmacies throughout the country that never had a PBM to support them? That's the question I'm posing. And that's a great question. Go ahead, John. No, and it's a very important point because if you dig deeper, you know, there's a few articles out there, you know, Financial Times has written about it. A number of the business press has written about it. I think they also did this to make what's left of the integrated company that much more valuable to private equity.

48:12You know, they've had some dabbling in it. And I think in many ways they are facing the pressure on the bricks and mortars of what Walgreens is facing now as they look to their future. And what happened to Crater Rite Aid? I mean, there was a consumer publication wrote out there how CVS basically stepped on the throat of Rite Aid all the years with their PBM to the point where they killed it. And we always were facing the challenges, you know, is it about independent pharmacies, small business entrepreneurs not being able to operate efficiently? Well, we run the largest GPO in the country. We run the sixth largest warehouse.

48:52We're out there. Congressman, I'm sure you know from your colleagues and your friends still owning it. They're shopping every day. They have to be as economically efficient and have to compete economically every day. But they can't buy better than getting paid below what it costs to buy out there in the system. And for so long, CBS has been proven that they paid themselves better than they paid everybody else. So I think it shows though, if big entities are having trouble, it's not about the poor, inefficient, unincentivized independent pharmacy that can't run their business well. It's about, we hear it all the time, right, Congresswoman, when you have a rigged system rigged against you, there's no way you can make it work.

49:39And the people getting hurt are those was covering the benefits because they're clearly paying more. A lot of literature out there taught about how big employers are shopping and don't want to resign. And a lot of them haven't resigned this year with the big three or five, they're looking for alternatives. And I know more Cubans in that space. There's a lot of efforts in that space to break down this oligarchy of people feeling they only have a few choices. But a lot of it is, the pressure is there now. It's not just about independence. It's about all the pharmacy that's left. And in many cases, we're the last ones left standing in communities.

50:19So, Congressman, you know, that raises that thing. If you take away a pharmacy, I mean, look what's going on in the Rural Health Transformation Program. Where are people going to go? They're talking about hospital deserts. They're talking about doctor deserts. Finally, they're getting attention that pharmacy deserts aren't just there's no pharmacy there it's the pharmacies that can't give you all the drug therapy services all right good point and polypharmacy pharmacy shopping for the average person out there is a real health care danger to patients and it frustrates as you know congressman those pharmacists who want to help their patients but can't provide every service because they can't afford to carry every drug.

51:03You're right. You're right. It's so tough out there these days. But I just want to again reiterate how big this is with CVS. I mean, I really think this is significant. Yep. And it represents billions of dollars. The CVS Retail Profitability Simulator that I plugged into two different AI financial models shows an annual segment revenue of just their pharmacy services,$137 billion, and adjusted operating margin at 4.3%. And that's operating 9 ,000 locations, 5.91 billion adjusted operating income. Income per store equivalent is$650 ,000. So it's still going to be a profitable model. model. It's getting the federal and state governments off their backs and operating as two separate entities still enables them if you're not auditing, if you're not keeping on it, just like you said, Representative Carter, if you're not continuously monitoring the foxes and the hens and the eggs that are being stolen, you could just be doing business with a specialty contract from one entity through the next.

52:26And now they can say to Tennessee, hey, we don't own pharmacies anymore, but we can still do contracts with our own pharmacies. That's exactly why they're doing it. And having their own GPO and getting into manufacturing of drugs. I mean, just looking at it, Todd, this vertical integration Congressman Carter's talking about, I think Congress is now, you've dealt with a lot of the symptomatic problems Congressman Carter, but now you're getting to the root of the disease. You know, is this big insurance, big healthcare? You know, keep this in mind. In the top fortune 10 companies, CVS is number six and United Healthcare is number three.

53:06You know, they're bigger than Berkshire Hathaway. They're bigger than ExxonMobil. And Express Scripts is number 12, I believe. Yep. So follow that PBM money. It's a big part of where this is all going. But yeah, Yeah, you don't have to worry about them. They will still find ways to be profitable. Oh, yeah. Oh, yeah. Tom, one thing I want to make sure viewers understand not to lose sight of is, you know, Congressman Carter has accomplished a lot, but he has been dogged on this bill of, you know, protecting Medicaid prescriptions and PBM Reform Act. It's an important thing, not just on spread pricing to end it and pick up on the billion dollars of reforms to state and federal taxpayers that 14 states have already done.

