Prescription for Better Access – Details, episodes & analysis

In this episode, we sit down with Stacie Dusetzina, Ph.D., a leading health economist from Vanderbilt University Medical Center to discuss the critical healthcare and policy trends shaping 2025. From shifts in federal leadership to the evolving impact of the Inflation Reduction Act, our guest provides expert insights on what to expect in drug pricing, health insurance, and patient access in the coming year. We explore how the public and private sectors are addressing affordability challenges and highlight innovative approaches to improve access to essential medications. With a focus on the future, this conversation offers a thoughtful outlook on the policies and market dynamics set to redefine healthcare in 2025.

Stacie Dusetzina, Ph.D., Vanderbilt University

Vanderbilt University Medical Center

A primer on copay accumulators, copay maximizers, and alternative funding programs

IRA

Medicare Part D

Pharmacy Benefit Managers (PBMs)

Medicaid

CMMI’s Medicaid group negotiation 

COVID-19

Statins

PCSK9 inhibitors

Imatinib

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In our second of three episodes in conjunction with members of ACCESS Forum, we engage with leading experts to uncover the multifaceted challenges of access and affordability in cell and gene therapies. Our conversation investigates how these treatments' innovative yet complex landscape leads to challenging regulatory pathways, pricing models, and reimbursement strategies. 

Alicia Silver, MPP, Head of Cell and Gene Therapy, ADVI Health
Eric Faulkner, President, Passage Health Associates
ADVI Health
Alliance for Regenerative Medicine
ARPA-H
Bespoke Gene Therapy Consortium
Blue Bird Bio
Blue Cross Blue Shield
Medicare DRG Rates
NICE (National Institute for Health and Care Excellence)
Novartis
Passage Health Associates
REMS Program
Single Case Agreements
Spark Therapeutics

Medical terminology referenced in this episode:

• Alzheimer's
• Aspheresis
• CAR T therapy
• Hemophilia
• Hepatitus C
• Luxturna
• Metachromatic leukodystrophy 
• Myeloablative Conditioning
• Sickle Cell Disease
• SMA treatment
• Spinraza
• Vaso Occlusive Crises
• Zolgensma

Biosimilars are entering the market at their fastest pace ever. In this episode, we interview a renowned health economist and an expert consultant in biosimilar distribution and patient support to explore the complex landscape of biosimilars, including examining the hurdles and breakthroughs in achieving acceptance by payers and providers and how best to improve patient access and affordability in a market dominated by established brands.

Dr. Jason Shafrin, Senior Managing Director, Center for Healthcare Economics and Policy at FTI Consulting

Marina Allen, SVP, Fingerpaint Market Access, Patient Support & Access Strategy Leader in Pharma-Biotech

Biosimilars

The Biologics Price Competition and Innovation Act of 2009

PBMs (Pharmacy Benefit Managers)

Medicare Advantage

Humira (biosimilars)

340B program

Inflation Reduction Act

Medicare Part D

"brown bagging and white bagging"

Mark Cuban (CostPlusDrugs)

GoodRx

average sales price (ASP)

electronic health record (EHR) system

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Scott and Mark welcome Dr. Mark McClellan, a distinguished health policy expert who has served as the Commissioner of the FDA and the Administrator of CMS, to look ahead at the major policy activities in 2024. They discuss how the government's role as regulator and purchaser of drugs will influence the drug industry and the patient's ability to access and afford medicines this year. They also discuss the challenges and opportunities for improving public health and the emerging role of artificial intelligence.

Dr. Mark McClellan, PhD, Director and Professor of Business, Medicine and Policy at the Duke-Margolis Center for Health Policy at Duke University

IRA

Medicare Part D

Pharmacy Benefit Managers (PBMs)

Medicare Advantage

FDA commissioner Rob Califf 

The Ryan White HIV/AIDS Program (RWHAP) Part B

Medicare Modernization Act

FDA

FDA's Office of Regulatory Affairs

Centers for Medicare & Medicaid Services (CMS) 

Centers for Disease Control and Prevention (CDC)

Per Member Per Month (PMPM) billing 

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In our 2023 podcasts, there have been a series of revelations about the complexity and unintended consequences related to drug access and affordability. This episode explores the essential underlying tension between the notion that affordability and access are deteriorating while science is advancing so rapidly. We interview Rachel King, CEO of Biotechnology Innovation Organization (BIO), to explore the priorities for the industry and how the challenges related to patient access and affordability could jeopardize innovation for patients today and in the future.

