Can we afford the cure? Exploring drug costs, access, and outcomes

Rising prescription drug costs are creating difficult choices for patients, clinicians, employers, and health care systems. At the same time, breakthrough therapies and other health care innovations are expanding treatment possibilities — raising urgent questions about how to improve access while keeping care affordable and sustainable.

In this Permanente Live fireside chat, Stephen Parodi, MD, executive vice president at The Permanente Federation and The Permanente Medical Group, speaks with national health care leaders Peter J. Neumann, ScD, director of the Center for the Evaluation of Value and Risk in Health at Tufts Medical Center, and Maisha Draves, MD, MPH, associate executive director of The Permanente Medical Group.

Watch the webinar or read the transcript for insights on:

• Balancing access to life-changing medications with the need to manage rising costs
• The growth of GLP-1 therapies, the promise of biosimilars, and the growing role of artificial intelligence
• Evaluating value of pharmaceuticals through clinical outcomes, safety, patient experience, and total cost of care
• Using deprescribing and coordinated care to improve outcomes and reduce unnecessary spending

Transcript

Transcript is autogenerated. Although edited for clarity, it should not be considered an exact replication of the webinar and may also be updated as needed.

Stephen Parodi, MD: Hello, and thank you for joining Permanente Live. I’m Dr. Steve Parodi, an executive vice president with The Permanente Federation, and we’re here to talk about “A tough pill to swallow — Balancing access and affordability in pharmacy.” Now, if there is one word that captures the concerns of Americans today, it is affordability. Health care and prescription drugs in particular is central to that concern. We have more pharmaceutical treatments at our disposal than ever before, but many come with tremendous price tags. In fact, the Bureau of Labor Statistics recently reported that drug prices have risen three times as fast as overall inflation since the 1980s. On average, medications account for 11% of individual patients’ health care spending, and about 21% of health care costs born by employer-based insurance. Now, there are many reasons for these trends, including the cost of drug discovery, clinical trials, regulatory approval, and bringing those medications to market.

Pharmacy benefit managers and other middlemen may provide efficiencies, but also introduce complexities. Pricing arrangements seem to defy traditional supply-demand economics. The U.S. is one of two countries in the world that allows influence through direct to consumer marketing. On top of that, patent laws, generic drug manufacturing, and emerging biosimilars complicate the picture. Biologics bring these affordability challenges into sharp focus. Made from living cells, these products have transformed treatment for cancer and rare diseases, but can cost $30,000 a month or even more. Biosimilars have no clinically meaningful differences from approved biologics and offer the promise of expanding access to these therapies, and yet the United States still lags behind other countries in adoption. That gives us a lot to dig into today. Where the public policy and where can we actually address these costs? What can the U.S. health care system do to achieve responsible pharmaceutical use and spending?

What roles do health systems and pharmaceutical companies have to address this situation? And most importantly, how can physicians ensure that prescribing decisions are driven by clinical need and not by what patients or insurers can afford? To address these important questions, I am joined by two experts today. Peter Neumann directs the Center for the Evaluation of Value and Risk in Health at Tufts Medical Center and is a professor of medicine at Tufts University School of Medicine. His work focuses on the use of clinical and economic evidence to inform decisions about value, cost, coverage, and reimbursement of health care treatments. He’s authored hundreds of papers and three books on the value in medicine, including The Price is Right: A Value-Based Prescription for Drug Costs. Thank you, Peter, for joining us today. We’re also joined by Dr. Maisha Draves, who is an associate executive director at The Permanente Medical Group and a practicing family medicine physician, literally a few doors down from me.

She leads work across the clinical quality, health outcomes, and economic value, including pharmacy, behavioral health, addiction medicine, resource utilization, and pain management. Again, thank you both for joining me. So Peter, I’m going to go ahead and kick it off with you. You’ve spent a career measuring value of pharmaceutical drugs and whether they’re “worth it.” How would you define value and worth? When is a drug effective when in fact we’re facing some of the biggest barriers when it comes to price, budget, and the scale of need?