53:56But it's to make that reform permanent. But the equally significant part that works in tandem is he's going to get real transparency when we get this bill done, buddy. And I'm going to stay positive about this and doggedly. We are going to get this done. It also creates a mandatory transparent system of drug reimbursement pricing that creates this, we call this thing NADAC, which is basically just a market basket of how they get drug prices. But we'll make it mandatory for every pharmacy across the country to submit their invoices and get it from specialty as well and create a pricing list that every state will use and that CMS will be able to audit against when they get state claims.

54:38and the real cost of pharmacies to dispense and provide those services and manage care. And it's already being done for those states like California, like Colorado, Alabama, red and blue states that are doing this now in their fee-for-service programs. This will save the federal government and the state's money. It will bring the transparency, but the more important part of that bill, which is the most significant thing in this being a linked bill, is the pass-through. It takes that market basket, tells the PBMs, this is what you have to pay pharmacies for these Medicaid services, and that's all you can charge the states.

55:20And that's, you'll get a separate fee for your services, but this brings us to really what is a rational, transparent, accountable aspect of drug therapy services to pay fully for it on both the drug costs and the services that providers will get and that plan sponsors, in this case, state and federal governments on Medicaid, we'll see. And Congressman Carter, I know since that score, because a lot of it was about the changes from the one big, beautiful bill, there's a lot of work going in to help educate CBO. I just know that, look at what the states have done. They've just come out with an audit in Ohio, which is one of the first states to do it about things they need to do to improve their managed care system of oversight by the state.

56:08One area that got the highest grade, their management of their single PBM for their Medicaid managed care program. State after state have done evaluations. They've documented and put it into their budgets that they're saving collectively over a billion dollars. I firmly believe we can help explain this to CBO and keep all of you and your policy colleagues in both the House and Senate on track that this is a reform long overdue to save state and federal dollars. So I say to anybody listening out there, support Congressman Carter. Talk to your members of Congress. Now that they're back, we got to get this done in lame duck, buddy.

56:45I'm very curious what you see, our pathway in lame duck to get this last big piece of the puzzle done. Well, you know, first of all, obviously we know what happened Tuesday. So we're going to have a we're going to have a new majority starting in the next session. So we know that that's going to have an impact. Although I will tell you that one of the things that I'm very proud of is the fact of how we worked on these issues in a bipartisan fashion. I tell people all the time, you know, I never went to my pharmacy counter when I own my businesses and ask someone if they were Republican or Democrat.

57:22I mean, you know, all I knew was the medicine was expensive. And really, when we're working on these things, this has been bipartisan, particularly at the committee level with energy and commerce. We passed a lot of good bills that have gone to the floor and passed out of the House. A problem has been the Senate a lot of times. And getting something through laying duck is really going to depend on a number of different things and that primarily what else is going on. You know, with the Republicans controlling the House and the Senate and the White House right now until January 3rd, we may be throwing some Hail Marys.

58:05We may be trying to get some things done before we lose power. And if that's the case there, you know, I don't know how much more room there'll be for anything else. But this is a very important part, Todd, of finishing the fight, because if we get this whole system and pass-throughs as proven as a mandate, it, I think, will drive some parameters that can affect what's reasonable and relevant. and looking at the pharmacist fights back for the federal employees benefit programs, proven to be, you know, a billion dollars that the federal government has been overpaying. And for private sector points of what's coming up in what now just got enacted in the rules from the Department of Labor.

58:51It will give what people have been talking about since I've been in this industry for 20 years. How do we get to what really it costs to pay for the drug services and the service associated with it? how do we end this pharmacy alphabet soup of acronyms and, you know, what are you really paying? What's really charged? What does it really cost? It really is trying to create a system that will be, what does it cost to have a drug in place to meet a patient's need as they walk into that pharmacy? Because that's what it's really all about, is it's about what do we have to pay for access. That's exactly right.