Rachel King, CEO, BIO (Biotechnology Innovation Organization) 

John Crowley, Executive Chairman, Amicus Therapeutics

James Robinson PhD, MPH, Chair, Health Policy and Management Division, Berkeley School of Public Health

The Inflation Reduction Act

Orphan Drug Act

Orphan Cures Act

PBM (pharmacy benefit management)

Medicare Part D

Step Therapy

Cystic Fibrosis Foundation

Therapies mentioned in this episode:

• RNAi
• Antisense
• mRNA
• Monoclonal antibody

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In this episode, we investigate the rise of Alternative Funding Programs (AFPs) that bypass coverage for vital specialty drugs.  Kyle Crowell, an expert consultant on AFPs, discusses how payers avoid their responsibility for costs by collaborating with third-party companies to exclude specific drug coverage and directing patients towards manufacturer-sponsored patient assistance programs (PAPs).  Patient advocate, Amy Niles from the PAN Foundation, describes how the mounting tension caused by AFPs are leaving patients to navigate the uncertain waters of their medication coverage and access, potentially risking their health and even their lives.

Kyle Crowell, Principal (Partner) at ZS Associates

Amy Niles, Chief Advocacy and Engagement Officer, PAN Foundation

Patient Assistance programs (PAPs)

Alternative funding programs (AFPs)

“AFP Caution For Patients”

“Pharma faces tough choices as alternative funding programs exploit charitable giving”

Medicare Part D

“AbbVie sues a behind-the-scenes company for exploiting its patient assistance program”

Federal Trade Commission

Carl Schmidt from the HIV and Hepatitis Policy Institute

Copay Accumulator Adjustment Programs Lawsuit

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Patients are experiencing remarkable weight loss thanks to the new generation of GLP-1’s and the downstream health benefits may go well beyond diabetes. In spite of the dramatic results for patients, insurance plans have started to put up more barriers and are even denying the drugs on a more consistent basis. For this special Obesity Week 2023 episode, we interview Dr. Angela Fitch, President of the Obesity Medicine Association, a faculty member at Harvard Medical School and most recently a Co-Founder and Chief Medical Officer for knownwell, a new obesity-focused primary care company.

Show Notes:

Dr. Angela Fitch, President, OMA

Obesity Week

Obesity Medical Association

Dr. Fitch’s patient care center: Knownwell

Seeking treatment for obesity? Find a clinician here or here.

The Treat and Reduce Obesity Act of 2023

The drugs discussed in this episode: 

• GLP-1 (Glucagon-like peptide-1) 
• Wegovy (Semaglitude)
• Victoza (Liraglutide)

An article on the use of “bootlegged” Semaglitude: Demand Rising for 'Bootlegged' Weight-Loss Drug | MedPage Today

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Employers are discovering this fall that they are expected to shoulder a 6% health insurance increase for 2024. What can employers do to combat the accelerating cost of health insurance without jeopardizing access to vital drugs? In this podcast episode, we talk with Matt Ohrt, a former HR executive who achieved a 20% reduction in health insurance costs for his employer. Matt has a new book and new company to help other self-funded employers strategically lower their sponsored health insurance costs for 2024 while ensuring employees have optimal access to care and treatments. This is an essential listen for employers seeking to balance cost-efficiency with the provision of comprehensive, high-quality healthcare benefits to their employees.

Matt Ohrt, Co-founder, Chief Healthcare Officer, Self Fund Health

Self Fund Health

Merrill Steel 

How Does Direct Primary Care Work?

Matt Ohrt’s book:  “Save Your Company: Don't Feed the Beast: The Employer Healthcare Success Formula”

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Many of the most beneficial therapies are prescribed or administered within physician offices yet these providers face a multitude of challenges attempting to get authorization and coverage. In this podcast, we interview a practice manager who is not only on the frontlines of the battle to help patients but is also an award-winning advocate for access. This episode will explore the barriers faced by providers and their offices and what can be done to win the day-to-day battles with insurance companies and PBM’s so patients can access and remain on treatment.

Julie Baak, Practice Manager, Arthritis Center

Arthritis Center

Rheumatoid Arthritis

Psoriatic Arthritis

Reactive Arthritis

The importance of ultrasound in identifying and differentiating patients with early inflammatory arthritis: a narrative review.

Growing Shortage of Rheumatologists “Very Concerning”

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This episode delves into the intricate web of Washington's influence on patient access, exploring the multifaceted factors that shape healthcare legislation, policies and their impact on patients, other key stakeholders and drug pricing. With an insightful interview from one of Washington’s top healthcare experts, listeners gain insight to the complexities of legislation, such as the Affordable Care Act and Inflation Reduction Act. This is certainly the “wonkiest” podcast episode as we attempt to provide an understanding of the current landscape of patient access and look ahead to how Washington's decisions will shape the future of patient access.

Lance Grady, Executive Vice President, Avalere

Avalere

Cardinal Health.

Public Health Emergency (PHE) 

AMP cap 

The Affordable Care Act (ACA) 

Innovation Center 

The Inflation Reduction Act (IRA) CMS

Like this episode and want to here more? Check out our past episodes here!

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