Peter J. Neumann, ScD: Well, first of all, thank you very much, Dr. Parodi, for inviting me and for holding this webinar. We do measure the effectiveness and cost-effectiveness of drugs. There are methods that are used in conventional analyses. There are debates about some of those methods and certainly questions about appropriate endpoints and timeframes and the perspective of the analysis. But that said, we do have ways of measuring benefit. Value to your question is the benefits produced for the resources required. What are we getting for what we’re spending? And that’s a very important question to ask, not only about pharmaceuticals, but for about medicine in general. And these studies are being done and they can be used to inform decisions by health insurers, by clinicians. We do want to get the best value for our money, and that means measuring value and disseminating that information.

SP: Dr. Draves, I’m going to ask you a similar question here, which is from a health system perspective or even as a physician leader, how do you look at that from a value-based perspective, right? I mean, there’s the short-term benefits, long-term benefits. Some of these medications, you don’t see the actual — from a clinical care delivery perspective — return for many years, especially with some of the newer agents that are on the market. So I’m curious, has that changed over the last several years, decades that we’ve been practicing?

Maisha Draves, MD, MPH: Thank you for that question, and also thank you for allowing me to join you today. When you think about it from a system or from a physician point of view, you think about the individual patient, and then you also think about either your whole panel or the whole population. And really whether or not a medication works is just a starting point. That’s the initial value of the medicine is we’re going to use it for treating of X condition and does it actually work? But there are also a lot of other considerations in its value. How safe is it? What are some of the risks? And also some of the long-term benefits. A lot of studies are done showing benefit at year one and year two. But to your point, sometimes we care about year five and year 10. And can the patient stay on the treatment for that long?

They’re switching insurances sometimes depending on where they’re employed. The cost of the medication may dictate how long they can afford to stay on it and the side effects, how long they can tolerate it. Really, it’s a lot about their quality of life, how well the drug performs on what it’s supposed to, the safety issues, and then the total cost of that care. I think as a system, it also is really important that we keep reevaluating the medication when it gets expanded uses, when longer term evidence does become available, and when other treatments come on the market. So the answer is really about the access to medications that are effective and safe and that are going to make really clinically meaningful differences in a patient’s lives and their health outcomes, and then really thinking through that value in terms of affordability, not just the one time you pick up the medicine, but over that full cost of care.

SP: Thank you both. And for the audience here, if you have a question for our speakers, please submit it through the chat, through the webinar. We’ll be selecting those questions and definitely working them into the Q&A portion when we get done with some of the questions. I’ve got so many for both of you, but I’m going to hold my fire because we want to make sure we get to the audience’s questions too. So Dr. Draves, sort of pivoting on this, there’s a big set of medications that have hit the market just recently. They’re really transforming clinical care as well as pushing the boundaries when it comes to scale and pharmaceuticals. So of course we can’t have this conversation without talking about GLP-1s. And so I think there’s general agreement that GLP-1s do have clinical effectiveness, still studying at scale for what that looks like. And from the standpoint of tolerability, also a number of open questions, but we’re talking about a huge share of the population that potentially could benefit from the use of GLP-1s, and yet employers are excluding them from their plans and insurers have excluded them from formularies and out-of-pocket costs have been shifted to people, whether they’re consumers and/or patients, however you want to characterize that.
And interestingly, Medicare is kind of a first mover here. So CMS has cited to statutorily launch a pilot program around this. So what do you think this all speaks to in terms of pharmaceutical costs, efficacy, safety of these drugs, scalability of the drugs? And Maisha, what do you think we’re going to do with all of this?

MD: Thank you for that question. No day goes by without talking about a GLP-1 either with a patient or as we’re trying to solve real problems and access in the full system, so thank you. One, I want to say thank you for GLP-1s. It has opened the conversation up that obesity is a condition that our health care system can and should address with our patients. And for our patients, there are therapies that can be effective and it’s de-stigmatizing talking about it. So as a family physician, I’ll just say that being able to talk about and address obesity both with an individual patient in my exam room as well as in a population or across the system is a new conversation that’s now only a couple of years old, and yet obesity has been here for a very, very long time. Also, GLP-1s are in a milieu of treatment options.