59:31I couldn't agree with you more. I am very optimistic, by the way, about the lame duck session, and certainly make no mistake, we're going to be pushing as hard as we can to get this legislation voted on. Well, I'm going to wrap this up, but I want to share a quote with you that brought me a lot of excitement that I heard in June, and it was from you, Representative Carter, saying, and I quote, I have a lot of gas left in my tank, and I want to make it clear that I have no intention of retiring. I still want to be relevant, and I'm not ruling out anything, even the possibility of running again in two years.

1:00:09And I was thrilled to hear that quote, buddy. So we hope to. Thank you. Thank you very much. You're very kind. You know, I tell people all the time, I think I got a disease and I think the only I think the only cure for it's embalming fluid. I know it's strange, but I really do. I really do love it. And especially when and I'm not trying to patronize anyone, but especially when you represent a profession as great as pharmacy. And that's one thing that I think that we fail on in our profession is really telling our story and having patients tell our story. Look, when I still had my business, I'd get phone calls at home.

1:00:53I'd have to go in the middle of the night to get medicine for people, all of those things. And this is what pharmacies do. This is what pharmacists do. And we provide a valuable service to Americans. As I said earlier, you know, when you talk about health care, you want accessible, affordable, quality health care. the most accessible healthcare professionals in America are pharmacists. And we provide that accessibility. We provide that reliance and giving people comfort to know that they've got a healthcare professional right there in their own neighborhood, right there in their own community.

1:01:36Absolutely. Well, yeah, I mean, I got to accue that and again, thank Congressman Carter on behalf of IPC members in all pharmacies, including, I don't care if they're independent, certain chains, grocers, people in communities for what you've done for community pharmacy and elevating it to a part of healthcare. I still think we need your continued involvement. I know you're leaving Congress, but you're not going to be a stranger to staying involved with policy and with patient needs to keep pharmacy at that discussion when they talk about healthcare providers. It's not just hospitals. It's not just doctors.

1:02:16They've got to keep talking about and pharmacies too. And I know you still will have a role. We will all desperately need you to continue once. You'll be out of Congress, but you won't be out of what your passion is. And I, again, have to thank you for what you've done. And I know what you're going to continue to do to work with us all. And I really want to thank you for being there always as somebody we could turn to and your staff. I mean, it's just been incredible. And I'm going to make a plug, buddy. Please get other pharmacists to look at public service. It's vital they have a seat at that table.

1:02:51They've got to be in that room explaining to policymakers what they've learned from being healthcare providers and community servants. Absolutely. And by the way, you know, who, What was it? Terminator? He said, I'll be back.

1:03:09That's right. And we'll be back with more twerks. Hold on. We have a short commercial break and we'll be right back. Thank you so much to John Covello and representative Buddy Carter for this amazing interview. Thank you. Great. Thank you, Todd.

1:03:31This episode is sponsored by Independent Pharmacy Cooperative, widely known as IPC. Established in 1983, IPC is the nation's largest group purchasing organization owned by Independent Pharmacy. With a mission of maximizing the success of community pharmacists, IPC works to provide members with access to effective programs and services designed to enhance profitability for independent pharmacy. Read more about our mission by checking out our website at IPCRX.com. That's IPCRX.com.

1:04:13Thank you. Hey, welcome back to This Week in Pharmacy. Interesting topic and story. Today's been a packed twerks. We have a lot going on this week in pharmacy, but something that I want to bring to our listeners' attention, if you're listening on your podcast and you want to look at this on YouTube or we're also streaming on LinkedIn, in, we'd like to review an article from US Health or US News and World Report. And the title was how GLP One patients select telehealth platforms and achieve success. This was a 2026 US News survey. And I'm excited to have a representative of US News and World Report with us, Gretel, Gretel Scholler.

1:05:04Welcome to twerks. Thank you. Thank you, Todd, for having me. I'm looking forward to it. And no stranger to this week in pharmacy, Kelly Stovall with Independent Pharmacy Cooperative. Kelly, it's so good to have you back. Great to be here, Todd. All right. So when the team at U.S. News and World Report reached out to us and asked, would I be interested in extending some of the conversation around this article? they had me at hello because I was like, absolutely want to dig into this. I'm going to kick this off to Gretel first. Give our listeners just an overview of the research and how this ties into GLP-1.

