Evolving After a Pandemic | Robert Popovian, PharmD, Chief Science Policy Off., Global Healthy Living Fdn., VP of Econ. and Policy, Equideum Health

Speech to text: 

Mike Koelzer: [00:00:00] Robert for those who haven't come across you online, introduce yourself and tell our listeners what we're talking about today. 

Robert Popovian, PharmD: My name is Robert Popovian . I am a pharmacist, a PharmD, and I have a master's in pharmaceutical economics and policy. I am currently the founder of the conquest of advisors. I work as a chief science policy officer at the global healthy living foundation.

I'm a senior health policy fellow at the Progressive Policy Institute, and I'm also vice president for Health, Economics, and Policy at Equity and Health, which is a blockchain technology company. And hopefully today, what we should be talking about is what have we learned from this pandemic and how can the professional pharmacy and technology and all these things that we've sort of came across really continue as we come out of the pandemic and to the future.

And how do we evolve ourselves as not only a profession, but as a healthcare industry and. 

Mike Koelzer: Robert, I'm glad you call it pandemic. I think that calling it COVID and talking about COVID is no longer hip, you know, it's like we date ourselves, so we have to talk about pandemic, but you know, what is it? Every hundred years they're supposed to come, but now bad, it gets so much attention in the news that it can sell so many ads from it.

We're probably going to see a pandemic about every year or two now. 

Robert Popovian, PharmD: Yeah, you're right. I mean, we've had pens made in the last two decades, right? It's just on a much smaller scale. 

Mike Koelzer: I remember reading something about the swine flu and how that was going to be big, but then it kind of petered out.

Robert Popovian, PharmD: Exactly. So we've had occasions where pandemics were happening. It's just not to the scale of that. What we've seen both in the US and also globally with what we've seen so far, and really, we never saw the disruption that we saw and not only disruption to our everyday life, but to the healthcare system and how.

We need to learn from this and move forward as a country on how we deliver health 

Mike Koelzer: care. If you look out five years, is it a much healthier healthcare system because of the pandemic we had or is it still broken? I think 

Robert Popovian, PharmD: Hopefully we'll learn from it. So it will be much healthier. It definitely showed some holes in it, right?

That our healthcare systems showed some vulnerability. I mean, uh, if you remember the dark days of 2020, where everything was shut down, March, April may always be all the way into June really realizing the healthcare center. We were pretty vulnerable. The point at that point, if, if you're a patient and I had relatives who happened to be patient non COVID related patients, and you needed to see a healthcare professional, the only entity open that you can go in and see the healthcare professional in person was the pharmacist at the pharmacy.

Unfortunately, We can't forget those things. And we need to create an environment where we use all of our resources as healthcare professionals, to be able to deliver health and not go back to the same old way. We used to practice medicine and pharmacy and everything else 

Mike Koelzer: from 2015 through 19, I was kind of a recluse here at home when the business was suffering because of all the DIR fees.

And I didn't really like my employees. And so, but I kind of felt like what hole was I feeling as a community pharmacist? You know, when I started feeling useless, maybe, cause I wasn't looking at the patients in their eyes, you know, but then I got in there, I had a big staff change, right when COVID hit just by chance.

And we weren't even doing vaccinations or anything, but I turned a corner saying community pharmacy. Are really needed. Maybe if you have a person who knows their technology well and can get around the internet and things like that, but throw in there, some of us old farts with some bad eyesight and people maybe who don't know their way around a smartphone and all kinds of stuff.

And in a hurry, you see that community, healthcare workers, especially pharmacists on the front line or 

Robert Popovian, PharmD: crucial. Absolutely. And this, this is what frustrates me a lot of times. I mean, I sit back and think about it. I'm willing to say this publicly, I've written about it. I've published about how pharmacists were the only health care professionals during the dark days of the pandemic.

That really, if a patient wanted access in the community, there were the only ones available. If not, you have to go to an emergency room or hospital with nobody wanting to go because of all the infections that were going on. But why am I, as a former executive of a pharmaceutical company, saying this publicly and not the American pharmacist association, not the pharmacy associations at the state level, they're still apologizing.

They're still trying to fight a fight that really doesn't exist. We need to have pharmacists. For example, one of the things that [00:05:00] I've been really pushing for for the last 12 months, is that pharmacists should have the same ability to even eye patients as physicians do. That means we shouldn't have to rely on prep act and emergency authorizations to do these things.

We should have the same ability and the same rights of immunization as physicians do. That means if it's FDA approved or there's an emergency use authorization, or if it's CDC recommended a pharmacist can do that. That's why we needed the prep act. Then the emergency authorization to administer to COVID vaccine positions didn't need that.

That's not right. That's what we should learn. And this is where I get frustrated sometimes with the pharmacy associations on the state and federal level that instead of standing up and fighting that issue, they're still fighting the Rolex of two decades ago of trying to get provider status, which is important.

But first let's make sure that pharmacists are able to practice at the top of the license and then let's fight for payments and everything else, which I think it will come through because people realized that not only we were the only ones available in the community, people like you serving the patient, but you not only serve them, but you're a very cost effective model of serving patients at, uh, at the level that they need to be served.

Mike Koelzer: If you look at the organizations, all right, let's put it in three levels. Well, it could be a million of them, but let's say there's either. And we won't pick on any individual one, let's say the multitude of organizations. It's probably not malevolence. They're probably not trying to do the work of the AMA against pharmacy or something.

Maybe it's incompetence, maybe it's having a different idea and then maybe not having the right vision. Where do you think the associations fall into this thing? 

Robert Popovian, PharmD: I think they fall into it, they want to do the right thing, but they don't see the future. Like I see the future or you see the future of Mike because you've served patients and they don't see it that way.

They see it as well. We have this niche business model that we've created in the community. We should preserve that. And my thing is that model is going away. You know, I know that that model is being targeted by pharmacy benefit management companies. Every single day you need to evolve is basically it's not a new pair.

As an institution and for me to evolve, it means that you take the opportunity to educate the masses of what happened during this period of time. That was very extraordinary and made sure we didn't go backwards. Instead we move forward. I was pointing to people and saying, look, there's a reason why the federal government had to step in and give an emergency authorization for pharmacists to administer a COVID vaccine.

