Complete and Fundamental Payment Reform | Antonio Ciaccia, 3 Axis Advisors

Transcript Disclaimer: This transcript is generated using speech-to-text technology and is intended to capture the essence of the conversation. However, please note that it may contain multiple spelling errors and inaccuracies. It should not be relied upon as an exact or comprehensive record of the discussion.

Mike Koelzer, Host: [00:00:00] Hello Antonio. Hey there, Mike, 

Antonio Ciaccia: how are you? I'm doing great today. 

Mike Koelzer, Host: Wonderful. Hey Antonio, for those that haven't come across you online. Tell our listeners who you are, why we're talking 

Antonio Ciaccia: tonight. Uh, my name is Antonio Ciaccia and I am the chief strategy officer for three access advisors, uh, a drug pricing and data analytics firm.

And I am the CEO of 46 Brooklyn Research, which is a nonprofit dedicated to making drug pricing data more understandable and accessible to the general public. Uh, previously I spent just over a decade with the Ohio pharmacist association, uh, running government affairs for them. And, uh, more recently, my firm's three access advisors just signed, uh, a contract with the American pharmacist association where we will be helping them, uh, basically.

Turn the pharmacy, hopefully upside down. Now. Here's what I wanna 

Mike Koelzer, Host: find out. I wanna find out how I can be like you and have everybody. I talk to sing my praises, cuz I got a lot of people that hate me recently at the pharmacy, but everybody I've talked to, they say, you gotta talk to Antonio, you gotta talk to Antonio.

And I'm like, come on. He can't be all that, but I'm hearing it from everybody. So I said, I gotta get Antonio on here. How do I do that? How do I rise up like you? So everybody is praising 

me 

Antonio Ciaccia: first off. don't be as overrated as me. I mean, I prefer to jump over low bars—it's easier.

some of it's dumb luck. Some of it is obsessive persistence. I have in a number of ways, found myself at the center of a lot of major pharmacy issues. Um, some of that I believe is dumb luck. Others of it is, um, creating those opportunities in creating those, uh, moments of disruption. Um, I've been very dissatisfied with what I see, um, as the output from pharmacy right now from a policy perspective.

Uh, and I'm very dissatisfied with what I see from our drug supply chain as a whole, uh, I find the system inherently backwards and broken. it's an itch I can't. Just seem to finish 

scratching. 

Mike Koelzer, Host: Okay. Let's back up. You come from a background with a communications degree, not in pharmacy and all of a sudden this pharmacy stuff bothers the hell outta you.

So where does the jump from communications back in college and all of a sudden you're the golden child of disruption. Where does that leap 

Antonio Ciaccia: come from? So I'm glad you said child, because I'm gonna rewind a tape even further. I am the son of another Tony Chacha. I'm the grandson of another Tony Chacha. Us Chachas are not very imaginative when we pick names.

uh, so my dad 's been a hospital pharmacist for almost 40 years. Hmm. In his spare time, uh, he worked in an independent pharmacy and he also worked picking up shifts at small chain growing up, you know, I was always, um, Enamored with pharmacy, not because of what I got to see in the pharmacy, but because I got to see what my dad did between the hours of seven and nine 30 at night, which was when family members or friends would call him and say, Tony, I just got diagnosed with X, Y, Z.

The doctor just prescribed for me, B, C. And, um, you know, he would basically walk them through and hold their hand, you know, how to best manage their disease state with the drug therapy that had been prescribed. Uh, generally speaking patients felt, uh, largely under equipped, uh, to deal with the disease that they had just been diagnosed with.

And they felt under equipped to work with the medication regimen as prescribed by that doctor. And even if they kind of understood what they were supposed to do, they trusted my dad to guide them in the right direction. To me. I found that, uh, trust. Uh, that they had in him was very attractive. Um, so I actually set out to be like him.

I actually started Ohio State in the pre-pharmacy program. I did about, uh, a year and a half until I said, uh, organic chemistry kind of sucks. I'm outta here. yeah. And, I had worked as a pharmacy technician for three years and, you know, I, [00:05:00] I really liked the interaction and the engagement with patients, even though I didn't know anything, the lady at the bakeries would always bring over donuts.

So I loved, I loved, I just loved the interaction. Yeah. Um, but what I saw was a profession that was getting busier and busier and busi. More and more bogged down by insurance, you know, not just insurance, but I mean, you know, customers asking, well, could you help me walk down to the bleach aisle and things like that.

Right. And as the prescriptions are building up, building up. Yeah. Uh, I was like, do I really wanna do this for eight years and go through organic chemistry? Uh, no, I was much more interested in politics. Mm-hmm um, and journalism, uh, which is ultimately what I pivoted course to 

Mike Koelzer, Host: What was the significance of the seven to nine 30?

Was the pharmacy closed then? And your dad was given the extra effort? Yeah, 

Antonio Ciaccia: exactly, exactly. It was totally closed. Uh, you know, sometimes in the hospital he wore, he used to work off shifts on shifts, but when I say seven to nine 30, I mean, that's when. I saw my dad off the clock. Yeah. You know, actually engaging with the patient.

To me that was pharmacy. It wasn't just making sure the green pill was the green pill and the yellow pill was the yellow pill. So 

Mike Koelzer, Host: after your PoliSci and, and your communication degree, how many years after graduation were you out of pharmacy if you ever were before, then you got back into the leadership of it.

Let's 

Antonio Ciaccia: say just when I thought I was out, they pulled me back in they pulled you back in . Yeah. So I graduated from Ohio State with dual degrees in 2007. My first job out of college was working for an association management company. And that company managed nine different national associations at once. We essentially acted as the back office.

So I ran the magazines. The marketing, the communications and some of the fundraising at those associations. Now, some of those associations were very interesting, the international nurses, society and addictions, the sudden cardiac arrest association. And then you had far more boring associations, like the association of credit union, internal auditors.

Wow. So I enjoyed that, but, uh, we really were just kind of plug and chug for different insert association names here. Sure. Um, the company that I worked for, uh, was sold to another larger association management firm in Olathe, Kansas. Um, I decided that my future was in Columbus, Ohio, not Olathe, Kansas. And so I helped transition those associations to a larger firm.

At which point I reached out to Ernie Boyd, the executive director of the Ohio pharmacist association. I said, " Ernie, I know journalism and magazines. I know, uh, membership, uh, management, your web platform is the exact same as the one that I just worked with. My dad's a pharmacist. My entire background was in pharmacy at, at a fundamental level.

If you come in and invite me up on a, on an invitation to lunch, I will promise you that Tony Chacha will buy a membership with the Ohio pharmacist association and just like any good executive director of a pharmacist association does, he says I'm gonna take that membership. yeah. Right. And so Ernie and I, uh, met up for lunch.

Um, he didn't have a job open for me. Um, I explained to him what I thought I could bring. And, uh, he said, look, if you, um, basically help me, uh, raise some money, uh, and take on a bunch of responsibilities. Uh, I've got a job for you. And so we built it from there. How many years ago was that? Almost 11 years ago.

Now, did you 

Mike Koelzer, Host: know him at. . 

Antonio Ciaccia: I did not know Ernie Boyd at the time. I did not. How 

Mike Koelzer, Host: many states could you go to right now? You've already done one. How many could you go to, let's say you didn't live in Ohio and let's say it's 2020 right now. The timing, right. Or could you go right now to 49 of these and create a job at most of 'em like you did?

Antonio Ciaccia: Uh, that's a tough one. Like, I mean, some Association's been dealt very hard hands recently. Yeah. Oh yeah. Oh yeah. And not just, but not just recently. I mean, some of it, some of their own doing, uh, some of it is perception that I think is unfair. Yeah. Um, some of it is fair associations do not have a secret magic wand sitting in the back office, waiting for somebody to pull it out and waive it.

Um, it's a challenging, uh, job, um, and the resources are not there. So I'll give you an example from this association management company I worked with, you know, half the people there, you know, association management was not their background. Uh, you know, we were paying, you know, people maybe 30, 40 grand a year to [00:10:00] come in and run membership operations for national associations.

Well guess what I mean? You go find better work, you know, Working at Amazon sometimes. Yeah. Yeah. Right. So the associations are really victims of their own circumstances. You look just when you think you've got somebody talented, there's something better for them to do. 

Mike Koelzer, Host: I hope none of my employees are listening, cuz I always think that too.

I'm like, if they're too good, it's like, why the hell are they working for me? You know, I don't think I'm not sure how that came out. I wanted to come out good for them. They've gotta do better than working for this old guy, but you're right. When you get someone really talented in there, they stick around for a bit and then maybe they're gone.

part of it's just the economy. you can make more money maybe 

somewhere else. 