1:05:50Right. So we actually conducted this survey over the course of the summer, over June and July, and we surveyed over 1 ,200 adults in the U.S. who had used a telehealth platform to receive a GLP-1 medication within the last 12 months. And it was a series of 30 plus questions on various aspects of how they choose and decide which telehealth platform they choose and also just their experiences using a GLP-1 medication. Part of that survey was used for an earlier project that came out in August, actually, where we evaluated and rated telehealth platforms that sell GLP, brand name GLP one medications and gave them a star rating.

1:06:34So that was the first step. And then this was part two to sort of see how consumers are actually using these platforms. So I understand this in concept up until about six months ago, where I was able to do a short telehealth follow up on a condition and treatment that I was in a short-term treatment. And it made me quickly think about our community pharmacies who have access to their patients nine times more a year than their physicians and connecting with them about a multitude of different things. Kelly, how can independent pharmacies support GLP-1 patients beyond dispensing and continuing to engage even through these telehealth platforms?

1:07:22I think we have to remember that we're treating a condition in most cases with GLP-1. The GLP-1s, there may be diabetes, maybe there's blood pressure involved. So you really have to look at the whole person. And so from a pharmacy perspective, our pharmacies can actually provide that support needed when they start this treatment. some of the medication follow-ups on it, whether they're looking at how they're managing their side effects, the adverse effects. So whenever this new medication started, no matter how it was fulfilled, a lot of times that patient will come to the pharmacy for that health support after that point.

1:08:08I wanted to kind of dig deeper into where that support's coming from, why that support is being offered. Gretel, something about the report that I was excited to read is access to behavioral and psychological support increases weight loss success. And of those who lost over 20 % of their body weight, more than half, 52%, had access to behavioral and psychological support. And for those who lost no weight or less than 5%, less than 25 % had access to this type of support. What does that tell us about the evolution of telehealth and behavioral health? Well, I think a couple of things. First of all, I mean, GLP-1s have been touted as a sort of miracle medication.

1:08:58And I think especially for people who are using telehealth to get these medications, I think they're focusing on what's the quickest and cheapest way I can get the prescription. And so I think patients often underestimate how much guidance they actually need. This is not a one and done, you know, type of therapy. So I think when starting these GLP-1 medications, consumers overwhelmingly focus on the prescription and not sort of their long-term needs. And so as you mentioned, the data that we looked at showed that when people are choosing a telehealth platform, they're actually focusing on different things.

1:09:36and they're focusing specifically 29 % of them are choosing platforms that are offering a thorough initial medical screening and 26 % are choosing platforms that are, are choosing platforms that offer supportive medical follow-ups. And those things are important. I don't want to discount them. I think they're an important part of the process of rigorous initial screening, getting medical health history, getting baseline blood work. Those are all important as is, you know, regular checkups with an actual healthcare provider, whether that's, you know, via video consult or telephone call or such.

1:10:13But what I thought was interesting, as you noted, they don't seem to prioritize the other types of support that we have found seem to be associated with the greatest amount of weight loss and greatest amount of success. And that is, like you said, behavioral and psychological support. So of the people who had the most success with weight loss. In other words, they were losing over 20 % of their body weight. Over half of them had access to behavioral and psychological support. So those would be things like stress management, so coping tools to use non-food coping tools when you're stressed, you know, learning how to sort of to pivot hunger cues and food noise, exercise coaches, dieticians, food and nutrition guidance, food trackers, all of these things are helpful in sort of that weight loss process.

1:11:04I think it's important to remember that, you know, treating obesity or overweight is not, you know, handled in a vacuum. It requires lifestyle and behavioral, you know, changes. And usually most people can't do that alone. When I think of what Gretel's sharing, Kelly, I think of independent community pharmacies who have personalized relationships with their patients anyway. And when I see the term of what it's going to take to see a patient through, we're talking about a minimum of 12 months of ongoing counseling through this process. And when I think of myself, when I lost about 20 to 30 pounds, which would have been 15 years ago and how that made me feel about myself, the confidence that I felt, the reduction in my own stresses because of my lack of confidence or wearing a bathing suit or whatever it is.

1:12:07I can understand how psychology and behavioral health is now tied into this, but providers really have to be prepared for the total of treatment, not just the medication, but the support along the way. Kelly, what kind of opportunity does this present to independents in particular? And where has IPC really kind of leveraged the program or programs like that? No, first I'll say something that Gretel said to really maybe think about this in behavioral health. you know, we know with bariatric surgery that mental health and behavioral health really added to the outcome of that procedure. And those that went without it really struggled with the success of that procedure too.