We have to remember that even if you’re taking the medication, you must follow good nutrition. You have to still get protein and fiber and water in there. Otherwise, there are the safety issues that must be dealt with and considered about muscle loss and frailty or falls and hip breaks. You have to think about the other medications that there are to offer. And for some people, surgery may still be the right option. Sometimes a GLP-1 with a surgery may be the right option. Really what this comes down to is the science in GLP-1s have almost moved faster than our ability as a system to figure out the fair and affordable way to get these to patients who need it. There’s the coverage that looks at the evidence of the care, the price, the payment, and the ability to support the treatment, nutrition, exercise, and they’re all still aligning while we’re really going through a huge experiment when you think of the bridge program of putting it out there in a very wide population and seeing how it performs.

The evidence really wasn’t based on patients over 65. Some of the treatment indications are much more expansive than what may have been studied. So really through this Bridge system with Medicare, we’re going to be learning how does it perform in the older population? How does it perform with other types of medical conditions? Making it more important as doctors and as a health care system to have the right wraparound support. Is this the right drug for the patient? Is it going to give the right benefit? What are the safety risks? What is the monitoring program around it for that patient? And how do we still support proper nutrition and exercise? That way you get the best value out of the medication and the strongest chance of having a meaningful benefit. And in the meantime, the system is really catching up with how to navigate paperwork, how to navigate payment.

What we’re dealing with now is less about which patient is going to receive the medicine, but what channel? Is it through their employer? Is it through a government payer? Is it through a direct consumer? And where and how as clinicians are we there to support the patient no matter where they’re getting the medicine from? Because it still has to clinically produce a good outcome. It still has to be safe and they still need nutrition and exercise support.

SP: That’s incredible, right? I mean, the comprehensive nature of what these pharmaceuticals could achieve and the need that needs to wrap around it. So thank you for framing that. Peter, I am curious, as Dr. Draves sort of referenced here, I mean, we are embarking on a natural history experiment nationally with these particular drugs. And I’m curious from an economics perspective, I mean, what should we be studying here? Because that kind of has gotten lost if you want my opinion. We haven’t really actually overtly said we need to look at this. So from your perspective, what should we be doing?

PN: First of all, Dr. Draves made many good points, but let me add a little bit on the economics of these therapies. So in addition to being effective in the way she described, the studies have shown they’re cost-effective, at least in many eligible and adherent populations. There’s the promise of cost offsets, cost savings even, avoiding long-term complications, which are costly, avoiding hospitalizations. There’s the prospect that these drugs not only are effective, but in the long term, they can offset cost and save money. In addition, the prices of these drugs have been coming down over the years pretty rapidly with competition. Generic drugs in these classes are coming, not soon enough, I know for many people, but they are going to be coming over the years. Medicare has already negotiated for Medicare beneficiaries the price of semaglutide. New drugs are coming, which presumably will be better than the existing drugs for these indications.

All of that I think is part of the good news story here. Now, clearly there are short-term severe budget issues, and we’re seeing the kinds of restrictions that you mentioned at the outset. So what do we do? Part of it is a government response. Dr. Draves has mentioned the Bridge program, which Medicare has launched, which has a $50 copay for Medicare beneficiaries and has had pretty good uptake so far. There may need to be other responses by government bodies and private payers. Price volume caps, for example, are talked about. There could be some more creative financing mechanisms. The other thing we should say, and the economists often emphasize, if we have new therapies or for that matter, new procedures or other interventions that are good value, we should look really carefully at the medical system for things that are lower value or not good value or even sometimes harmful or wasteful and displace those kinds of things even as we add new interventions like the GLP-1s that are good value.