This should have been authorized from the beginning. We shouldn't have had to wait for that to happen from day one, when those vaccines were available, pharmacists should have been able to get most of those vaccines. Unfortunately, state associations don't see eye to eye with me on that. And neither does the American pharmacists association to a certain 

Mike Koelzer: extent.

Break it down a little bit more for me. Where do you see the associations going? Where do you want to go? And do you think there is still a divide? Are you just saying. Well, now everybody should know the lesson or do you think there still is going to be a divide going down a different direction? 

Robert Popovian, PharmD: I've given you a perfect example.

Right now. I deal with a lot of the safe associations on the pharmacy side. And they're a model to go after the pediatrics, you know, to start immunizing children. My issue is that we don't have a pediatric immunization issue in this country. We have the VFC program for peeds. Pediatric vaccination levels have always been very high in the United States.

Yes, there's some drop-off because of the pandemic and we need to have the catch-up doses for these patients to come. But what we have in this country is that under immunization of our adult population, who COVID aside, who got the flu vaccination rates and the pneumococcal vaccination rates were nowhere close to the 20, 20, 20, 21 healthy, uh, uh, healthy levels that we need to be.

Uh, so, uh, in other words, adults are where we need to focus our attention on, who is going to come to the pharmacies and want to interact with. Instead, they're chasing their tails with pediatrics and to expand the pediatric vaccination, which is fine, but that should not be the priority. It should be ensuring that pharmacists have the same ability to immunize adult vaccines as physicians do.

That means they don't have to wait for a CDC recommendation. As soon as it's approved by the FDA or authorized by the emergency authorization through the FDA, pharmacists should be, I will have the ability to immunize those 

Mike Koelzer: patients. If I'm a pharmacist listening. Now I'm saying, Robert, [00:10:00] are you living under a rock?

Because every pharmacy shouts on their Mar keys, they say, come in for your flu shot. So what am I missing? Why are all the pharmacists doing this? But you're saying there's a problem, 

Robert Popovian, PharmD: but it's not just flu shot. It's not just about the flu. It's about pneumococcal. It's not just about flu and pneumococcal. It's about shingles.

It's not just about those, all these other vaccines that adults have access to that pharmacist and certain state. I'm not saying across the country, in every state, but certain states prohibit pharmacists from unionizing those vaccines for adults. In addition, in almost every state, except for maybe about six of them, you still require the CDC to step in and give a recommendation before the pharmacist can actually immunize.

That's not the case with physicians as soon as physicians. As soon as it's FDA approved, physicians may immunize. Now they may choose not to, but that's their choice as a professional. They're not being governed by the state. So my intent is to pass state laws in every state that says, as soon as the drug is approved by the FDA or early emergency utilization is provided or it's CDC.

Granted, uh, for recommendation, pharmacists should be able to uni's we don't have to wait anymore. Just like we have to wait for a couple of months, right before the emergency authorization comes through for HHS, for us to be able to do the COVID COVID vaccine people forget. So that's my goal in life is basically to allow pharmacists that have the same authority as a physician does, in immunizing.

Mike Koelzer: Are there any states that say zero vaccines? We don't care if the doctor says it's okay. So in all states they're doing maybe some flu shots by the doctors. Yeah. Um, 

Robert Popovian, PharmD: almost every state allows flu and pneumococcal. That's the thing that we fall into the trap, because what we see is that, well, it's for pneumococcal.

Well, that's not the only vaccine adults get there. There's all these new vaccines that are being developed. There's a shingles vaccine. And at some point we have to realize, so the other thing that we run into the trap that you hear from people is to say, well, we can't administer anything until CDC recommended, well, CDC recommendation putting COVID aside.

May take months, if not years before something gets recommended, especially for the adult space. And I can give you multiple examples of that. So are we willing to say that we're going to wait for months and years after a product has been approved by the FDA for the patients to have access to that product through pharmacies while in the same time physicians, you know, most often don't carry those vaccines, especially for adults because they don't know how to control the inventory, and it's not lucrative enough for them to, can you carry things that you're going to have one or two patients walking in once every two months or something to get the vaccine done.

So in other words, we're creating an access barrier for patients and the best way to get rid of that excess barrier is for the pharmacist to have the same authority as physicians in immunizing, adult patients, 

Mike Koelzer: period, 

Robert Popovian, PharmD: devil's advocate again, here we go. Robert, you want everybody to get the vaccines, but if I come in and.

I want Lipitor or something, 

you know, 

Robert Popovian, PharmD: nobody can just come into my pharmacy and get it. They need a doctor's prescription. And guess what? The DEA is never going to say it's okay. Just for the pharmacy to hand out Lipitor. So why the big push for the vaccines when every other drug doesn't really have any of this clearance?

Well, no, because we have over the counter drugs that treat disease areas. Correct? I knew you'd have an answer. Correct. So that's one thing, but I don't disagree on the Lipitor example for you to be diagnosed with hypercholesterolemia requires a diagnosis. The vaccine doesn't require a diagnosis.

You don't need a diabetes come diagnosis, you qualify for it based on an FDA label or a CDC recommendation, you know, it's not like, so the only hangup to be honest with you, which is a two excuses of why this would not, should not happen. You also don't want duplication, right? You don't want to get the vaccine in the physician's office and then go to a pharmacy and get the vaccine and the pharmacist's office.

Right. But that can be resolved because we have state registries, which everybody participates in so that they can register the patient when they administer a vaccine. So those things are excuses to me. The real challenge we have in this country is that giving a vaccine to a patient is not a diagnosis.

Robert Popovian, PharmD: Similar to what you just talked about with Lipitor. 

Mike Koelzer: That makes a lot of sense. Why aren't the associations saying maybe it's too big of a leap and the AMA is going to be against it. And let's baby, step this in here. Is there any argument that it's done through baby steps and it's not going to happen with this 

Robert Popovian, PharmD: big leap baby subs.[00:15:00] 

Going to have you perish as a profession. We don't have time for baby steps. We don't have time as professionals. We don't have the time, especially on the community level because people are pushing into mail order and replacement technology and all these things. Right? So that's one, the second part of that excuse that I hear is that, well, if we don't get CDC recommendation, for example, we're not going to get coverage for it through a third party, through insurance or Medicaid or Medicare.