Antonio Ciaccia: There's a saying in the association business, uh, you, we put the non and non-profit yeah. um, and, and, and it's just, it's, it's a harsh reality. Um, I think one of them, one of the things. So, I mean, answer your question.

Yeah. I mean, I do think that, um, there are a lot of things that can be done at associations to turn them upside down, uh, in a good way. Um, I do think that associations can achieve more, but I also think that that's a partnership. Um, you know, I struggle all the time. I think, you know, Ohio has been in the news.

I think we get a lot of credit sometimes too much. I think there's other states that do a better job sometimes, but we're like any business, you know, the Ohio pharmacist association. We staff, according to our budget, if we don't have the budget, we don't have the staff. So a lot of associations are sitting there rubbing two sticks together, trying to conquer a multi-billion dollar industry and their members, call 'em up and say, why haven't PBMs killed yet?

Or why am I going out of business? When are you gonna fix this for me? And they're sitting there with a budget of less than a million dollars going after 

Mike Koelzer, Host: a, 

Antonio Ciaccia: a multi billion dollar industry. 

I had 

Mike Koelzer, Host: my good friend over the other night and I don't know why he asked me this, but he said, who would you consider a musical genius?

And I said, well, I would consider Paul McCartney musical genius. And I would consider. And some other names came up and I said, I would consider John Leonard a musical genius. And he said, well, is it just, you know, is it a coincidence? They were both in the Beatles. I'm like, no, but that's why they're the Beatles, you know, because they had these two guys happen to come together.

So I know I'm gonna miss some names here, but recently I talked to Scott Conor and I talked to Eric PackMan. And if I've got this right, I know Eric was back in Columbus. You're in Columbus. I don't know where Scott is, what part of Ohio he was from. But is that just, 

Antonio Ciaccia: he was in Medina, which is near Cleveland.

How far is that away? Maybe two hours, 

Mike Koelzer, Host: two hour drive. I'm not sure where Ringo is, but is this like a beetle coincidence that you three guys all kind of had this love? Because it seems like a pretty strong triangle. That's making a lot of noise in a good way for pharmacies now nationwide. 

Antonio Ciaccia: I think there's a little bit of talent there I'd like to think there is, but I think it's mostly persistence, um, and effort.

Uh, every job I've ever had. Uh, I started working out at 15, my dad, uh, and, and mom instilled in me the importance of, you know, going out, working hard, earning your keep, um, always being, uh, as helpful as you can. Uh, I've never, um, from graduation and on. And even before that, there, I've never believed that there's such a thing as a nine to five job ever.

Um, I carry my work home to a fault. Um, and, uh, it's something I talk about with my wife all the time is that, you know, I, I have a problem turning it off. . Um, so I am, um, the way that I've conducted my career is that, uh, my cell phone goes to everybody. Um, I answer emails late sometimes. Yeah. But I'll always email them.

I'll always respond. Um, a lot of my best work occurs, like my dad between the hours of seven and nine 30. Yeah. And now with kids, it's the hours between nine and midnight. And 1:00 AM. If, if I, if I have just enough espresso. Um, but, um, I am very obsessive, uh, with, with my work and yeah. Uh, I believe that you have to be obsessive, especially if the challenge, uh, requires it.

And, uh, in pharmacy I learned maybe five, six years ago that the old way of doing things and the typical amount of effort. Was not going to cut it. If you were going to solve these existential issues that are in this profession. And I will say that while my initial motivations were, you know, saving pharmacy, I believe that it is much bigger than pharmacy.

It [00:15:00] is fixing a system with which pharmacists are trapped. Um, and so, uh, if you want to fix that system, you better bring your game and bring your time. And that's, that's how we typically do things. And Scott and Eric, we're a big part of that, but I mean, there's a litany of other pharmacists, uh, you know, in Ohio, there's obviously Ernie Boyd, our executive director, we have mark Kratzer, independent pharmacist, John Kohler, Barry Klein, max peoples.

I mean, we have. An amazing group of pharmacists that there's an understanding in Ohio, that we're not gonna take crap anymore. And, and we're gonna do whatever we can to fix this system. Even if sometimes it comes, you know, it's not perfect for pharmacists, but we're gonna do whatever we can to fix it.

And you're in 

Mike Koelzer, Host: background, you've got a picture and three things come to mind in that picture, a hammer tablet scattered around and a broken vial that was smashed by the hammer. Tell me who each of those could represent. I 

Antonio Ciaccia: definitely would consider us the hammer that that goes without saying us is who, uh, honestly, you know, us is a very informal us.

Mm-hmm , uh, you know, I, uh, you know, formally I work with Eric PackMan. Ben link, Kayley Boston, uh, at three access advisors. Um, my board is over at 46, Brooklyn Scott McGowan, Mike Sharp, Jeff Barone, Eric PackMan. I, I consider that us. Um, I consider anybody and everybody that we've worked with to unravel this supply chain as us.

Um, I could get very formal with that. I could get very broad 

Mike Koelzer, Host: with that. Do the tablets in the vial and we're just playing around here. Do they represent one group or could you think of symbolism that represent both of them 

Antonio Ciaccia: separately? Uh, the pills are actually what we want. Okay. And I view the vial, uh, in this context as all the proprietary black boxes and the veils of secrecy that prevent us from getting exactly what we want and what we need.

Um, I very much believe in healthy profit incentive and healthcare mm-hmm . Um, I, I disagree with, um, the hurtful, uh, uh, barricades that prevent us from actually having a system that, um, that we deserve. Um, I think that profit and healthcare should be derived by how well you make a patient better. Mm-hmm , uh, instead we reward those who can capitalize on conflicts of interest and a lack of transparency and completely warped incentives.

Um, arbitrage is what. Determines the winners and losers in this system. And, um, and that has to change 

Mike Koelzer, Host: the vial that was smashed. Uh, I heard you mention something about black and I'm thinking dark and I'm thinking secret. So back up on that description, who is that? It 

Antonio Ciaccia: is those that stand in the way of a more efficient and value added.

Hmm. And, and most people would probably predict me to say, it's PBMs. It's not, uh, it's not, there are, there are good PBMs out there. And there is vital PBM functionality that exists in this marketplace. Um, our job and just like there's vital pharmacy expertise that we need in this marketplace. I view every cog in the supply chain for the most part as vital.

The key is how do you actually bend it so that you actually get it to function in a way that you want it to? Because when you actually undress the supply chain from top to bottom, including pharmacy, you will find that how we reward those members of the supply chain is extremely backwards. I think that we over reward, um, uh, just oversimplified, bad behavior, and we under reward the best behavior.

Mike Koelzer, Host: Is there anything I'm missing or is it all. Money. And what I mean by that is someone would say, oh, it's not money. It's pride. It's its power. It's this, it's that. But I don't think I'm missing anything. Is this all about money and the games not being played, right. Because the money points aren't going to the right people for the right reasons.

And so 

Antonio Ciaccia: on, this is borrowed you'll, you'll find that I don't have perfect answers to everything because I just go, 

Mike Koelzer, Host: I don't have perfect answers for anything. So you're ahead of me. 

Antonio Ciaccia: Uh, but, but in general, it's about value. I mean, everything that we talk about in healthcare now in a big, in a big picture setting is value.

So I'll give you an example. Okay. I [00:20:00] always hear about major differentials in how we care for people at the end of life, hospice care. Mm-hmm you talk to somebody that has horrific hospice experiences and you talk to others that have. Excellent hospice, uh, experiences. But when do we ask, like how do we actually reward those who did better?

And how do we penalize those who did terrible? So just a recent example. My grandfather. So Tony, Tony, Tony, catches the, uh, my dad's dad. He passed away, uh, three weeks ago. Okay. Oh my condolences. No, no sweat. We're all going there. One day he was dying. I got all, I got everything out out of him that I would ever want.

Good. Um, he's amazing, man. But we had the best hospice experience that you could imagine. And, I hate hearing when somebody does not. Yeah. Well, the question that we have as a society is how do we incent what happened to Tony Chacha senior in dissent? What happens to those who have a horrific experience?

Yeah. The truth is in many regards, we actually pay the same for those things. And so the one that did a crappy job for, you know, John Q, whoever, all right. Yeah. That company got paid the same. It is a company that did work for my grandfather. And the same thing happens in pharmacies. 

Mike Koelzer, Host: Arguably on that, Antonio is they got paid more because they maybe didn't have as many people there or they weren't calling on the phone as often or doing something.

So they actually got more incentive. Now, it could have been that the opposite of someone from your grandpa was just a bastard and just a mean person and so on. But usually the people are good, but the system has cut corners. So they've actually got more incentive for probably giving worse service. 

Antonio Ciaccia: Exactly.