SP: Peter, it’s interesting where you went with your comments because if you look at it with the GLP-1 story, I’ll call it, there was an initial price point. And do you think that what combination actually drove this in terms of the prices coming down? Because there’s a supply-demand issue and then there’s clearly there was in some form, although not price controls, there was a government intervention. So I’m curious. It’s

PN: Likely a combination of real competition. We had two companies with products. We had injectables, now we have orals. There’s, again, the promise of new therapies coming. So there is this debate about whether to what degree competition works in health care and in pharmaceutical markets in particular. And it does seem like competition works in many cases, though not all. We don’t see a lot of competition, for example, traditionally in oncology or in cancer drugs and rare disease drugs. We do see it in some of the more crowded therapeutic classes. We do see it when there’s genuine substitutions and alternatives, and I think that’s been part of the story of the GLP-1s. Now, clearly there’s also been government intervention. The government has stepped in and negotiated lower prices for Medicare. I mentioned semaglutide, that’s part of the Inflation Reduction Act, Medicare drug price negotiations. The Bridge program is separate from that.

That’s another way the government has stepped in and said, “We need to make these drugs available.” So that’s not just competition, that’s the combination of competition and the government coming in. And that’s probably what we need in that scenario and in other drug classes where we want patients to have these worthy medications.

SP: Dr. Draves, can I ask you a hard question? Let me ask you a hard question. So I’m going to riff off of what Peter was just talking about, and I actually happen to prescribe some drugs that are kind of old and are orphaned and used to be cheap and are now expensive because there isn’t any competition, and actually there’s no incentive to create a new competitor. And I know that you and your role have had to wrestle with that over the years. So I’m curious, so there’s some solutions for some particular products that maybe make sense, and then there’s some where because of patents or because of other issues where they’re orphaned, you don’t have those same options that we were just talking about with the GLP-1s.

MD: I think what’s really important here is where we get into trouble is when the transparency of pricing is not very clear, when we don’t have competition, and so prices can go up even if the cost of goods to make that drug is not that high. And then the other is really through the supply chain itself. You have the manufacturer that sets initial price and has the cost of goods understanding to make the medication. But then as you go into the PBMs, the warehousing, the health care system, the pharmacies, along that whole chain, each player has to be incented to provide the right high quality care and at affordable and reasonable prices for, at the end, the patient themselves, both in their premiums, their copays, their cost shares, the health care system itself, the payers, the employers, and the providers to be able to provide that medication.

Right now we have a system that is pretty opaque. We have a system where how a price of a drug is set is very opaque, and we can often end up with a lack of competition in the pharmacy industry. And so I think the trifecta is always when we can have the transparency in price setting, the transparency across the whole chain that eventually gets a medication to a patient, maintaining competition even with orphan drugs, and then finding affordable solutions. And then at the patient and the provider level, it’s a lot of shared decision making, really making sure you’re giving the right treatment. It’s the right care at the right time for the right patient.

SP: Peter, I want to keep this competition theme alive for just a second here and talk to you a little bit about biosimilars. What do you think needs to change when it comes to the U.S. and how would we or what would foster more widespread adoption of biosimilars?

PN: So we have seen biosimilar uptake in the U.S. over the past years, decade. It has not been as strong as in Europe, that’s clear. There are concerns that going forward, there are lots of biologics that may not attract biosimilar competition. We have complicated molecules and small populations and we may not see it. We’ll see. So I think we’ve had a real mixed story in biosimilars in the U.S. As far as what we can do better, I think two things I would highlight. One, interchangeability. They seem to do a better job at that in Europe. Interchangeability laws I think still impede biosimilar uptake in the U.S., that’s one. The other is incentives in the system. A big theme I think of any discussion of, well, health care generally, but pharmaceuticals in particular, there are still incentives in many cases to use higher price drugs. There may be higher rebates and higher prices for that reason.
We do have reimbursement rules that lead some physicians to reimburse or to prescribe rather higher cost drugs because reimbursement is higher. So I think we have to look at incentives like that.