1:13:04And I think, you know, there's multitudes of studies on that. And I think that's a trend we can latch on here because it's, in essence, it's the same thing in that a patient is losing a large amount of weight sometimes very quickly but all those same behaviors are there and perhaps those stressors that cause emotional eating and all of those things are still there as well so they have to you have to look at the whole patient in this situation and I think there's you know we can really draw on the parallels between the two and what we've learned from one and bring it into the other you know in education on that so you know I I think pharmacists have an incredible opportunity to have a close relationship with a lot of their patients.

1:13:49And when this medication is started, you know, they can have those conversations as well, because a lot of times anxiety will increase because that emotional outlet of food is no longer there. So some of those things have to be taken into account. And if there's medication around any of that, of course, we can we can help with that as well. um you know i think also just being there to speak about the side effects that may they may see because you know more than likely they will see some side effects and it's always deciding is this side effect when i should stop the medication it should i call the doctor is this normal and being able to have that conversation is very helpful um for the patient as well and And there's some interesting effects that we know from GOP-1.

1:14:41A lot of people feel flat, if you will, kind of a loss of pleasure. We know that GOP-1s can decrease cravings across other areas, not just food. So that's something that conversations can occur about with the pharmacist. And a lot of times you can have these conversations because there's already a relationship formed there. And, you know, even beyond that, there's support programs that may include remote monitoring. We may talk about that a little bit later, Todd, but we have a very good opportunity to do remote monitoring with scales at home. You know, Bluetooth that can upload that way. And the pharmacist can, you know, help manage that with the patient.

1:15:27There's a lot of opportunities there. and and you know why you may not think of a pharmacy as your number one place to get nutrition advice it is very much part of what a pharmacist does when they counsel patients on their medication and so that's another area that they can discuss around the glp ones and adherence let's not forget about adherence because missing two like having a big gap between one dose to the next, if you go a week over and you miss a shot, then your side effect profile will change dramatically. So, you know, just instilling in that patient that that adherence is important in this medication just as it is with any other.

1:16:15Adherence and comorbidity where you know that there's probably a high percentage of something else happening in a person's life that's going through a drastic change in their body makeup and in losing weight. And there's another aspect that we have to be realistic, and that is the cost side of all of this. The primary reason patients switch telehealth platforms is cost and the value that they perceive from it and the support or the lack of support that they're getting. Greta, share with us some of the data that you guys had researched that was tied to the cost of these programs. Right. So we found from our survey that about a third of respondents had actually switched platforms over the course of their treatment.

1:17:09And oftentimes that means they're skipping doses or they have to restart from scratch. So the number one reason that patients switched was, as you mentioned, was on cost at 57%. That was the main reason. But the second reason was lack of ongoing support. So sort of what we've just touched on. And I think people don't realize, you know, all the side effects that these medications can have, as well as, as you mentioned, the psychological support that sometimes becomes necessary because you're still going to get hungry. You're still maybe going to want those fries or, you know, foods that aren't great for you.

1:17:43And then the third reason that people switched was at 28 % was they did not see the weight loss results they wanted. And again, I suspect this is part of the, because of the lack of ongoing support, lack of, you know, real oversight. And I think it's important to remember, and it's easy to forget, especially with these types of medications, that weight loss is not a sprint or healthy weight loss, especially is not a sprint. It's a long-term marathon. And what we also found is that the folks that were most successful at losing weight were the ones that stayed on it and were consistent in taking those medications.

1:18:20So 78 % of patients who stayed on GLP-1 for 7 to 12 months or more lost over 10 % of their weight loss compared to only 41 % who stayed on it for under a month, which is, again, not surprising because these medications, if taken properly, are meant to sort of take a good year to sort of see full soulful results and have a sort of consistent strategy to them it's not the type of thing you take a week before an event and expect a miracle so yeah yeah yes i think of once again coming back to the relationship the natural relationship that people are comfortable enough to share with their provider what's happening in their lives questions answers back and forth Sometimes telehealth might be easier to do that, certainly more of a convenience.