And this is, this is what I talk about in pharmacy all the time. You know, I, I, I think pharmacy has far more value than the general public assumes, but let's just say it's not, uh, pharmacy is, is really minimal value. Okay. Yeah. Whatever value it is. Okay. I want the most of it. And so what I get frustrated by, and, and it was a guy that I grew up with, uh, who entered the pre-pharmacy program in Ohio state.

The exact same time I did, I was working at marks. We had more time to work with patients. Um, it was a bet, it was a more rewarding experience at that time. He was a technician at CVS. Okay. And that's when they introduced the red light green light system on a computer. So if the patient had been there, you know, for a certain amount of time, yellow light, yellow, light, yellow light, a patient's been there for, for, for a too long, a time red light, red light, red light, it's beeping right in your face.

Okay. Well, There's nothing that I, in a general sense, see no difference between a pharmacist that's at Mark's pharmacy and the pharmacist at CVS pharmacy. Now, granted, there's going to be differences, but the incentives drive the CVS business model. And I don't mean to single them out, but really any pharmacy inserts any pharmacy, the business model tells the pharmacy owner tells the pharmacy manager, tells the shareholders, fill it faster, fill more of it and fill it with less invested resources, which means spend less time with the patient.

If you could do that, you will maximize your margin. Now the same prescription could get filled across the street at insert, whatever pharmacy you want. All right. Jim's pharmacy, Jane's pharmacy. They spend more time with the patient. They are costing themselves money. Yeah, that is an inherently broken system.

And to me, when I talk about value, I wanna start quantifying what Jim or Jane's pharmacy is doing. And I want to compare that value to what's happening at the burger flipping pharmacy, because in my head, in a sloppy sense, I know which one's better. Right. But we need to actually start quantifying that.

And if you start bringing that down to the drug level, you know, now we'll talk about pharmacy, the business model. So right now the primary way with which we reward a pharmacy financially is through the dispensing of a drug. Yeah. Okay. Now that has to change. But for, for right here right now, 90% of your revenue, all right.

Behind the counter. Is going to be through the dispensing of a drug. Now some pharmacies might do some MTM, little things like that. Sure. Alright. But for all I intend and purposes, your margin and your mission lives in the dispensing of that drug mm-hmm . And so until we actually sterilize. What's happening with the drug?

How will you ever be able to pay for value if you don't even know what the hell you're buying and what price it should be when 

Mike Koelzer, Host: You buy it? So, in other words, the first thing that has to happen is we've gotta know what the base price [00:25:00] is, and that gets all into the rebates and DIRs and Mac fees and all that kind of crap.

Is 

Antonio Ciaccia: That right? Exactly. Correct. It's it, it's boiling E everything down to its base. You know, when I see something that's a mess, I wanna boil it all the way down. I need to see what's happening in the foundation of that system. And when you're talking pharmacy, the foundation is dispensing and sometimes I hate getting bogged down in dispensing because I wanna talk about the other things that pharmacists are doing.

Right. Okay. Right. But you'll never be able to move that so long as the overall reliance of the business model is predicated on dispensing until you fix that. I don't see anything that you can build on top of 

Mike Koelzer, Host: It seems to me that for the people making a ton of money on this, a lot more money than the value is recognized on purpose.

They have obfuscated to never let anybody close to that. And if you get close to it, then they're gonna hide the contract to not show you what that means and on and on. So there's a lot of people fighting you. Would that be fair to say 

Antonio Ciaccia: AB? Absolutely. Absolutely. Um, and, and pharmacy is the, is, is a, I think a beneficiary in this reform, uh, uh, push, but I, I, I, I think it's really important to point out that PBMs didn't create this mess.

Actually, pharmacies were part of the problem. 2030 years ago, because there was a pharmacy that was hiding the ball. You know, you don't know the price of a drug and I'm gonna charge you whatever I want. The only competitive forces that were impacting pharmacy were whether or not the patient could get a better price across the street.

Now, those are what I would consider to be traditional market forces, where a patient was making a decision based on price and service on where they wanted to get their prescriptions filled. Those are healthy, competitive forces, but today we have removed those traditional forces because right now the payer has no power at the counter.

All the power has been forfeited to the insurers and the PBMs and the system that we have today. I think a lot of that is because we have stripped the patient of their power. When I first 

Mike Koelzer, Host: started, I remember my dad and I actually had a little bit of an argument in a nutshell, blue cross. At the time, you would tell blue cross what your acquisition price was.

And then the audits would come back and look at your invoices and so on. But that was just before basically the first Mac list went into play. And for us at the time, I was thankful for the Mac list because then we didn't have to be thinking of what our price was. And we didn't have to prove that price in an audit and pull our invoices out.

Mm-hmm so I was happy when the first Mac list came way back 

Antonio Ciaccia: when yeah. Ultimately you have, uh, a needed friction. I mean, on one side of the supply chain, you have, you. Drug manufacturer, wholesaler pharmacy. Each one of those entities would love for nothing more than to charge whatever they could get away with.

Okay. Mm-hmm and that was what we had, you know, 30, 40 years ago. But there was an, I think there was a little bit more of an understanding that, you know, you don't fleece the public. And so I, even though you, could charge whatever they want for all I intend and purposes, I thought that they, the, that side of the supply chain had been largely restrained.

Okay. Yeah. Well then came then all of a sudden the prices started to outta control manufacturers, wanna charge more wholesalers, charge more pharmacies, charge more that created an impetus for the payer to say, look, we need somebody. To get a, to get ahead of this. And so your insurers and PPMS came in and acted as a necessary friction against one side of the supply chain that wanted to charge whatever they could get away with.

And so ultimately finding that balance is where that system needs to be. But what's happened over time. Is that through a number of things? Uh, PBMs have grown so large that they now have excess power on the other side of the supply chain and the other side of the supply chain, we need a lot more than the other side.

So yeah. So now that you have all this excess power on the payer side, well, now you're starting to compromise what spits outta the other side. Your pharmacy care is going down. All right. You have massive consolidation in the wholesaler marketplace. You have a lot of consolidation in the, in the manufacturer space and they're not bringing the same.

Level of treatments, the value added treatments to the marketplace that they were many moons ago. Does it mean that nobody's doing anything of value on the other side anymore? Absolutely not, but the excess power of the insurers and PBMs has had a delirious effect on the output of the pharmacy wholesaler, uh, manufacturer combination.

If this played 

Mike Koelzer, Host: out again in a different universe, would it play out the same way? Was it always built that the PBMs were going to be able to be the ones that consolidated and had the monopolies and things like that? Or if this played out again, if this was 1975 again, and played [00:30:00] out, is there any scenario where the pharmacist became the powerhouse or the, you know, the people became the powerhouse or does it always kind of play out this way?

I 

Antonio Ciaccia: I think it does. I think it does. I think it always plays out this way because, you know, I always say, never trust anybody, trust their incentives, you know, and that's not to say that anybody's bad or good is said more often than not. You can trust their incentives. You know, what does this, what does this individual or this organization have to gain and trust that when they have an opportunity to gain, they will move in that direction.

And so if manufacturers could charge what they want. Don't be surprised when they charge maybe more than they should. Uh, and the same thing goes for wholesalers and pharmacies. And guess what? Now, the same is true for the cops. Uh, the PBMs who are hired as the cops to, to reign in the other side, uh, now they're charging whatever they can and now your insurers are.

So at the end of the day, you don't really have anybody in the supply chain who has the right incentive to render a fair deal, not just on price, but from the actual quality of the service as well. And the good nobody's actually there doing what needs to happen, which is finding that balance of cost and 

Mike Koelzer, Host: value.

Did the pharmacist screw up at first by being greedy 30 years ago, causing the PBMs to come in? I agree completely with your scenario, but it doesn't seem like there's any. Power for the pharmacist to legally make a ton of money right now, even if they wanted to, where was that lost? 

Antonio Ciaccia: Oh, they can, they can make money if they want to.

But I would, I would argue that they, it would be way outside the lines of what I would consider to be ethical. legal, 

Mike Koelzer, Host: but full of loopholes and not ethical. 

Antonio Ciaccia: Yeah. Yeah. Yeah. There's some companies out there that can help pharmacies make, uh, unfair money out of the system. Gotcha. I'll put a little heat on my pharmacy folks here, you know, and this is hard because you know, not all pharmacists think alike, but you know, look, pharmacists have a professional obligation.

Okay. Over 90. Okay. And, there's a lot that goes into doing everything that you need to do from a compliance standpoint to meet the needs of that patient. How many pharmacists do you know that can do those things in 15 seconds, let's face it. You can't, you cannot adjust service to the patient and do it in 15 seconds.

You cannot, but there are pharmacists out there that are signing their name at the bottom of those prescriptions, saying that they did. And in many ways I feel bad for that pharmacist because they're under ridiculous expectations from whoever that they're working with. But my challenge back to those pharmacists is whose name is on the license, whose name is on the prescription that you, that you ultimately signed off on and pharmacists along the way, allowed the business model of pharmacy to buckle them.