SP: Peter, I want to also touch on Dr. Draves’ comments about transparency and ask you a question about PBMs. And you know that at the federal level, there’s been a number of actions, even actual bipartisan support for reducing the cost of middlemen with PBM legislation and attempting to directly contract with manufacturers or systems. So I’m curious what you think about that. Is that getting at some of the root of the problem? Is there more that needs to be done?

PN: I think the answer to those questions are yes, it’s getting at some of the root of the problem and there’s more to be done. So the PBMs negotiate prices, they manage formularies, they process claims, they do some good things. There have been concerns and problems. One is transparency as was mentioned. It’s been hard to really know how the money flows. That’s been a bit of an opaque kind of black box in many cases. Secondly, the incentive issues, this idea that you’re better off with higher list prices because your rebates are higher has led to concerns. And by the way, the list prices still are the things that drive the patient cost sharing, so it’s not clear where those rebates are really going inside the PBMs. The other issue has been an issue of market power and vertical integration. There are three large PBMs.

They’re buying up the pharmacies, they’re steering patients there. So how do we deal with those three problems? And the legislation began to get at this more transparency about where the money’s flowing, ending some of the rebating practices, at least starting to do that. It did not go as far as ending some of the ownership agreements or antitrust kinds of solutions that some people have advanced. I think it’s an area where we need more competition as well, and this is something that the employers need to be aware of, and maybe it’s something for the regulators to be looking much more closely at.

SP: I see some really good questions coming in, so keep them coming. Dr. Draves, I’m going to ask you a question that gets at the heart of us as prescribers. So where do you think de-prescribing actually fits into the conversation? Obviously we want to provide high quality care, but is there also questions of affordability, access, and safety that are folded into that?

MD: I think it’s important every time you see a patient to check up their meds. What list of meds does the patient think they’re taking? What list do we have? Are they the same? I think it’s about the biggest thing we do in a health care system is give a patient a medication to help them with their health conditions, and they go home and they have to manage that on their own every day of the week. So really important to get that list right. Within that, really, you hit it right. Is the medication providing the benefit that it should? Is it safe? Is the patient having side effects from it? Are those side effects tolerable? The other is are there duplicate medications that a patient should stop taking? The other is how many of the medications are actually to address a side effect of another medication?

And if you can pare down that list, does a patient actually just have a better quality of life? You also have to look at the drug interactions, and then just the treatment burden and confusion that can come with being on so many medications, which ones are in the morning, which are at night, which is with food, which is on an empty stomach, which one I can’t have hot water with, can be pretty complex. It may lower the cost overall for that individual patient and as a system, but really the benefit is around making sure that they’re effective medications, they’re safe, and that the full quality of life of the patient is being maintained. Definitely, we should review that and consider de-prescribing when a harmful event happens, when a patient is hospitalized, goes to the ER, even during routine visits. The biggest therapeutic tool we have, a medication list, is as appropriate as it can be.
And again, it changes over a patient’s life depending on their life goals and depending on the severity of some of the conditions. So at the right time, it can be different answers for the same patient.

SP: I’m hearing a theme here, Dr. Draves, that when you’re thinking about pharmaceuticals, you can’t look at it in isolation. I mean, it really is a comprehensive total patient approach and care, and what you’re getting at is not just even the medical needs, there’s also the broader social health angles of care that need to be accounted for. Thank you so much for this conversation. I’m going to pivot us to some of the audience questions which are coming in fast and furious and I think are actually pretty interesting. So let me kick it off with the first one. And without naming names here, we’re familiar with some of the newer therapies that are out there that are potentially curative, but cost for a single episode of care or dose, somewhere between $2 million and $4 million.

And this really is pushing the boundaries of what anybody can actually afford. So whether you’re a large insurer, whether you’re an employer that’s self-insured or a health system, these costs based on the levels of population that might have these diseases that could be cured are cost prohibitive, to just be frank. And so the question that really comes up here is, do we need a new financing model to account for these multimillion dollar drugs? Do we need national risk pools? Is reinsurance a question? This is somebody who’s pretty sophisticated here. Are there multi-year payments? Is it amortized? All those sorts of questions are wrapped up in here. So I’m going to open that up to both of you. Maybe Peter, I’ll ask you to kick it off.