1:19:15Maybe they're in their home, so they feel a little bit more comfortable. Definitely a convenience of scheduling time with a provider to go through the program, to go through the treatment, check where they are. And then, Kelly, you have brought us back to remote monitoring because I want to take, I'm a pharmacist, I'm checking up on my patient. I want to collect as much data as possible. I want to check blood pressure. So it's time to connect that blood pressure cuff and be able to transmit that information back to the EHR, back to the physician in some way, so that that collaboration comes full circle.

1:19:52When that physician starts getting a taste of this treatment management push, now the whole concepts that we've been talking about now for three, four years, which is where it's not just about dispensing anymore. It's really about holistic health. It's about moving forward. It's health for life. It's not even just condition based. It's like, hey, you're going to check in with your pharmacist after your treatment. You lost 20 % of your body fat. You want to stay lean. You want to stay healthy, maybe build protein. It's time to do a little bit of bodybuilding or get ready for a triathlon. Guess what?

1:20:31You come back to that same pharmacist who understands what you go through and connect into the next phase. So Kelly, talk to us about the other things that can be connected into this, which includes our remote patient monitoring. No, that's a great point, Todd, because a lot of patients that come to these medications have complex conditions going on. Like we mentioned hypertension, diabetes, and, you know, obviously diabetes was really the first reason for this medication. medication but anytime you are treating a patient and there's weight loss and other conditions are changing that needs to be monitored it needs to be monitored regularly hypertension one I've I've personally known people that that did use this medication and they were able to go down in their blood pressure medication or they were able to come off of their blood pressure medication and monitoring of that along the way is important because it can go too low and and so it's not always just looking for that high sometimes you're you're you want to monitor so you can better manage the medication that you're taking along with this so pharmacists can pharmacies can help with that a lot it with remote monitoring and you know cgms continuous glucose monitors help with anyone on a diabetic with a diabetic patient on keeping tabs on those blood sugar levels which is really important with this as well so there's there's just really a multitude of ways this can be monitored like I mentioned before weight scales because a lot of times you know maybe a patient feels like they're not losing but maybe they are losing maybe they're losing three pounds a month which is considered acceptable, you know, even though there's an urge for others, some wanting to want it to go more quickly.

1:22:27Right. But we want it to be in a healthy way. And sometimes just, you know, showing that and saying, no, this is good. You're doing well on this and, you know, helps with the confidence in the protocol that also allows them to continue to follow that clinical protocol and care plan.

1:22:47incredible dr jeffrey egler chief medical officer of noom he has a quote in the article that says we think of glp ones not as the tool but engagement support lifestyle changes in behavioral science as the real tool and i think that's really special because that's built on relationships And that's built on trust with the provider as a guide. And once again, I think that can set the stage for a person that had struggled with weight loss in the beginnings and throughout the process to once again feel a trust in their medical provider. And our country's in desperate need of coming back to the trust in medicine and healthcare and providers.

1:23:35So this is a major opportunity. Yeah, no, I think that was a great quote. I think it really sums it up well. Again, the sort of holistic approach to weight loss, and as well as, and I think he made another point, is that it's one thing to offer all of these tools. We also have to make sure that the user is using and engaging with them in the right way. And whether that's tracking their weight or following meal plans that are recommended, getting enough protein and other nutrients, exercising, especially strength training when it comes to, you know, GLP-1s. I think, you know, I think a lot of people are surprised it was something anecdotally we noticed of people surprised to see sort of the rate of muscle loss with these medications if you're not exercising, especially strength training.

1:24:25So I think it's one thing to offer these tools or support tools, but also we have to make sure that people know how to use them and use them well. And I wanted to share sort of, I think this was interesting, And I think it's an outgrowth of sort of the level of a decrease in oversight with a lot of these telehealth platforms and people getting these medications rather easily and then injecting themselves at home. The Poison Control Center put out a study where they cited a 15 ,000 % spike in poison control calls since 2019 regarding GLP-1 medications. I mean, most of them had to do with medication and dosage errors having to do with using units versus milligrams and things like that.

1:25:12I mean, most of these people, you know, have never injected themselves at home before. And, you know, there's very little guidance on how to do that at home or how to read the dosage and which line to read and all that kind of stuff. Yeah, there comes the ability to get on a telehealth consult or to schedule some time with your pharmacist or someone that can help guide you through that. This has been fascinating. A shout out to the health division at U.S. News and World Report. We were with Gretel Scholler and a shout out to Independent Pharmacy Cooperative sponsoring today's segment. Kelly Stovall, thanks so much for your insights.