A pharmacist, you know, obviously is reliant on the paycheck in order to make ends meet. And I sympathize with it, et cetera. But enough pharmacists in this profession have said, I can do this at this speed. And it's okay. And so don't be surprised when the businesses that employ those pharmacists say, nice job.

Thank you very much. Why isn't the guy next door doing it? And all of a sudden it spirals outta control. So yes, I do think that there could have been pushback. If pharmacists in a collective fashion said, you know what, fire me, you know? Right. Or I'm shutting I'm, I'm shutting it down. I'm not giving a flu shot now, or I'm gonna spend this time with the patient.

I don't care. Who has anything to say about it, but pharmacists did not do that. And now here we are, it's get it out the door, get it out the door, get it out the door, get it out the door outside 

Mike Koelzer, Host: of like child abuse. Every other situation in life, everybody's played a part in the problem. Some of it might be quite small.

Some of it might be quite large, but everybody contributed to it. Some problem, and you don't have to take all the blame yourself, but everybody, everybody contributed 

Antonio Ciaccia: to it. That's one thing that I think is really important. And I, and I felt the pressure when I started doing government affairs for the pharmacist association, I felt the pressure from the other state organizations.

I felt the pressure from the national organizations. I felt the pressure from my own membership. I felt the pressure from my boss that pharmacy does nothing wrong and, and everybody else is the villain mm-hmm and. And what you learn along the way is that no look, nothing is black and white. Everything is degrees.

And to, and to pretend that pharmacy has no problems to pretend that pharmacists, you know, have no responsibility to bear for this system, um, is just inaccurate. And doesn't [00:35:00] mean that pharmacists are bad. It doesn't mean that PBMs are inherently bad. What it means is that we have a system that has run a muck.

Yeah. Okay. For whatever reason, whatever that is understandable reasons or, or not understandable reasons, the system is broken and it is on every member of that system to make it better. Yeah. Back to the PHA stuff. You know, I've known Scott for a long time. And Scott wanted to hire me at, at a PHA as, as, as a bonafide staff member.

And I said, look, Scott, it's, it's very important to me that, you know, I have, I have started in pharmacy. Yes, I, I bleed pharmacy. I know pharmacies can do more. I know pharmacists can help patients, but I find it very important to advise rather than be advised because I don't trust any member of the supply chain, uh, as much as I trust myself.

And, we really believe that this system has to be fixed and we need to be able to talk about it in as objective a fashion as possible, which is why we are so obsessive with the data. And we are putting out reports telling you what happened to the monthly prices of hydroxychloroquine in lisinopril, who cares except us I dunno, I don't know, but that's how detailed that we feel we have to be because we want it all out there so that we can see every little piece of how the system works.

Cuz you will never fix it unless you see how it's, how it works in operation. Say 

Mike Koelzer, Host: that part again, Antonio, about you wanna advised instead of be 

Antonio Ciaccia: advised, it's very important to me. Um, what we do is our mission is to fix a system. And so let's say for example, and, and this, this is all, this is kind of, it's part of its trust, but part of it's just an important pH philosophical delineation as well.

Like I know a PHA, I trust a PHA. Um, I know pharmacists, I trust pharmacists. I know some companies, you know, in the supply chain I trust, but again, I don't trust anybody. I trust their incentives. All right. A PHA, you know, ultimately works for pharmacists. That's important. I think that pharmacists, you know, deserve a much better system with what we have today, but sometimes pharmacists I'll, I'll use, I'll use examples in Ohio.

I've had instances where pharmacists ask for things that I think are not good things for the system as a whole. Hmm. And so I push back on them. So I feel it's very important. Um, we've built enough of a reputation. We've built enough of a, of a, uh, of a, I, I hate calling it brand, cuz it sounds so stupid and manufactured, but um, for lack of a better term yeah.

You know, brand that. We are here to call balls and strikes. Yeah. And, and I, and we want, we have always tried to position ourselves a after we finally, you know, got everything off the ground, we said, we wanna make sure that we're always in a position to call balls and strikes, and we don't want any, we don't want anything, uh, polluting our ability to do that.

Being 

Mike Koelzer, Host: advised would be more like being an elected official with constituents, telling you what they want. And you're saying N now I've got enough to bring to the table where I want to give the advice. And that's a gift I'm giving. I'm not just here to serve constituents that may, but quite likely might not have the root of the problem 

Antonio Ciaccia: at heart.

Yeah. I mean, look, one day we might fall flat on our face and I might be in a position where in order to put food on the table, I've gotta do things that I'll have to hold my nose for, but we built our reputation. By not being anybody's sock puppet. Yeah. And, uh, and, and as long as we can keep it that way, we're going to, these are things that I've had conversations with.

Scott, I've talked to Michael House about this too. The president of a PHA, uh, that, look, I'm not saying that we're right about everything, right. I think that we're right about a lot. Um, but I think that where the system needs to go, I think that pharmacists will be very happy in the system that we think needs to exist.

And based on that, um, and this is, this is why I think a PHA is, is of real value to pharmacists is that you look, they're not just gonna sit here and chill for things that just make a system worse. Uh, you know, they, they, they reward pharmacists at the expense of, you know, patients, et cetera, et cetera. You know, I have seen from the PHA board and from Scott.

A willingness to call balls and strikes within this, uh, profession within this industry. And so long as, as they, or any entity that wants to work with us is willing to do that and will let us do what, what we think is right. We will be willing to work with them. 

Mike Koelzer, Host: This thought then if I got this right, that's the reason [00:40:00] why Antonio doesn't necessarily become an employee of a PHA.

It's really the three axis that's hired because that maintains your strong identity, that you are there as advice, not to necessarily take every. As respectful as I can, every whim of the pharmacists in the group. And then try to run with that when you may not believe that's the, the base of the, the cause.

Exactly, 

Antonio Ciaccia: exactly. So, I mean, I, I don't wanna speak for a PHA, but let's just say, let's just say in our drug pricing research, we found that pharmacists making $5,000, uh, in margin per prescription, on, you know, generic Abilify. Yeah. Is that okay? Whether it's a PHA, N a CDs N CPA, Uh, they might say, Hey, maybe we don't wanna talk about that.

Right. You know, maybe, you know, we're getting killed on all these other prescriptions. Hey, let's not talk about that one. No, no, we're gonna talk about that one. we're gonna talk about every drug that we think is overpriced, regardless of whether the pharmacies make the money or the PBMs make the money, because we wanna know, look, why is that drug so overpriced?

You know, look, maybe we want to pay $5,000 a script for, uh, an organ transplant drug that makes sure the patient stays out of the hospital. Yeah. Right. That makes sense. Okay. Yeah. Let's pay the pharmacist to keep the patient outta the hospital, but for just every day, run of the mill script, we should be paying for the actual value.

And so a lot of the data research that we've done will show, Hey. They're generic. Leveck is paying out $5,000 a script. Why is CVS Caremark paying that? I'll never forget. I, I was, I was presenting at the, uh, at the pharma society, the state of New York. And I was, um, this is after we did a project for them over three axes.

It was the first big Medicaid project we did after my work in Ohio. And a pharmacist came up to me, a guy I knew. And he said, Hey, you know that generic Leveck thing, you really shouldn't be talking about that because it's making up for all the other losses that I've been getting. And I was like, look, look, I get it.

I, I feel, I feel your pain. Like I don't, but, but I don't want you to get the underpaid. And I don't want you to get overpaid. You know, you, you shouldn't screw the SI, you shouldn't have that incentive, uh, to go out and chase these prescriptions. That'll make you 5,000, cuz you're gonna. Exponential time with that patient.

You're gonna leave all these other patients, uh, you know, by the wayside. You know, I want you to have an even incentive when you're dispensing those drugs. And if we're gonna add an incentive, I want there to be a value attached to it. I want you to do something more and be rewarded for more because otherwise, all right.

The other pharmacies that are just doing it, kicking out, kicking out, kicking out. All right, they're gonna get over reward. Because they didn't spend time with that patient. You know, it sounds sloppy, but that's what motivates me. And, and, and I think people should be, should be enthused because, you know, a PHA is willing to engage on those terms.

I, I believe they genuinely want system reform for the better. That 

Mike Koelzer, Host: is really interesting because that's really hard to get across when you've got someone like Scott and his enthusiasm and his cheerleader, you know, and he says, you know, look out here comes Antonio, you know, and, and on fire, some people follow this guy named Jesus, you know, and everybody said, he's gonna come and be the king and all this stuff.

And all of a sudden, like the way he wins is up on the cross. And I kind of picture Scott saying, here comes the king of Ohio. Here comes Antonio, and he's gonna do this and this. And all of a sudden, you know, you put this report out and stuff, but the thing is, I. Talking to you. And that's why I love this long form talk because this is where you have the time to say, no, look at it, Scott and a PHA is investing in this base and the base is what changes because anybody can get out and just, you know, pick at the PBMs or something.