PN: All of the above I think is the short answer. These are obviously very, very expensive. They tend to be small populations, sometimes ultra orphan populations. So we’re not typically talking about a lot of patients with these $2-4 million drugs, but they clearly raise challenges. So I would say a few things. First of all, we should be measuring the not only effectiveness, but the cost effectiveness. Some of these drugs promise very strong lifelong health benefits. And when you consider those, the $2-4 million becomes a bit of a different conversation because we are, for many chronic therapies, paying quite a bit of money, tens of thousands or more sometimes every year. So the $2-4 million one-time therapies, sometimes it’s an empirical question, but sometimes look favorable by comparison or at least equal by comparison, not always, but that’s one that we should be measuring that and thinking about the value being delivered here.

But to the financing questions, even if that’s true that the cost effectiveness is reasonable by some measure, there are short-term budget realities. And so there we get into some of the alternative financing. And you mentioned a couple paying over time and installments, outcomes-based agreements where you stop paying if it’s not working, if that’s possible. And that raises a lot of measurement questions and clinical questions about appropriate endpoints and such. But there’s certainly work being done in those areas. Multi-state purchasing, federal oversight of Medicaid programs to pool the states together and negotiate on behalf of all the states. We’re seeing that. The federal government is negotiating sickle cell therapies, for example, right now. It’s just starting, but there could be models like that. Reinsurance, stop loss, government stepping in at some point. I think those are kinds of things we have to look at. And there may be more creative financing even beyond all of those options, but definitely we can’t rely on old ways of paying for things in light of some of these new therapies.

SP: I got a question for you, Dr. Draves, because I don’t disagree with what Peter was saying. On the other hand, we’re probably one of the few industries where we price things, or at least these are being priced based on what maybe traditional or standard therapy would’ve cost over a given lifetime, which may or may not be actually relevant to how much it costs to actually develop the drug or produce it. And so I’m curious your perspective on that. Does that make sense economically speaking?

MD: I think you bring up a really good nuance and there are a few components to it. The cost of a curative drug, if it’s priced to say the patient is cured to the point where they no longer need any other health care service over their entire lifetime, then wanting to ensure that that full cost of a cure is then attributed solely to that one portion of the treatment or drug in time. And I think you bring up a really important point. The patient, it may be a cure, but they may not return back to a baseline. We don’t know the durability of those cures. We have one-year, two-year, three-year, five-year studies. When you’re talking about a cure and never needing any other health care again for that disease, now look at the durability in year 10 and year 20. The other that needs to be taken into consideration are the multiple parts of the health care system that are still needed to deliver that one treatment.

So if you have to pay for the one drug itself of the full cost of care, then how do we account for the cost for the referrals, the cost for the pre-treatment workups, the cost for the centers of excellence, the hospitalization, the post-treatment ongoing monitoring, the side effects that can occur, the travel and the caregiver support that’s sometimes needed. Those are actually all part of the care, not just the cost of the single medication. And then again, really what we often see in the cures is it halts a condition or it can be fully curative and restore, but it doesn’t mean that the patient never needs health care again for that condition. And the treatments themselves can cause new side effects that now are a new set of care and utilization that that patient must undergo. So I think there are some flaws in thinking that a curative treatment should be equal to the full cost of all care that that patient may need because they still do need a lot of care across the health system pre, post, and long durability.

SP: Peter, I’ve got AI questions coming in fast, so I’m going to ask one of them, not all of them. And the one that’s sort of interesting here is you’re probably familiar with the Utah example where they are now allowing autonomous AIs to refill medications for patients if they’re “deemed to be stable.” I’m curious, from an economic perspective, what do you think that the potential is there? Is that going to help control costs? Could that actually blow up costs if things are just renewed without necessarily review or what?