1:25:57And a shout out once again to U.S. News and World Report. We will have your team back. You always bring us some of the best twerks, and we're here to do that and to bring best knowledge and information. So, listeners, thank you for listening to This Week in Pharmacy.

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1:27:39hey welcome back to this week in pharmacy special opportunity to engage josh marsh vp and gm of a cygnexus access and patient support at cardinal health josh welcome to the show Thank you, Todd. Thank you for having me. Looking forward to the discussion. Yes. So been a big week in pharmacy. Goodness gracious. Just had Representative Congressman Buddy Carter come on and lay it out of what 2027 is going to look like for pharmacy, the impact that some of the news this week has made. But I wanted you to come on specifically around a Gartner survey that captured a lot of information. I'm going to have this link in the show notes.

1:28:26And that is, while 50 % of customers say Gen AI makes interactions easier, 87 % say that access to a human is essential. and we've had so many discussions, Josh, about the leverage of AI in pharmacy care and how no matter what, it always comes down to the PharmD's assurance and excellence. Just like if you use a pharmacy tech through workflow, it still comes back to the pharmacist in the end of giving that final approval. Tell us a little bit about this report in Cardinal Health's research, as well as your department and what you guys are doing to make AI more usable for our pharmacy operators.

1:29:09Yeah, absolutely. Todd, as you said, a lot of news this week. It feels like the theme in healthcare right now is expect the unexpected. And, you know, at Senex's Access and Patient Support, we operationalize centralized hub programs. So patients who are prescribed a specialty therapy can be enrolled into these programs and then we can help them navigate, you know, reimbursement, insurance hurdles, financial toxicity therapy, disease state education. And so our focus really with so much changing in healthcare is let's not forget about that patient who needs to get access to that life-changing drug that they need, right, from, you know, the referral from their physician.

1:29:49And, you know, one of the things I saw in the Gartner report, that 50 % and, you know, 86 % stats that you shared is really what we're hearing from patients as well. Something that I've been saying over the past year is, you know, when it comes to AI, patients want AI to enable their healthcare teams, not to replace their healthcare teams. And for some transactional type of conversations or, you know, transactions, and I think that those are, that's where AI can really shine more administrative. But when a patient's been diagnosed with, you know, stage four cancer, they want to talk to a human who has lived through life and has experienced the trials and tribulations and can provide real empathy and guidance on what this journey looks like.

1:30:37So agree wholeheartedly with what we saw from the Gartner report that AI is here to enable us. It's really, really showing some improvements in terms of speed to therapy, reducing administrative burden. But we can never forget that person on the other end, right, that needs to be there to support that patient throughout their journey. I think of the word trust in how the entire being, the entire purpose of our pharmacists and what they do in every sector, specialty rare disease, compounding, hospital system, is based on assuring that it's a trusted decision that is being made because of the oversight of that team.

1:31:21We got the pharmacist that is that wide receiver or the running back who's taking the ball from the quarterback of care, our physicians, and making sure that everything is in place. AI is just a tool of that. And I think that trust comes to the public and saying, can these decisions be trusted? And they're not thinking that way. They're thinking of pricing. They're thinking of access. They're thinking of questions getting answered and feeling like that those questions are being answered by a human. And it's behind the scenes where I see the power of AI empowering our pharmacy care support teams.

1:32:01So customers are using that Gen AI for more than just answers. Like we said, 58 % of the customers who use Gen AI have used it to complete tasks on their behalf. And I want you to talk to me about how do we continue to leverage tools to extract information that now gets pulled back into the treatment decisions that our physicians are going to make based on what we're extracting. We might be using text. We might be using surveys. We might be pushing them to websites. Talk to us a little bit more about that. Yeah, I think I'll double down on what you said around the value that we're seeing with AI at Synexis, which is using it on the back end.