This is where it changes. But I imagine, and this isn't really a question, I guess it's more of a comment. It must be hard for Scott and you to get across that. Here comes Antonio. But it comes kind of as a whisper almost, but a very strong base whisper. You know what I mean? 

Antonio Ciaccia: I, I, I know exactly what you're saying.

You, you mentioned like, okay. Why, why, why the buzz? Okay. Uh, uh, on the onset. Okay. Uh, I'll, I'll give you a brief story. So when Ernie Boyd turned me onto lobbying for the pharmacist association, one of the first things they had me do is that Antonio, we need you to work on Mac pricing reform. Okay. It's a big priority.

We had just gotten our PBM audit bill and, um, N CPA had been parading around this map of the United States that colored in all the states that had a Mac pricing bill passed. Okay. And Ohio wasn't colored in. So all my members here are looking at me saying, what the hell Antonio, you suck until you turn that white Ohio blue.

Yeah. [00:45:00] and, and so I'm okay. I'm going. I'll go, go pass a Mac bill. Well, um, we ended up. Passing, what was at the time heralded by NCPA is one of the. Amazing PBM Mac pricing laws in the country. Uh, it had unprecedented transparency, blah, blah, blah, blah, blah. The press release was amazing. You would think that pharmacy just died and gone to heaven.

Um, you know, our speaker of the house at the time, really, uh, uh, we called it major chips to get this thing done. We moved heaven and earth and it passed like the week before it went into effect. The express script sent new contracts out to all the pharmacies saying we don't use Mac anymore. We use, uh, generic, effective rates.

I will never ever forget. I mean, Mike, I worked my. I worked my butt off. I mean, we did everything we could to pass the best bill that we could, uh, you know, we had crossed the finish line and all of a sudden they took the trophy away. And, and so I called, um, uh, gentleman at NCPA. Who's no longer there.

Uh, and I said, whoa, whoa, whoa, whoa, whoa. Yeah, right, wait. They can do that. and he is like, oh yeah, yeah, yeah. We're seeing more of that now. And I'm like, yeah, dude, you gotta be kidding me. Like I just called, I, I, I sold my whole membership on, on this. We just put out the press release saying how great we are.

The speaker of the house called me, cussing up a storm about everything that he was gonna do PBMs and their mothers and . And, and, you know, we, we thought that we had just done everything that we needed to do and, and here they knew that it wasn't perfect. And it sounds like it is derogatory to NCPA. I don't mean to, because I love NCPA, but like I I'll never forget.

I flew back to DC. Uh, for an event, I don't know what it was. And I said, I am going to N CPA. I need to see the whites of this guy's eyeballs. When I talked to him about this, because as somebody who takes his work very seriously, uh, and doesn't wanna, and doesn't wanna undermine himself in the eyes of the members, right.

And of the legislature, I had to know, why were you parading around this stupid map? You know, of saying, go past this bill when it actually doesn't do anything. And so I, I went in, I asked them, I said, tell me out of all these blue states that you've circled in on this map, how many of these states have actually solved the problem?

Can you guess Mike? 0, 0, 0. And so I said, so what are we doing? What like if this is what, what you told me and my members, this was a top priority. My members listened to you. Okay. And, and they're telling me, this is the number one priority. And so I used all of the pharmacies, Chis, all of the pharmacies, and the credibility to pass something that didn't work.

You have to be kidding me. And so it was at that time where I said, we are not gonna follow these people's playbooks anymore. All right. I'm not walking into a lawmaker's office and saying, here's five claims that Joe, the pharmacist, was underpaid on mm-hmm because I remember I'll never forget. I was in, in a meeting with a CVS Caremark lobbyist and he said, Hey, all those under payments look bad.

Is that pharmacy where those claims are from still open? I said, yeah. He's like, well, maybe he's making some money on some claims. And I was like, shit, I need to figure this out. And so I went back to the pharmacies and asked, Hey, well, show me the claims where you're making money. And sure enough, it's like, they're losing a hundred, they're making a hundred.

I'm like this doesn't make any sense. And so we just, we, we just start completely 

Mike Koelzer, Host: over. And now in fact, the insurance is like, you know, we're not gonna wait around for that. Again, we're gonna put right in the contract that if, if the government gets rid of DIR fees, we're gonna do this. And if they do that, we're gonna do this.

I mean, they're like in their own contract, they're like three steps 

Antonio Ciaccia: ahead. Totally. And, and that's when I decided no more fake wins, you know, no more, you know, no more. Yeah, we're gonna, we're gonna pass this prototype bill. We're gonna vet things. We're gonna talk about things and we're gonna look at the big picture.

And so part of the reason that, again, I think some of this over credibility that I've, that I've been able to get is that we just decided like, look, we're not going to do what they, what everybody tells us to do anymore. We are going to say what actually makes a system better because right now, if this current system is able to go on the autopilot that it's currently on and left unchecked, this profession and pharmacy benefits as a whole as a whole are heading off of a cliff.

And so I feel that we need to stop messing around with these little like chintzy bills that do not accomplish things. And I think that we need to be going for the whole Ench lot, which is not just getting pharmacists paid $50 a prescription or whatever it is. We need to go after it is complete. And fundamental payment reform.

We need dispensing to be a known predictable set level [00:50:00] margin across the board so that the incentives are equally spread across and we need to start moving profits into. The outcome of the patient and the service being rendered by the pharmacist. Once you do that and it, that it's magic wand stuff. I mean, it's way harder than what I've framed it, but it is incredibly important for both the chain pharmacists who are sitting there pumping out 500 scripts, uh, all the way to the independent pharmacist, to the am care pharmacist, you name it.

But every pharmacist deserves a system that rewards them when they make patients better. Because what it does is it makes those pharmacists go above and beyond and impact a patient in a good way. They become more successful and they are over rewarded. And conversely, the pharmacy that operates in the back of the liquor store, you know, that's not set for spending time with a patient.

That's just flipping them, flipping 'em across the counter and not spending any time that pharmacy probably goes out of business. And, and that's probably a really good thing, Antonio, 

Mike Koelzer, Host: Is there any law? Needs to be changed or could be changed to improve everything, or is this all an incentive period? And if you set things up right, and make the right incentives, basically you don't need the laws to make the incentives.

I mean, that's the question. Are there any laws that can't be manipulated by someone to keep the system bad? 

Antonio Ciaccia: Yeah. I mean, I think there's some things that can be done. I mean, I've learned that laws are imperfect. Um, you know, even if you think you've outsmarted the industry, you know, the industry is paid well to outsmart, uh, yeah.

You know, those laws. Um, but you know, for example, you know, if, you know, if I have a pro, if, if, if I'm a kid and I have a problem, keeping my car, you know, out of a ditch or, or under 60, you know, It's probably smart for my dad to take my keys away. So one of the things that we've noticed that we've seen in our data, um, time and time, and again, is that PBMs are taking advantage of a lack of transparency and horrible conflicts of interest.

And they are fleeing the system, uh, you know, in a number of ways, whether it's spread pricing, specialty pharmacy, over pricing, steering, you know, transaction fees, Gerber dispensing fee, effective rates that we're seeing now, like there are a number of things that they can do, um, to gain price for their own advantage.

One thing that I think from a policy perspective, and I don't know if this is FTC or, or Senate, whatever the hell I, I, I don't know exactly where it is, but if you are PB. You have a vested business interest in pharmacy, you have no business setting price in that system. Um, so rather than allow them, you know, just pass the law, fix the Mac.

No, no. You know, so long as PBMs have arrested interest in the supply chain or in, in pharmacy, I think that there should be a strict prohibition on their ability to set prices for their own pharmacies and for their competitor pharmacies, because time and time again, we've seen them abuse that, that, uh, that power 

Mike Koelzer, Host: you've got basically PBM zoning, pharmacies, their owning wholesalers, or there's other stuff in there too.

I mean, there's, there's this vertical thing going up a mile high with, with ownership of stuff. And at least you're not saying necessarily cut those all apart, but at least you're not gonna be. Setting the prices and making your pharmacy make more than the next one. And so on. 

Antonio Ciaccia: Exactly. I had people beat me up, uh, back when the, um, the CVS Aetna merger was going on, they said, this is the biggest thing that's coming.

You know, we need to fix this. I was like, eh, you know, CVS, Aetna, I'm not, I'm not, I'm not, I'm not gonna throw pom poms on or anything, but like, you know, to me, the fight was CVS Caremark, not Caremark, Aetna, that, that, that, that does not scare me. Um, you know, as I said before, you have two sides of a supply chain and, and a lot of people want to kill PBMs, go do away with PBMs.