I, my thing is, first of all, vaccines are not super expensive. They're not like you're not talking about a cancer drug. That's a hundred thousand dollars a year, you know, from, we know from COVID, you know what the cost of COVID vaccine was. Each shot was about 20 bucks. There's a lot of patients out there who will be willing to pay.

You know, for cash, why are you suppressing their access? They're willing to do it. Yeah. They're willing to do it. There's a lot of things we've learned from the generic market where you and I had that conversation in our last podcast. And we have evidence now there's a lot of patients who are searching for cash and generic people never thought this would happen, right.

That they would go pay cash out of pocket for generic medicines instead of using their insurance card. If we create a cash market for vaccines, especially for vaccines that are not super expensive, which we know there are, yeah, let's say 80% is not going to do it, but then you, you basically saying that 20% should not be allowed to pay out of pocket and get the access to that vaccine.

I'll give you one perfect example. So, um, when the, uh, when the meningitis B vaccine came out, there were very few people who were ministering. The vaccine, first of all, a pharmacist could use this sort of vaccine because it was not recommended by the CDC. So they couldn't. And in the places that they could in states that they could, they, there was no insurance coverage for most of the time, but I had a lot of parents calling me because they knew I worked for Pfizer at that point, who were saying, look, I'm willing to pay for this damn thing out of pocket before my kid goes through the dormitory, because I'm scared to death with having them come down with meningitis.

So in other words, just suppressing their needs because maybe 80% of the population may not pay for it. What about the 20% we know from the generic market, that if you create a competitive cash marketplace, people, patients will switch and not use their insurance and pay for it in cash. We know that we have the evidence now get 

Mike Koelzer: the whole damn vaccination thing out of insurance.

Just say, look, it's going to cost whatever. It's going to cost a hundred dollars a year to get vaccinated. And we know this is true. Let's reduce insurance. Premiums by like $500, which would be the inflated price of all this baloney. And let's reduce that by 500 and let's have a hundred dollars a year cash payment.

People would have $400 in their pocket, but they might not like it because they don't think insurance is doing. Or in the meantime they're getting 

Robert Popovian, PharmD: screwed. Exactly. You're right. I mean, it's not just vaccines and it's not just generics. I'll give you another example. So JAMA published an article about medical services provided in hospitals.

So in the study they looked at what happens if a patient is willing to pay cash versus using the insurance, what they found in like 70 procedures that they looked that in every case, the 70 cases of procedures, the hospital was willing to take less money in cash from the patient that they were actually getting reimbursed to.

So that tells me there's a cash market available. What if we just get patients to pay for it out of pocket, we will get better return on investment because what you're doing is getting rid of a lot of the middlemen in there and you know, about metals and how they inflate prices. So there's multiple examples such as vaccines.

It's generics, it's procedures in hospitals. I mean, there's evidence now we know that the market works. If you let it work. And if you have a competitive marketplace where people are transparent about their prices, 

Mike Koelzer: my brother, he had shingles, I don't know, a few years ago. And now about like 10 seconds out of every minute, he gets a zap on his back from this, uh, where the nerves were damaged or something like that.

And I think about a couple of things. One is that COVID has put a kibosh on things like. Shingles shot for the last two years. I think about all the poor people that are going to get shingles now. And then I think about hearing what I hear from my brother about that pain on his back that may never go away.

That's worth like $10,000 for me not to go through what he's going through, you know, and it's like, maybe I wouldn't buy that, but let me have the choice. And then let me have the choice of a pharmacist doing 

Robert Popovian, PharmD: it. Exactly. Instead of having to get an appointment and go to the physician and get it [00:20:00] done in the physician's office, why can't the pharmacist administer these things?

And, you know, shingles are not a problem. Pneumococcal is not a problem. Flu is not a problem, but there are other vaccines we're talking about, the travel vaccines, right? When patients have to travel, now we don't travel. So that's another issue. Well, who's traveling well? Yeah. We're going to go back to international traveling.

Why do you have to go to a physician to get all your travel vaccines or get off the authorization or prescription for a physician to get all the travel vaccines done. Those are all requirements. It's black and white. There's no diagnosis, right? If you're traveling to a certain country, you have to get certain vaccines.

So why can't the pharmacist administer these vaccines automatically when they become available in the market? When they get approval from the FDA that then gave a vaccine that was approved several years ago, it's set. At least I haven't checked recently since about 12 months before that CDC hadn't made a move.

I mean, CDC wasn't me. So any state that requires only pharmacists administering CDC required vaccine could administer this vaccine 

Mike Koelzer: to the patient time is of the essence with allowing pharmacists to do this. Tell me again, why do you think the associations are not pressing this? 

Robert Popovian, PharmD: I, I really think that they get, they get into an area that they believe well it's enough to have flu and pneumococcal, and they don't realize what the future of vaccines looks like because they don't, they're not privy on what the, what is being thinking about being developed.

Right. So I wrote an article actually on the hill last year about the future of a lot of diseases that are going to boil down to vaccine cancers, uh, you know, HIV and things like that. Alzheimer's Parkinson's so we better get used to it. That vaccines are going to be part of not only. These pandemics and infectious diseases, but chronic disease management, perhaps, or treatment or treatment of chronic diseases.

So they're not thinking long-term, they're thinking here and now, and they don't realize I'm thinking 4, 3, 4 years down the line. And the reason I'm thinking that way is that as these products come into the market, every time a new product comes in in certain safety, you literally have to introduce legislation to allow pharmacists who miss these things.

We're not going to have a federal authorization like we did with the COVID. So imagine the waste of time, the resources and efforts, and nobody has explained to me coherently, uh, why shouldn't pharmacists have disability other than, you know, those things that they get fooled. Flu and pneumococcal and shingles and the insurance issue, which to me is a non-starter because we have case examples on paper, people are willing to pay out of pocket for certain things.