PN: So like all things AI, there’s a lot of uncertainty here about where this will go and what its impact will be. And I have listened to debates on both sides of this, and I think you can make arguments on both sides. There are really compelling reasons to believe AI will bring efficiencies and lower costs in some cases, reducing administrative costs, making it easier to get diagnoses quickly and accurately, and avoiding some of the costs of the diagnostic odyssey that would otherwise occur on and on. Billing, quality control, all kinds of things that go on now with a lot of labor costs and inefficiencies could be done in theory with AI and save a lot of money for the system. And we know that the U.S. has many flaws in its health care system, one of which is very high administrative costs compared to other countries say.

On the other hand, you can think of ways that AI might increase costs, help hospitals up code. You could think of ways to identify real comorbidities and symptoms that people have which might not otherwise have been recognized. There’s a lot of unmet need in the system and AI might help drive more people to more care. There’s all kinds of telehealth that might become possible and that could just raise costs for people who would otherwise have gone without care. And that’s just scratching the surface of some of these impacts. It could help the hospitals up code, it could help the insurance companies guard against those kinds of things. So how this will play out, I think really is not very clear. There is a kind of cynical view that nothing new in health care saves money, even though it seems like it should.
I don’t know that good quality control often saves certain money, but drives costs elsewhere and those kinds of things. So I think we’re going to have to wait and see, but certainly that’s not the only part of this. If AI can help improve health and improve outcomes, that’s really the important question alongside the cost question.

SP: Thank you, Peter. Dr. Draves, I’m going to throw you the last question here, which is you work in a health system, you’re familiar with an internal pharmacy system as well. What role do those types of systems, whether it’s this system that you work in or other large integrated models, have to play in making pharmaceuticals more affordable and what system changes could be made to make them better?

MD: I’d say in a system where you’re integrated and the full health care team — payer, provider, inpatient, outpatient, pharmacy, lab, radiology — are all under one roof, there’s really just a lot of opportunity. It means that from every angle we can sit at the table together to make good decisions. Since we’re talking about medications, I’ll talk about formulary. When we look at formulary and we choose medications that’ll be our first line or second line or preferred therapy, formulary, non-formulary, the physicians and the pharmacists are sitting together reviewing the clinical evidence. It’s non-biased. We do our own academic detailing and we review really the methodology, the results of any drug. We make decisions together about which medication is going to be the right medication for our formulary as well as in practice recommendations, first line, second line, third line. That insurance that those practicing, those pharmacists that are practicing, those physicians that are practicing and in that specialty are making those decisions, looking at it from a quality point of view, a safety point of view, an access point of view, and an affordability point of view really ensures a lot of trust in the system, a lot of trust in the decision making, and both a responsibility and an accountability to then to adhere to those decisions that we’ve made together.

That drives market, that drives volume, and then people understand that that can bring prices to something that’s more affordable when we are negotiating through contracts. Then we monitor our own performance and we have conversations again about how we are adhering to our own recommendations without prior authorization, but really through a shared trust, responsibility, accountability for, like I said, the quality, the safety, the access, and the affordability to really good care for patients. So I think when you have a system like that that’s rowing together from all of those angles and you’re making decisions together, you own your decisions and then it’s easier to adhere to your decisions rather than a third party or someone else making and enforcing a decision upon you that you may never have really agreed to. So I think the system can drive high-quality care and can drive affordability through that shared decision-making process.

SP: Well, thank you so much, and I want to thank the Permanente Live audience for joining us today. We have definitely covered a lot of ground today. And one theme that stands out is that medications, while they can deliver, their greatest value only comes when the people who need them can access them. And addressing affordability will require more than just one single policy and one single program. It’s going to take evidence, incentives, responsible prescribing, and collaboration across health care, government, and industry. Peter and Maisha, thank you so much for bringing your expertise, your perspective to this important conversation. Thank you to everyone who joined us, and we hope today’s discussion gives you new ways to think about how we can protect access, improve value, and keep patients’ needs at the center of our decisions when it comes to pharmaceuticals. Thank you and have a great day.