I think, as I said, a lot of their functionality is still needed, but at a simple level, I think it's okay to get rid of PBMs. I would argue I should have been with the insurer all along. You know why? I, I, part of the reason that I think pharmacies are stuck in this predicament is because they've been outsourced they're on an island.

They're no longer integrated with the overall goals of the health insurer. Now they're under the thumb of this PBM that does not have the same incentives as the health insurer. So, um, you know, I'd like to see PBMs go away, not for the same reasons that, that I think a lot of pharmacists want them to go away because I want that functionality back in the, back in the mothership of the insurance company, I, I would take my chances with an [00:55:00] insurer all day relative to a PBM.

Mike Koelzer, Host: So Antonio, you and Eric, I'm gonna give you this magic button and with this button all time stops. Okay. The world stops you then. Work with a PHA and you and Eric get to have your fun with all the numbers and things like that. I talked to Eric, I know how much he loves all that stuff. How long would you keep that button stopped before?

You'd want to go in and like to try stuff or say, Hey, give this, you know, try this one on for size a PHA, or let's throw this in front of some, uh, legal things and stuff. I mean, would that be like a hundred years that you'd like to do this before and, and give them this full package? Or do you guys enjoy or desire some feedback?

Would you like to be on this for like a year before you show anybody or five years before you show anybody? And then turn that button back 

Antonio Ciaccia: on? It's a hard question to answer, because I, uh, like as you say that I know there's a lot that needs to be done. It takes a lot of time to do it, but, um, I am, uh, very restless.

Uh, and I just like to go 

Mike Koelzer, Host: and going also means seeing the 

Antonio Ciaccia: results probably. Exactly, exactly. Because look, this is, you know, this is, this is not a science, you know, this is, this is a work in progress. Um, you know, one of the things, you know, as much as we get into the PBM stuff and the drug pricing stuff, I love all that stuff.

It is fun, but you know what I like the most is getting pharmacists in a position to actually render a higher standard of care to a patient. So we've been talking for an hour. We haven't even talked about, like, the thing that I actually am most proud of is that, you know, one of the biggest things in pharmacy is provider status.

Okay. And in the state of Ohio, I now have four of the five Medicaid managed care plans that have all launched programs that are paying pharmacists for clinical services rendered under the medical benefit. Okay. So we have. We've been working with United healthcare, uh, since April of, of 2019, uh, getting that off the ground, it formally launched on April 20, uh, April, 2020.

Um, we have, um, Buckeye health plan, which is the Canteen plan in Ohio. That's working with two FQHCs in health. UHCs working with two, uh, independent pharmacies. Uh, we have a care source that is now off the ground with two independent pharmacies in a health system. And, um, you know, here very soon, we're gonna have Melina jumping in with, uh, about 10 pharmacies, community pharmacies, and each one of those plans already has pharmacies on deck and they're doing it without.

The department of Medicaid authorized provider ID numbers, which means that they're paying out of their own admin costs, not their medical expenditures. They are paying out of their admin to pay pharmacists for clinical services, transitions of care, bringing diabetic patients to goal blood pressure, monitoring, all the things that we know pharmacists can do.

Those are all programs that are off the ground right now. Ohio is ground zero for provider status. To me, the most important, the most exciting thing is like, yeah, I wanna sterilize all this drug pricing fat, and it's fun to be, you know, expose the BU the bad guys. Um, but at the end of the day, like, what do we actually want?

We want a system that actually uses the expertise of the pharmacist to make patients better, to bring value back to planned sponsors. That is what drives me. So yeah, you could slow this damn, uh, ward, uh, world down for, for 500 years. We probably wouldn't be done, but I say, why stop. 

Mike Koelzer, Host: Okay. So it sounds to me that this whole PBM thing, that's what you were talking about, the basis of getting the dispensing across the board and fixing that and so on.

But the cool things you're talking about with the provider status that has. Probably less to do with that base being needed or, or, or am I wrong? Did you bring a lot of the data from 46 Brooklyn and three access to them? And did you have to get that quickly through their mind in order to build these? Or was that 

Antonio Ciaccia: more separate?

I, you know, they're, they're in tandem. I mean, look, you know, if you're the American pharmacist association much, like we were at the Ohio pharmacist association at the end of the day, you're pharmacist, your practitioner, whether you view them as a dispenser or a, or a clinician, they are sandwiched between that, that, that supply chain that I mentioned, drug maker, wholesaler, pharmacy, PBM, uh, insurance company, that's where they're stuck.

Okay. And so what I would like to see is hopefully that core part of the business, the [01:00:00] dispensing function. Be, uh, uh, as close to a break, even proposition as possible down the road. Okay. Now, now yeah. Pharmacists should make profit. Absolutely. Okay. But dispensing right now, almost all the profitability is reliant on the dispensing.

I wanna minimize that over time and I wanna grow the incentive or grow where profitability resides into the actual care of that patient. And so it's impossible to divorce those two things, because look, you could start over rewarding Jim's pharmacy. Who's just kicking butt grant. Every, every patient's staying outta the hospital.

Well, if all of a sudden express scripts figures out, Hey, Jim's, pharmacy's really kicking butt loves to slash his Mac rates cuz he is making so much money on the medical benefit. That doesn't fix anything. Okay. You want those pharmacies that do the best you want them over rewarded. And so some pharmacists will hear that and say, oh my God, you know another salesman for value.

Well, great PBMs are already grading us out on value. And now I'm getting DIR fees. Trust me, I get all that. The key is the PBM. Who has a conflict of interest in the pharmacy marketplace. Shouldn't be setting those, those, those metrics either. You know, ultimately we need to really objectively set prices and objectively set measures for what makes a patient better.

The second is that an entity that you compete with is setting those measures. They're completely broken at that point. You cannot trust those metrics at that point. So that's why sterilizing those conflicts of interest goes far beyond, oh, will I get paid enough for lisinopril this week? No, no, no, no, no. It was way beyond that.

Pharmacists will not li will not be able to work in a system that pushes them forward and encourages them to succeed so long as their competitors are setting, have their finger on the dial that determines how profitable 

Mike Koelzer, Host: they'll be. That's exactly right. I've always said that with wholesalers that have their fingers and everything, they don't really care.

How family life is in someone's household. They want to see the pharmacy. Arguably in some cases, some cases they don't care. A lot of times all they wanna see the pharmacy survive enough to stay open, but not much more than that, you 

Antonio Ciaccia: know? Yeah. PCMA has a big ad campaign out right now talking about, Hey, pharmacies don't have it so bad.

You know, some states have more pharmacies than they did 10 years ago, blah, blah, blah. Look, access is important. The standard of care is way more important. Uh, you know, when I read stories like the Ellen gobbler, New York times article that sickens me because that's the output of our system. Okay. And a pharmacist wanted to be like, well, it's PBMs fault that you know, that that's.

No, it is the system design and PBMs are exploiting that system design. Yes, they are accentuating pharmacies, a bad incentive problem, but this is not a PBM only problem. This is a fundamental problem within the business model of pharmacy. And I think it is an, it is incumbent upon a PHA N CPA, OPA you know, a H P I don't care who it is so long as you're a pharmacist, you took an oath to care for that patient.

And right now, this system disincentivizes the care of that patient. Every single pharmacist should be disgusted with how this system is designed and should be actively working to do whatever they can to make it better. 

Mike Koelzer, Host: Is there any finish line? Is this a super bowl or is this like, you know, four outta seven wins?

You know, like a playoff, more like how many wins did you get this? Month or this quarter, it almost seems like an ongoing graph kind of thing to measure. And I will say a lot of times they're blind wins. I mean, nobody sees anything going on and then something pops up and it's like, that's a miracle.

It's like, no, it's not. We've been working on this for five years 

Antonio Ciaccia: using that analogy. I would say we're a nine and team. Uh, on the verge of not making the playoffs. Yeah. Um, and, and what I mean by that is, is that pharmacy has become obscenely compromised by the business model. And meanwhile, you have other healthcare providers that are, that are seizing other opportunities that are moving ahead of pharmacy.

Uh, conversely, and I'm not pro to technician responsibilities. I think technicians can and should do a lot more, but you have this major push by the major pharmacy chains, uh, and the mail order companies to move technicians into roles that they've not traditionally had before tech technician, immunizations tech, check tech, et cetera, et C.

Those are things that I'm, I'm comfortable with. I'm not comfortable in the current environment where there is a lack of accountability in terms of the quality of, of, of, of what's being rendered at one pharmacy versus another. I think technicians can do much more. I think they can do a good job at some of this, but I also don't trust handing, you know, the CEOs of our largest pharmacy organizations and companies to say, Hey, [01:05:00] you.