Now, do 

Mike Koelzer: Do you see any association that thinks of itself as a marketer? Do you see any problem in them doing this in terms of it hurting some other goal or maybe it'll water down some other area they're doing? Is there a negative, like if an association said right now, it's like, oh, let's do this. What's on the negative side for them pushing this.

Robert Popovian, PharmD: It could be, I mean, I don't know what their priorities are and, but you're right, because it's a trade-off right, because there's sort of certain amount of bandwidth that state, especially state associations with state legislative efforts have to go through because you know, as much as we talk on the federal level, It's really the state level, because that's who governs the practice of pharmacy.

It's not the federal government. I mean, put COVID aside again, it's the states that have to make that decision and they do have other priorities that they're tackling. But my thing is, for me, that's an important issue and it's been an important issue for me for about three or four years. Now. It's nothing new that I've been yelling and screaming about.

It's just that the COVID issue is just, and the pandemic. Sorry. We said we shouldn't use COVID. 

Mike Koelzer: We said 

that, yeah, we're not going to use COVID. People are sick of it. So we're going to now go under just pandemic 

Robert Popovian, PharmD: what this pandemic, it pushed some ideas forward that probably were lie mag. And the biggest idea was that look, when the chips were down and patients needed a healthcare professional in the community, pharmacists were the only ones period.

And that should be the slogan on every single association. Starting point when they talk to the people is that we were at, we were in the community. You couldn't go see a physician. If you want to see a primary care physician, you have to do a zoom call. Only way you could go see a pediatrician was to do a zoom call.

We were the only entity that stayed open and people could go into a pharmacy and talk to a pharmacist. Period is 

Mike Koelzer: the relative silence of the associations? Is this a huge windfall [00:25:00] for somebody? Or is it like, no, we're all gonna rise up together in the tide. Everybody should be talking about it. 

Robert Popovian, PharmD: Everybody should be talking to.

And the reason being is that, and the same thing happens in the medical community. When issues come up with regards to the practice of medicine or practice pharmacy, the legislative folks, the legislator, or the policymakers want to hear from the associates. They want to hear from the regular pharmacists and physicians, they don't want to hear from business people and everything else, because at the end of the day, they're the ones that are going to influence the behavior.

They want to hear why and why not. So the association is really, the focal point needs to be the focal point, maybe academia, but academia is also sort of pinched and busy doing other things. It's really the associations and pharmacists like you, who actually practice every 

Mike Koelzer: day. I read this like half a year ago and they were saying how the social media slash smartphone slash internet has taken over a lot of the spots where we used.

Church funeral get together now is taken over by some Memorial on Facebook where people are doing this, you know, and the giving as a community has taken over by GoFund me and the group helping out is taken over by a sign me up program or something like that. So a lot of the needs of the local church are now online.

Do you see social or the new media as another leg of what associations have done? And just like, let's say how churches, maybe how some of that attendance maybe has gone down for various reasons, but let's say some of it might be social has social media risen where some of the associations have gone down.

Can social do this somehow in place of maybe the associations that aren't doing it, or at least not as strongly. You'd like to see 

Robert Popovian, PharmD: social can do it, but again, you need to have somebody who actually goes on lobbies, right? Because these require lobbyists and these require intervention than the state level from a policy perspective.

So yeah, social media can be a component of educating and pushing the messaging out there. But at the end of the day, you need foot soldiers to be able to walk in and change laws. And you need legislators on your side to be able to change these laws and regulations, 

Mike Koelzer: What would be really effective. For a lobbyist, what are they doing?

Do they like helping write these things? Are they taking these guys out for lunch and slipping them some hundreds? Let's say a lobbyist was trying to push this. What would be a good 

Robert Popovian, PharmD: day for them a good day with them to get the attention of the legislator and really educate them on why is this important and supportive of data on the golf course at lunch?

Not anymore. I mean, the last two years nobody's seeing anything face to face, right? Because of that 

Mike Koelzer: pandemic, let's say after the pandemic, what's a good connection. And 

Robert Popovian, PharmD: After the pandemic, I think with the lobbying laws and regulations, both on the federal and the state level, it's really hard to think about how lobbyists are functioning versus 20, 30 years ago.

Uh, I think there's a lot of disclosure issues and everything else I think with. Good day for a lobbyist would be, being able to educate the individual of why this is important. So you just mentioned like all the priorities, the say associations have policy makers have also priorities, right? They are not just dealing with health care.

They're dealing with education on financing and taxes and, uh, energy and everything else in their state. So they need to prioritize that too. So it was a good day for lobbyists to move this issue on top of the priority of a policy maker to make it compelling and afford them to take time, because they're going to have to then trade off.

It's a trade off with other things. Is that 

Mike Koelzer: like a 20 minute meeting with one of the sides of the Congressperson? Or what does that actually look 

Robert Popovian, PharmD: like? It depends. I mean, it depends on the congressional member. Depending on who the policymaker is that you're talking to, maybe talking to their aid because they do a lot of the work and usually.

Uh, aids have specialties. That means there are certain aid, uh, that work with congressional members or even the state level that specialize on healthcare or taxes or energy or something, education, something else. So that's one thing, but then there are individual Paul's makers who have a personal interest in it.

We have a lot of healthcare professionals that are built on the state level and on the federal level that are, you know, congressional members or state legislators who may have a personal interest on the topic who will get 

Mike Koelzer: engaged. Some of my favorite movies are like time travel and things like that.

If you wake up tomorrow, Robert and you find [00:30:00] out you're one of the senators for Virginia. Does that put a smile on your face when you wake up in the morning? Or are you going back to bed 

Robert Popovian, PharmD: aria? Why wouldn't you like that? No. Uh, why not? Because I 

Mike Koelzer: have access to the head honchos for this. 

Robert Popovian, PharmD: Well, not really because my outlook in life is that I'm very curious.

I have three things that I look at. I'm a very curious person to start with. I'm very helpful, but I'm also relentless. And sometimes those things that don't work in policy and politics, because things don't happen as quickly as you would want it to. Plus curiosity. Sometimes it's not viewed very well in our world because curiosity means that you want change and change doesn't fit.