1:32:43AI is great at data analysis, looking at trends, identifying potential drop-offs for patients based on comorbidities, based on what insurance company that they have. And so that is where we have really focused is compiling that information to then give to that human pharmacist, patient, nurse, navigator, case manager to really empower them to have an open, thorough data-driven conversation. And back to the trust part that you mentioned, I think as much as some folks want to jump on the hey let's have ai do everything in terms of patient care once you try you break that trust with a patient with a healthcare provider that is supporting that patient's journey that can that can create really irreparable harm for you know that patient and they abandon therapy they get frustrated so for us where we've seen that value is really using it on the back end you know orchestration that administrative click click click that sometimes you have to do to then push that up to that human patient navigator, that pharmacist, that pharmacy technician, to empower them to have a trusted, really thoughtful, warm conversation with that patient that doesn't feel cold or transactional like it can sometimes with AI.

1:34:05Josh, let's turn now for the listeners who are interested in the business of specialty pharmacy, for example, let's turn to the purpose and the evolution of our hubs and how important it is to have the centralized support behind the scenes. There was an article that came out earlier this late in the summer on drug channels, and it was titled Hubs, the Bridge Between Patients and Providers. And goodness gracious, I couldn't give a better elevator statement about what a hub actually is. And that's a perfect analogy, a bridge between patients and providers. So talk Talk to us about hub evolution.

1:34:42Yeah, yeah, absolutely. You know, I always describe the hub as, you know, the center of a wheel, right, where that hub and then you have the spokes coming off the patients, the providers, the payers, the pharmacies, you know, dozens and dozens of stakeholders. And we become kind of that source of truth in terms of what is going on with that patient journey. So the physician has, you know, done all the appropriate clinical blood work, testing in the office. They've made a decision to prescribe this therapy, and then they, you know, they send a prescription in. Well, that doesn't, you know, start the patient's journey in terms of getting access.

1:35:20Insurance barriers, prior authorizations, appeals, co-pay concerns, right, around financial toxicity. So really bringing that patient, that provider into a centralized hub, communicating in the way that they want to be communicated with, whether it's a fax, text, email. You know, one of the stats I love to share is one of our oncology programs, over 60 % of patients interact with us fully digitally, fully self-service. But for those hundreds of patients a month who want to speak to a human, we're there to support. But we continue to see this evolution, you know, in the hub space. I always say 10 years ago it was, you know, a lot of people making phone calls to, you know, take care of kind of transactional administrative work.

1:36:04but now with the advancement of technology and not even so much AI. I say use AI where you need it, but sometimes it's just about interoperability, integrations, automation, and then keeping those stakeholders updated, again, through that channel that they want so that they understand what's happening. Sometimes that patient can kind of disappear once that prescription is sent from a physician perspective. So making sure that they understand where the patient is at in their journey and doing it in the channel and the modality that they prefer, we find has been critical. Something else that's critical is the fact that Cardinal's infrastructure through your division has enabled that a lot of that data, all of that data consistently is being pushed back to the EHR system so the physician has access to it.

1:36:52Oh my gosh, Josh, that's so critical. So talk to us about the integration with so we don't have to physicians don't have to run around and try to find the information it's all centralized and what's that's the power of the hub yeah absolutely you know i think the um the enterprise value that cardinal health brings to you know the synexis business but to health care as a whole um has been really really exciting to to watch over the past especially four or five years you know this flywheel that we have created a value not not just for Cardinal, but for patients, for providers, as you said, updating directly within the physician's EHR, the status of the hub enrollment and what action that they need to take.

1:37:33They're not pivoting to a third-party portal. They're not having to go outside of their natural workflow. Being able to share that data from a larger enterprise perspective directly back into the source of truth for the offices, that's one that we hear just a lot of fantastic feedback about in terms of I don't have to pivot, that I don't have to move away from where I work day to day. And then that richness of data, right? If you think about, you know, the larger enterprise, specialty pharmacy, patient services, the MSOs, there's so much there that we're able to do from an insight generation. Hey, where's this next hurdle going to be for this patient, for this physician office?

1:38:11And then communicate that directly into their EHR. That's a big value add for the physician offices and then ultimately the patients. Josh, this has been a wonderful update. We have to have you back on twerks. We'll dig in and we'll bring in one of the specialty pharmacies that you're working with. Hubs at the center of it all reimagining patient support with data, talent and purpose. We thank you so much for being on twerks. Awesome. Thank you, Todd. Looking forward to the next time. We'll be right back with more twerks.

1:38:52Thank you.