Will you tell us if there's a problem with technicians doing something? Uh, of course not. You know, the logo of the fortune 500 company is always smiling. So, um, you know, I don't trust giving that power to these companies because they have shown that they cannot be trusted with it. Uh, so if, if we all of a sudden give away the farm to the, to, to, to technicians, if we give away the farm to, you know, uh, pill pack and Amazon, and, you know, X, Y, Z mail order pharmacy, and we look, we can still make sure the yellow pill is the yellow pill, but what did we lose when we, when we push for this over efficient model of pharmacy, that patient engagement is crucial to their outcome.

And we don't quantify that. I'm okay. With a lot of these advancements. Is n't that I'm one to stand away from it, but I wake up almost every morning, thinking pharmacy is on its deathbed. Okay. The role of the pharmacist could be eliminated tomorrow and we never gave it a chance. Um, that's the stuff that I think about, which is why, you know, look, we need to be progressed.

We need to be moving. We need to be embracing change, but we need to be controlling what that change is because there are some that would do it just to yield higher returns back to shareholders and they would do so in a second, even if it came at the expense of the value of the overall system, that cares for our grandparents, our parents, et cetera.

And 

Mike Koelzer, Host: Antonio, are you glad that you're not a pharmacist? 

Antonio Ciaccia: I really could care less. Uh, I think it'd be cool. Uh, I, I, I know my dad would, would've, would've loved it, but, um, in many ways I really like looking at it from the outside now. I, I feel like, like an, like, like more of an insider now. I mean, if I did, if I didn't, there'd be something wrong with me.

Um, but I will say that the ability to look at it with a fresh, uh, set of eyes, you know, when I switched out of pharmacy, I actually switched to journalism and, and I look at pharmacy like a journalist. Um, it's part of the reason that the whole Columbus dispatch thing just blew up. I mean, you know, we looked at things, uh, in Ohio, like a case that had to be cracked and, and we were obsessive with telling that story and that obsession with telling the story, that fresh set of eyes that wasn't trained like, Hey, this is how the system is both Eric and I were able to come in as, you know, quasi outsiders to say, whoa, whoa, whoa, this is how it works.

No, no, no, no, no, no, this, this can't be how it 

Mike Koelzer, Host: works. Sometimes either have golden handcuffs as a pharmacist, not so much more now, but a lot of times you have like, you're kind of stuck thinking, well, I'm gonna do this because doing something outside of the norm of this would be. Too risky. And sometimes I almost wish that somebody would take my degree away from me and just force me to go out and, and, and do it.

And it's easy for me to say, cause I just had a nice, nice dinner at home and I'm still affording things, but sometimes I kind of wish that I was forced out. I understand 

Antonio Ciaccia: that. Um, because what you're, I, I think what you're saying is it might give you even added 

Mike Koelzer, Host: motivation. It'd almost be nice to have someone say, Nope, no more.

And it's like, oh shit. Now I'm forced to go and do something different. 

Antonio Ciaccia: Yeah. Um, that, um, That, that hunger or that, that, that extra motivation, however you wanna phrase it, is very healthy, especially in a time where, where there's needed change. Um, it's part of what, um, attracted me to, uh, working with a PHA, but we look, we have other people that we work with, the American pharmacy cooperative, which is a pharmacy buying group based outta Alabama, Tim Hamrick, Susan May, and bill E um, you know, have always been kind of color outside the lines, think differently.

Uh, you know, don't just tweak it, reform it, uh, types. Um, and most of the people that we, that I've found that I work best with are those types of people that, you know, let's not just go halfway, let's actually do it. Um, and that's one of the things I've been, um, in my limited exposure to a BHA previously, I knew Janelle Saba and I knew Mary Alice Bennett, both of which are past presidents of alPHA.

And what I knew about them is that they were extremely passionate about elevating the role of the profession. I usually take a PHA. My perception of a PHA was that it was very fluffy, you know, oh, we like the profession, you know, how wonderful we are. Um, and, and I knew Tom Mingan and I always thought, you know, his, you know, general demeanor left me with the impression of, of quiet, um, which can be falsely construed as, uh, disinterested or unmotivated, which he was not like Tim, Tom GaN was [01:10:00] an amazing, amazing guy.

Um, what I've learned about a PHA is that they actually want these system changes, but I think part of the reason they brought Scott in is because of that outward perception. Was everything okay? You know, pharmacy. Great. Um, and this is why I'm really, I mean, I've talked with Sandra Leo. Yeah. I've talked with Kathy Coon on their board who came from, who obviously is Ohio and then Michael house and you know, you don't hire Scott and want to go halfway.

No no, 

Mike Koelzer, Host: no, 

Antonio Ciaccia: no, you don't. You just don't. No, you don't. And, and my warning to them is it would, again, like, based on my perception is look. Make sure you really want change because if you want change, you hire Scott. And if you're kind of on the fence with change and you wanna kind of be restrained, you don't hire Scott

Mike Koelzer, Host: Yeah. Yeah. Scott told me when we spoke a few weeks ago, he said, either he's gonna get kicked out in six months by the board or, or he is, or it's gonna work, you know, you don't go halfway. And I 

Antonio Ciaccia: applaud them for taking that, that, uh, you know, for them it's, it's a risk, I don't view Scott as, as an inherent risk because I I've, I've known Scott for over 10 years and, um, you know, I can, I know his pluses.

I know his minuses. Uh, you better believe after he called Larry Merlo Lucifer. I called him. I said, I don't know if that's a good idea, dude. uh, but, but look, I mean, I, I, I think I, I think big picture, you know, um, I think we need to be, uh, assertive. I think we need to call it, call it like it is, but I think we need to be ready to work with people that we also perceive to be against us.

Um, whether that's doctors, nurses, PBMs, insurance companies, you name it. Um, I've sat in a room with, you know, the CEOs of, uh, of United healthcare Melina, et cetera. You know, I've, I've gone all the way up the food chain up to the mothership, not just at the state level. And these are people that you can break bread with.

Um, you know, you, we have to understand where their incentives are. Um, and, and try to meet them at a place where we have commonality and look, does that mean that we stop fighting OptumRx tomorrow? Absolutely not. I'll be issuing a report tomorrow on or something, you know, but, but, but look, we, as long as we are, we are clear and, um, and objective with what it is that we wanna accomplish so long as those things, aren't just, eh, let's pay pharmacists more money.

No, no, no. Right. If we can actually help them make a better system, provide a better value to patients. Yeah. We might have to push 'em up against the corner like we did in Ohio too, to get them there. Yeah. But the key is you can get 'em there. And so what I'm hoping that I could do, not just with a PHA, but any of, any of the people we work with is provide that level of accountability and that heat that pushes people to make this system 

Mike Koelzer, Host: better.

I'm an older guy and. And Antonio you're, you're not a millennial, are you? You're a, I think 

Antonio Ciaccia: I just made the cut I'm I'm 

Mike Koelzer, Host: 37, you know, I remember the old days and you do too, where these guys would hash it out in the house and in the Senate. And then they'd go out for a couple beers afterwards, you know, and I love talking to Scott and I love the analogy you use about balls and strikes because you can still go in talking with the PBM guys or this or that.

And the count might be off. It might be three balls in one strike or one ball and two strikes or something. But just because there's a strike or just because there's a ball, doesn't mean you never talk to that guy again, you know, you're still up to bat. You find the commonality. You're never gonna find someone perfect.

If you wait till they're perfect. Before you talk, it's not gonna happen. Everybody's gonna be out of a job. We 

Antonio Ciaccia: need to learn who they are too. I mean, I have my thoughts on, you know, what the leadership of CVS Caremark is. Like. I have my thoughts on what the, uh, leadership of United healthcare is, you know, Cigna, you name it.

Am I right? No, I haven't sat down with them. I haven't talked to them. Look, one thing that I've learned in this business, there are vendors. For everything. Okay. And like, we like to, we like, as pharmacy, if I was to rewind the tape seven years, I would sit there and think that there's some, there's some sinister man behind a cloak, who's dialing up the rates, you know, screwing Jim's pharmacy.

That's that, it's not true at all. Most of them, you know, have no idea how their own businesses operate. They hire good people who find good widgets to maximize profitability. You know, there, there are, there are tools out there that could just autopilot this stuff and maximize profits. So. Look, they're look, those companies will defend those practices until they're blue into face because ultimately they work for their shareholders, but we as pharmacy need to recognize that, that look there are humans on the other side and not all humans are perfect by any stretch, but trust that there's probably some good humans over on the other side, that you might be able to actually meet in the middle and say, Hey, maybe the system shouldn't work [01:15:00] like that.

Mike Koelzer, Host: I think there are, but I probably won't help. Like I tell my son and he's not in pharmacy, but he's part of the business. I say to him, that person you just talked to on the phone from the PDM. I said, they have no idea how much we hate them.

but I couldn't control myself, but they don't. They think they're part of this system, unless they're in the customer complaint department or something, they think they're doing their thing. And, and they're my mother-in-law has a sign on our fridge and it says there's so much good in the worst of us and so much bad in the best of us.