Uh, with the political environment. So, no, I wouldn't want to be a policy maker. 

Mike Koelzer: People used to say like, not to me necessarily, but to other people, you know, you've got very strong views. You should be a good politician. That's like, no, I mean a good politician, right? You got to give and take. 

Robert Popovian, PharmD: Absolutely. You generally don't have views.

Maybe you do in certain issues, but not on all issues because it is a give and take. And, and you also have to play the game, which, and you can't be curious because it's hard to change policy in this country. That's why I'm saying this is a seminal moment for our profession as pharmacists to step up and make the compelling case of why this should happen.

Mike Koelzer: As we watch TV, you know, we think that judges are very creative, you know, and we think that doctors are creative and politicians are creative. It's like, I've been in court some times, you know, and when the judge makes a ruling, you know, they just don't lick their finger and put it up in the air and, and make a decision.

I mean, they're like quoting all the laws that they're basing this on and stuff. And I think of comedians and rock stars and stuff, it's like, you think they're artists and they're creative and stuff. And it's like, they sing the same damn song, you know, thousands of concerts and shows in a row. And all of that's kind of the opposite of raising questions and being curious.

It's like, they pretend like they're artists, but it's kind of like putting your nose to the grindstone and doing this. Right. 

Robert Popovian, PharmD: Exactly. And it's if people have assumptions that are not true. Uh, I think a lot of times we assume people just make things up and they don't, uh, they are following certain rules and guidelines and suggestions and everything else.

And at that time those suggestions are outdated and just need to be called out. You might 

Mike Koelzer: be, if you woke up as any politician, would you want to go back to bed? Is there anything that you would 

Robert Popovian, PharmD: take? Yeah, sure. I would take it, but it has to be something that I can make a difference. I, I would say probably health and human services, because that's where it touches 

Mike Koelzer: healthcare.

Would you have to be a Congress person to be on that? No. 

Robert Popovian, PharmD: No. It's an appointee. It's an appointee position. A part of CMS or CMI because that's when you really touch healthcare. Right. Then that's my interest. I mean, yes. I have expertise in economics and policy. Talk a little bit about blockchain and things like that, but everything sort of funnels to healthcare.

And I used those expertise to move healthcare along and make it health care better for patients, which is at the end of the day, my patients are the only entity in the system. Besides I would say patients and employers, you're an employer. You know, these are the only entities in the system that pay for healthcare.

You know, people mistakenly say it's pharmacy benefit management companies or insurers. That's absolutely wrong. And it's not even the government because the government pays for healthcare through taxes. Guess who pays for taxes? You and I do. So when you barebone it, the only people who open their wallets are the patients on pay for healthcare in this country.

And employers subsidize a lot of the healthcare for their employees that pay for this help before healthcare. The rest of those people are. Consumers and middlemen and basically, or they funnel money from one center to another. So for me, it would be any agency that impacts patients' lives and employer lives, perhaps because they're the ones that really are in the middle of paying for the healthcare system in the U S market.

I always get a kick out of it when people tell me, well, we don't have a free healthcare system. I said, nobody has a free healthcare system. Canada doesn't have a free healthcare system. They just collect a bunch of taxes and pay for healthcare, but the taxes are not coming from the thin air, they're coming from individuals who work and pay taxes.

So nobody has a single, no single payer system or no, there's no such thing as a free healthcare system. It's just a matter of how do you subsidize it? Is it through taxes or is it for employees or [00:35:00] to patients who open their wallets every day to pay. 

Mike Koelzer: There's so many levels. And unfortunately there's some of those levels that try to opt to skate things on purpose.

Do you remember the old telephone game? Robert giver played that where you sat around and someone would say something on the end and then it would go through all the ears. And then by the time it came out from like the six person, the message would be all jumbled. You played that right operator or telephone or 

Robert Popovian, PharmD: something like that to hold the phone.

Mike Koelzer: But think about playing that when somebody in the middle, I E the PBMs are like saying something wrong on purpose, and then just to make it fun, they throw a foreign language on top of it. 

Robert Popovian, PharmD: Well that, and plus it's not just the PBMs. I mean, the. And I know more about the pharmacy supply chain than anything else in the healthcare supply chain is much less OPEC.

And there's only fewer in between like sort of like people who have their hands in the cookie jar. The 

Mike Koelzer: health care supply is not as opaque. 

Robert Popovian, PharmD: It's, it's not as opaque. And there's fewer in between people like what we have in the pharmacy business. As 

Mike Koelzer: in caring for someone who's sick in the hospital, or 

Robert Popovian, PharmD: like physicians or hospitals services versus pharmacy has so many Go-Betweens, it's like between the pharmaceutical industry and the patient, you know, you have all these entities within the supply chain that make money off of the supply chain, you know?

And, uh, I can name you at least half a dozen right off the top of my head. I mean, you're talking about pharmacy benefit management companies and insurers number one and two problems. Right. Then you have. Which makes money. Do you have academicians? And, uh, you know, you have wholesalers and you have consultants and, uh, you know, benefits, consultants and things like that, that their reimbursement is tied to like how much rebate contracting is done and everything else.

So it's all these people that make money off of this supply chain that are sort of in go-between that provide very little, if any value to it. You know? I mean, I'll give you an example. I was just on a, on another podcast and they asked me, they said, what do you think of pharmacy benefit manager company?

I said, well, I know what pharmacists do, what value they bring to the system? I know what physicians value. They bring to the system, nurses, Optum, optometrists, dentists, hospitals. Tell me what is the benefit that the pharmacy offers to the management company? What is the value? Is it saving money? Well, clearly we've shown that they're probably making more money off of it than saving money to the system.

So they're to the enigma, basically that we're like, sort of like we can't get rid of 

Mike Koelzer: what's that word, you mentioned academician academicians is 

Robert Popovian, PharmD: individuals like professors and everything else that we're working on. 

Mike Koelzer: They're part of that buffer. Sure, 

Robert Popovian, PharmD: sure. Because as pharma companies go into more rare diseases, the development of a rare disease, drugs, and everything else, you're not talking about, you know, there's individuals in this country that specialize in that.