I forget the punchline, but basically, you know, keep going kind of thing. 

Antonio Ciaccia: Yeah. I mean, look, it, it, you mentioned, you know, these, these current times, okay. 2020 has taught us anything. So there's a lot of good people out there and there's a few bad ones. Okay. Yeah. Uh, and that's true everywhere. And so I, some of the best pharmacists I know are CVS pharmacists.

I know some great, uh, PBM, uh, uh, pharmacists who are genuinely working to do good. Do they control? Yeah. You know, the Mac rates of pharmacy. Absolutely not. Okay. You know, there, there's going to be villains within all these companies. Uh, and there's going to be a lot of really good people too. And I, I, my job isn't to sort them out, I could really care less.

My job is to see where their incentives are and look at the data. The data tells me that the system with which these people are operating is not working the way it should be. And so I am agnostic on the individuals. Um, pharmacists included, not all pharmacists are. Uh, most of them are, but not all of them are great.

So, you know, look, we, we should, we, as, you know, individuals, you know, anybody listening to this, we should be working to build a better system and we should be agnostic on who it impacts. Uh, from a business perspective, we should ultimately that Say that the system is what's best for the patient.

And I think pharmacists need to be empowered and sustainable in a way that they can help benefit that patient. But, you know, we need to be wedded to the cause of a better system for the patient, more so than anything. And, and I know in some of my conversations with a PHA that's, that's something that they've talked about a lot is PA thinks of the patient first before anything else.

Mike Koelzer, Host: If you wake up every morning and you know, you've got somebody working on bringing everything to light. And then you do the best that you can do each time for a patient. There's no guarantee, but it sounds like that's a pretty good mix going forward. 

Antonio Ciaccia: A absolutely. And that, and that's one thing I'd give the credit to the Ohio pharmacist association, you know, Ernie Boyd, you know, the executive director there, but also the board, you know, Bridget groves who just, uh, left as president and TJ grin.

Who's the current president? One of the things that I've really loved about Ohio, which is why I would never leave them high and dry is they really. Got it. You know, they really understood that it's not just about shilling for pharmacists. You know, you need to have pharmacists back, you know?

Absolutely. But you should never advocate for something that undermines what is a better system for the patient in Ohio. We're really able to do that. I, and again, back to why you were asking before, but why the buzz, I feel that we've been successful because we've always kept that in mind where we've always been willing to talk about things that most traditionally we wouldn't wanna talk about.

Um, we've been willing to say, look, yeah, this would be really good for pharmacists, but this might not be that great for you as a payer. And, and because of that, we've built up a lot of credibility. That's why we've been in Axios. That's why we've been in NPR USA today, LA times. One of the things, and Scott talked about this too, and to me as an outsider, looking at pharmacy years ago, When we first started really taking on, uh, you know, a bigger role in this marketplace nationally, you know, when, when pharmacy stories would hit the media, I would look and see, like who's talking about pharmacy and, and it was, look, I couldn't find, I couldn't find our national leaders from our national organizations.

I would see Scott Kor's name, or I see my name, or I'd see some researcher at Vail Vanderbilt or something like that. Stacey Dessan or something. I'm like, why, uh, why is it? And maybe no fault of their own, but why is it that when an issue impacting pharmacy or drug pricing occurs, why is it that Axios calls my phone number?

Why is it that ed Silverman at sta news is calling Scott Canoe. They should be calling a PHA. They should be calling N CPA, but they're not doing that enough. Um, it's not that they're not doing that. It's not to downplay them, but like, I think that the reason that we've been as successful as we have been is because that ability to speak as objectively about the marketplace as possible has endeared us to media enough [01:20:00] that they seek out our opinions because it comes without filter.

Mike Koelzer, Host: So your point about saying, well, maybe good for pharmacy, but maybe not so good for the payer. There might not be an answer for that right away, but the reason the press is coming to you is because they don't maybe want that packaged answer. They trust somebody who says this might not be good for the payer.

It might be good for the 

Antonio Ciaccia: pharmacy because we've been willing to give them the nuanced answer. You know, that look like this isn't cut and dry, you know, this, uh, you know, and look, let's just say, let's just say I did that. Let's just say, look. You know, Bob Herman at Axios, you know, you're gonna ask me about pharmacy.

Okay. And I'm gonna tell you, look, this is perfect. It's the best , you know, it's this, there's nothing wrong with this. And then all of a sudden, whatever it is passes or takes effect, occurs, whatever it is. And all of a sudden pharmacists get this big win, but it comes at the expense of, uh, of the patient or the plan sponsor.

Well then what the hell am I then? You know? Yeah. You. So, so congratulations, you got one win and you lost everything forever. You know, if you are unwilling to be open about this stuff, you will just be another insert name here, uh, you know, on one side of an argument versus another side. And that's the crap that PCMA does.

Okay. And, and, and I, I believe that pharmacy should be more exalted than that. I think pharmacy should always position itself as you know, we're not going to do that crap. Um, uh, I, I don't know. I don't know if pharmacies collectively can do that. Um, but I know that that's what we're gonna 

Mike Koelzer, Host: do. Well, I think we're in a really cool time.

I mean, me 15 years ago, the only time that I had a chance to talk would be when one of the local reporters would say, give us 10 seconds. I mean, in 10 seconds you either say this is good, or this is bad. You don't get into it. Three hours or 20. Yep. Yep. You know, so, so this is, this is a real quality time, a real special time in history that people can spend some time in and hopefully understand deeper issues instead of just jumping right away to one side or the other.

Yeah. I 

Antonio Ciaccia: mean, look, the Columbus dispatch, arguably put us on the map back in 2018 and you know, that, that took months and months of meetings and poking and prodding, you know, they, they were, they, we were literally sitting at the Columbus Italian club reading spreadsheets and they were quizzing me on it, you know, like tell me, all right, wait, wait, wait a second.

What about this? What about this? Like you have to be willing to tell those nuanced stories because look, look what it turned into. The dispatch has done over 160 stories on drug pricing and PBMs. Okay. So, so look like, yeah, if you want to, if you want a pithy comment you want, you know, you want to influence something, you know, uh, for like a second go by all means, do it.

And again, back back to, you know, what we try to do and the people that we work with. We, if you want to, throw a bunch of crap out there and like, you know, try and basically pull the wolves over people's eyes that undermines our credibility. That is why, uh, I I'm, I'm really excited about where things are at right now, because I feel like the credit that we've been able to get has been deserved.

Um, part partly because I think our data work is the best out there. But like, aside from that is, we've been willing to be open and honest about all of it. You got 

Mike Koelzer, Host: it. That's exactly 

Antonio Ciaccia: right. And that's where the credibility 

Mike Koelzer, Host: comes. Yeah, for sure. Well, Antonio, your legendary status has only grown in my eyes now that I've had a chance to talk to you for an hour and a half here.

So my goodness, I'm really excited to see what's gonna be going 

Antonio Ciaccia: on. Yeah. I mean, it, it looks as far as, and I think what, what, what, what caused you to, um, At least bring me on right now is a PHA announcement. And, and the thing that I would say is, you know, I've had a good working relationship with Scott over the years, and I've gotten to know a lot of the people at a PHA, um, over the last two weeks, uh, especially, and from a pharmacy perspective, cuz I know that's a predominant part of your audience.

Um, I think you're going to see my advice to them, uh, in, in our discussion so far has. Let's start thinking differently and let's start attacking these things differently. Yeah. Um, let's be louder. Uh, but let's also be smarter too. And it's not to say that they haven't been loud enough or that they haven't been louder.

They haven't been smart. It's just that, um, you know, I, I plan to architect things in a very different way, and I think that if a PHA can thread that needle and Lord knows if anybody can do it at Scott, um, yeah. You know, a PHA can reclaim the podium, uh, and be an authoritative voice, not just on drug pricing, not just on pharmacist, [01:25:00] uh, but pharmacy, pharmacy marketplace as a whole, in everything that impacts the pharmacist by establishing that credibility and being assertive and gaining that credibility.

I believe a PHA can be the biggest influencer that there is in this profession. Um, and the question is what do they do once they have it? You know, hopefully, uh, they, they work to actually change. What I think is, uh, a system runs with luck and I, I, I believe that they will, we are ready for upheaval instead of pitchforks.

We have Excel sheets. Yeah. 

Mike Koelzer, Host: That's right. All right, Antonio, it's been a pleasure. We'll certainly keep in touch. Same here, Mike. 

Antonio Ciaccia: Thanks a lot for what you do. All right. Thanks 

Mike Koelzer, Host: Antonio.