So when they have the patient population with these rare diseases that you need for doing your clinical trials, guess what they're going to do? They're going to say, well, the clinical trial is no longer going to be thousand dollars per head. It's going to be $10,000 per head because I control these patients.

They also make money off of the supply chain. 

Mike Koelzer: In my mind, I'm always thinking that the heads, the scientists and things doing these are more employed by the manufacturing company. 

Robert Popovian, PharmD: No, this is not true. Actually, the way that research works. They have medical directors at PhDs and everything else that does too. They do some of the research and basic research and development.

But the clinical trial, when it comes down to doing trials, pharma companies don't do clinical trials. They contract out that service to help people like Mayo clinic, Cleveland clinic, individual physicians, who, and pharmacists that do those research, PhDs that do the research. Pharma companies are not enrolling patients in clinical problems.

They have a hand in the development of the protocol and everything else and the way the protocols are set up. But then they hand that out to contract research organizations and those contract research organizations. Then they contract out with different academics, different clinicians, different pharmacists, physicians, things like that to do the actual.

Mike Koelzer: You, and I have talked before about you being in the blockchain industry and so on, and that comes into play here somehow. Right? Keeping track of all these patients and all this research that's going on, especially the clinical research. Yeah. 

Robert Popovian, PharmD: So it's a great point. So I work with it. Could we deem help, which is a blockchain technology, AI, uh, federated learning group.

And one of the areas that it's working on is decentralized clinical trials. Why is decentralized clinical trials important is because imagine [00:40:00] me as a patient sitting in North Dakota and I have a rare disease, but there's only like three sites that are doing the research. And one of the sides, the closest site to me, is in Austin, Texas.

I'm not going to get on a plane. And go to Austin, Texas, and enroll myself, but I need that help. I need that as a patient, I qualify for this trial. So we need to have this centralized clinical trial where the patient can be somewhere different while they can enroll in a clinical trial being done somewhere else.

But why has blockchain come into this place? Because blockchain is inherently is needed for security of data, because the worst thing you can do, if you don't have centralized clinical trial, where you have the patient coming in, being monitored at the site and everything else in the data collected is that if they're sitting in another state or decentralized from the clinical setting, you're going to have to make certain that the data that's been collected is clean and is usable right at the end of the day.

And that's where blockchain comes in because inherently what blockchain does is secure data, you know, and make sure that it's not manipulated. Can you imagine now, um, again, I'm sitting in North Dakota and the clinical trial was being done in. And I'm part of a decentralized clinical trial. I need to go, for example, give laptops.

I have to provide some like my, uh, vitals have reason to be taken and everything else. You want to have a certainty that that data is not going to be manipulated or changed or any mistakes are made. So that's where blockchain comes into play is security of data to be able to be transported. 

Mike Koelzer: Are people ever disrupting that data on purpose and does blockchain help them?

That is just, it's just 

Robert Popovian, PharmD: accidental. It's accidental. I mean, it happens right. A decimal point means being moved and you know, you may not know why it was moved, but as a blockchain, you secure the data to make sure that it's not being manipulated unnecessarily because you need certainty of data. Right? At the end of the day, the most important thing is that as a pharmaceutical industry, as a clinician, who's doing clinical trials, you want to make sure that the data is correct because you're going to be applied for, uh, you know, approved.

Or get the patients to use it. You want to have certainty with that data. 

Mike Koelzer: I've heard of blockchain obviously for money. And then I've heard of it even for people that have solar panels on their house, you know, they can now sell bits of energy to their neighbor, even in stuff. And you can follow it through all this.

For 

Robert Popovian, PharmD: For example, financials have been using block technology, blockchain technology for a long time. It's been very well established. Why? Because you need certainty of this money moving around. You don't want it to be manipulated. Same thing with energy. You want to have certainty that the energy units are being appropriately, uh, utilized and moved around.

And same thing with data when it comes to clinical trials. But it's not just for clinical trials. That blockchain is being used now, or is being thought about being used, especially for decentralized clinical trials, because you don't have the patient physically there. Right as a site, but it's also being used for research and development between pharma companies.

Because as they collaborate, they want to have the data being pristine among the different entities that are collaborating to do the research. 

Mike Koelzer: Look, if blockchain didn't exist, if I was in charge of it, I'd be like, all right, everybody at least uses the same damn database. You know, let's all use the same columns or something.

And I know people don't even do that. So I can just see the value of blockchain. Yeah. We mentioned finance, energy and health. What are some other cool areas of blockchain right now? 

Robert Popovian, PharmD: Well, pharmacy actually in pharmaceuticals as being used for track and trace for inventory utilization, because remember you need to attract these drugs going in.

So blockchain technology is being used for that. Currently it's being used for reconciliation and things like that. When you have products being returned to make sure that the product has not been corrupted and manipulated. So technology is actually currently being used by the pharmaceutical industry.

And you know, this, you own a pharmacy, you know, when you have to send inventory back because of expired and everything else, you need to sort of keep track of these things. Uh, now these days, so that's where the technology is really being used, but the future, the near future is in clinical trials and research and development.

And long-term. Is in these new payment models that we're talking about, whether it's, you know, value-based contracting optimization contracting, when you start exchanging money and data, to be able to do you need certainty on that information. And that's where blockchain comes in. 

Mike Koelzer: I had a guest on and they were saying, look, we're never going to get rid of PBMs.

You're always going to need some bigger organization. That's going to be the one. Funnels the money back and forth and all this, you want to transparent, but you're always going to need this, but here's a question I hear a lot of whenever I'm on my dark [00:45:00] web conspiracy theory websites, I always, I always hear about, I always hear about people talking about, well, you hear it all the time.

I'm joking, but they want the Bitcoins and the blockchains to get the banks out of the middle of it. You know, you don't want the U S bank in the middle. You just want to verify data at a non-centralized banking thing. Is that ever a way to get rid of the PBMs? I mean, could this be so good that you would like easier payments and then not have this payment, but hemophilia and the middle.

Robert Popovian, PharmD: So I've given up on getting rid of PBMs. I don't think they're going anywhere, but what we need is transparency in the market for them, two things. Number one, transparent, be a hundred percent transparent. So that's where the flow. You know, and that comes in. One of the things that I've advocated the last few months is that audit rights employers and the federal government and the state government should have audit rights of the PBM books.

They don't have that. Uh, if you look at a lot of the policy decisions that federal government is proposing with changes in drug pricing and drug price, negotiation, and everything else, a lot of the reports that we're using to justify these policy positions are based on not only outdated data, they're using like 2016 data to make decisions on 22 and beyond policies, which is like you basing your household budget based on what you were making in 1985, 

Mike Koelzer: probably more back 

Robert Popovian, PharmD: then.

Exactly. Your net play was higher. Uh, you know, but my point is that you can't do that. So the federal government is the biggest, uh, like that they don't have access to the audit rights is mind-boggling to me because. Basically, they paid for the most pharmaceuticals in this country. So they don't have other prices; they're using outdated data.

But then when you start looking into these records whether they come from the congressional staff or they come from the CVO, you quickly realize that all their assumptions are based on some PBM. Executive said, oh, we pass back 95% of the rebates back. And there's no way you can audit them because you don't have OD requites.

So in other words, I've given up getting rid of PBMs. If we're going to continue doing the corrupt rebate contracting, which to me is extremely corrupt and increased, missing misaligned incentives in the market. At least the federal government and employers should have audit rights of the. And we should have complete transparency of where the flow of money though, is 

that 

Mike Koelzer: unprecedented to them not having audit rights there are there other industries that you could say, well, yeah, but look at the, you know, the X, Y, Z industry, you can't see those, or is this like an oddity that PBMs are keeping the government?

I'm not sure 

Robert Popovian, PharmD: if it's an oddity, but it is the one area that impacts everyday patients, right? Because of the lack of these audit rights and transparency, when you're forced by patients to have a coinsurance or deductible to pay based on an inflated retail price, you know, when they have those two entities in their insurance market, then patients should have a right.

They should know what's going on. And I'm sure it's not unprecedented that the government doesn't have all Detroit since other parts of the economy or purchasing that they purchase. But this impacts patients directly because a patient who walks into a pharmacy and has a core insurance deductible today is paying based on inflated, retail price.

And that's 

Mike Koelzer: not right. Here's the shameful thing I think about PBMs and the opaqueness is that I'm a patient. I walked into a pharmacy and somehow I got screwed. You know, I have to pay more money. There's a clawback or whatever. The thing is where I'm getting screwed. I don't really know I'm getting screwed.

My employer has enough going on, you know, 500 employee businesses in town. They don't really care if I'm getting screwed because they don't know. I'm not going to probably quit to find a different insurance somewhere else, because I know when the new year comes around, they might even switch insurances.

Anyways, if I try to find an insurance where some employer covers that insurance, it's like this never even gets back to the purchaser of the insurance for most people. And then it did. Then you got the brokers coming and saying, well, okay, we'll give you a discount. Well, they weren't told that the discounts off of an obscure AWP, it's just, there's so many levels in it's sad because it's the patient that's getting hurt, but no one knows.

Robert Popovian, PharmD: No one knows. And it's really, I don't blame the employers because they are not aware of it. And I talked to them when I talked to employers and finally, I actually wrote a paper last year. That's 12 steps. Employers can get. To protect their employee benefits from [00:50:00] pharmaceuticals and Northeast business group on health asked me to come and talk about the paper because they found it compelling enough.

And there's like simple 12th steps that you can take as an employer to really protect ourselves. But it requires work. And what PBMs are banking on is apathy. Yes. You know, as an employee, your job is to create a business model that makes money based on what you're trying to sell, or, you know, create not to develop healthcare benefits, right?

Healthcare benefits as something that you provide, because you want to, because you want to have a healthy work workforce and everything else. So they bank the PBMs and the insurance bank on apathy, they bank on, uh, not you not having the time to do so. And then they basically bank on brokers, do their selling for them.

That's why I always recommend it, like with. Employers, smaller employers hire consultants because there are these consultants out there that actually will tell you that they guarantee savings. When they go through your benefits. 

Mike Koelzer: As an employer, I asked my insurance person last year, I said, because they're always increasing, right.

So I said, and they give you like four or five plans to compare. I said, can you run my last year's claims through this year? Pretend like we're repeating this year, but with the new structure, the new price thing. And can you tell me how I came out or like, no, we don't have that function. And I said, all right, well, let's say that I'm going to have the same this year.

You know, I tried to word it some way. They're like, no, we don't have that function. It's like, so then I have to go to my son and say, Hey, can you, I can't figure this out. Give me some scenarios. He was like, well, if, if so-and-so does this and gets this medicine and so on, we'll get this. Took him to give it to me.

And then I barely understood it. You know, even though I'm supposed to understand stuff like that, and it's crazy, it's all on purpose to, 

Robert Popovian, PharmD: yeah, it's all purpose. They make it difficult. They make it very complicated. The more difficult and complicated you make the system, people are just going to throw up their hands and walk away, right.

And say, you know what? Fine, you're going to increase my prices by temper. Like my premiums are only going up by 5%. I'm happy. The reality is your premium should have probably gone down by 5%, but they're banking on your apathy. I'll give you one perfect example. So, um, PBS will always tell you they have these national formulas, right?

That they sell employers all the time. And, but in the clause that says, well, as an employer, you have the right to pick and choose. You can change the formulary. It's up to you. You know, we're just, this is a recommendation from. The reality is that 99.9% of employers will never change that because as soon as you start messing around with it, first of all, you have to take the time to mess around with it.

But secondly, to be around, so, oh yeah, by the way, your premiums, in case you're making any changes, are going to go up by 20%. So what are you going to do? Forget it. I'm just going to walk away and take whatever's on this. 

Mike Koelzer: My dad used to complain to me before we built our house. He complained to me. He said, Mike, I hated dealing with the builders because when you told them that you wanted to take one of the windows out, they'd say, okay, uh, that'll save you 200 bucks.

And then you say, okay, well I want to put the window though. The one I took out and saved 200 on, I want to put that over there, down the wall. They're like, that's going to cost you a thousand

Robert Popovian, PharmD: bucks. Yeah, exactly. So that's why people have a tendency for PBMs to come out and use words like that. Like people have choice and people can make like the best example I hear from PBMs as well. Physicians have access to any prescription that they want to write as long as they have to go through a prior authorization system.

Right. But they make the prioritization system so complicated. A physician, like, are you kidding me? I'm not going to spend five hours going through this. And they. 

Mike Koelzer: A previous guest of mine was saying how some of the smarter minds he knows worked for PBMs. And I'm like, how do you know? They're smart though?

I said, what do you mean? You think they're smart? And he said, well, when we both know the same information, we both had the same input. They seem to do a real good job of capturing that and kind of spitting it back and see in the big picture, understanding it, all these people come into a PBM, they use those skills to find the best ways to connive, to make it as a Pake as they can, what an ironic situation.

Robert Popovian, PharmD: Yeah. But we let them do it right. I mean, we're basically allowing them to do it. I'll give you an example of the federal government, federal government through the sunshine law and you and I are healthcare professionals. If, uh, if, uh, if a pharma company buys us a cup of coffee, they have to report that right.

A $5 cup of coffee. They're okay with that. And they were okay with collecting all that information and [00:55:00] putting the burden, but they don't want any transparency on how much rebates are being collected or how much fees and concessions are being given and how much is flowing back. So it's, we're letting them get away with this.

Uh, and it's, it's gotten worse because with two of these vertical integrations, more opacity has been produced into the market. They can hide money. I mean, I always get a laugh out of research that comes out and says, the majority of rebates go to, uh, that are collected. Actually pharmacies are the ones that benefit from it, but you have to step back almost a hundred percent of rebate contracting, almost a hundred percent of it.

There's some exceptions coming through specialty drugs, right. Or whatever's considered a specialty drug who dispenses specialty drugs in this United States. 80% of the market is the PBMs and the insured, the integrated market. Right. So yeah, technically it goes to the PBM pharmacy. And it's controlled by the pharmacy dollars.

Right. But the reality is the PBM really. So it's all a matter of optics, you know, it's, uh, we've had a lot of this happen as, uh, policy makers have been asleep at the wheel and they're not willing to do anything about it. That's the problem. We 

Mike Koelzer: know that PBMs and the insurance companies want this stuff opaque.

Are there other players that wanted opaque to some of the politicians wanted opaque because they're staying elected because of all the backhanded stuff in Washington, are the politicians benefiting from this being opaque still because of the big money in the elections and things like that. It's not just confusion, right?

Because even something confusing, it seems like if people really wanted to understand that they could, I got to think there's, there's a ton of money in this that has spread out from the PBMs and the insurers to other people who say, let's keep it opaque. 

Robert Popovian, PharmD: Let's be honest, the campaigns cost money and politicians are no different than anybody else that they need the money to run these campaigns.

But overall, I think that's not the major influencer is the major influencers because it's a complicated system intentionally made to be complicated because the way I look at it is that even individuals who are not influenced by politics or campaigns and things like that, like CBO or HHS, that these are appointees, these are staffers that are government employers, employees.

Why are they calling out these things? You know, so that's what tells me there's more about apathy, more about they bought into the arguments rather than the money and the politics of the issue that is sort of evolving. In my opinion, if, if, if it was true, it would be all the policymakers that would be opposed to it.

But the reality is staffers within CBO who should know about. R as complacent and as compliant with this whole market moving the way it is. What's 

Mike Koelzer: a cool way that you look to the next week and say, hi, I feel kinda good 

about 

Robert Popovian, PharmD: that. So it's finishing a research project, getting a publication done, uh, thinking about a new research project that can move the, move it forward.

Hearing news, like the FTC is going to actually ask for public comments about investigating insurance or PBS news. Like that brings me out, which is a no go, right? Well, not necessarily. So yes, there was a vote on the FTC level with regards to doing a formal investigation, but FTC now, after that vote didn't happen because it was a two, two tie.

So two Republicans voted against the two Democrats voted for. And it didn't go anywhere. FTC now has announced that they're looking for public comments about looking into the issue of PBM. So it's a little bit different than a formal investigation. So they're looking for public comments. So people are going to have the ability public is going to have the ability to comment about the PBM contracting models and things like that.

So those are the types of things that I get excited about. And then the other thing is that as I see the profession and the pharmacy profession moving forward, as they do things to really make the changes that we need. Because look in this business, since I was in pharmacy school, everybody told me that mail order was going to take over the world.

You know, that's not true. You see all these ads about mail order pharmacies and everything else. One thing you notice is that there are no old people, it's all the young people getting there, whatever they're getting through mail order, you know, their prescription. I'm fine with that. That's not the population that pharmacists really need to intervene with that are looking for help from pharmacists is the chronic disease patients who are elderly, who are using multiple therapies.

And to this day, I can show you data that shows when patients get sick. They don't want mail order to actually want to walk into a pharmacy and see a pharmacist. And we need to take that to [01:00:00] heart and start putting our big boy pants on as an, as a profession and start advocating for being able to become truly practice on top of our license, you know, because that will help patients that will help other health care professionals because they don't have to do that work.

And it will help most, mostly our society because. We know we have better access to pharmacists than any other healthcare professional in this country. It was proven even more during the pandemic. Now we just need to take that information and be, not be able to be scared about talking about it and promoting it.

And that's another thing, you know, you and I are pharmacists. Pharmacists are not self promoters in general, most healthcare professionals aren't, they're not self promoters. And that's something that bothers me. And I believe that there's a need for self promotion. There's a need for every pharmacy sufficient to have the slogan that during the pandemic, we were the only ones standing up.

And the only one that patients had access to during the community period and the story, I don't want to hear any excuses. Are 

Mike Koelzer: Are you at your computer? Are you on the phone? Are you at home versus traveling? Where's your most powerful? 

Robert Popovian, PharmD: It's talking to people who are giving me ideas or talking to them when to convince them that this is a new 

Mike Koelzer: model.

You're getting the most done by verbally talking to people 

Robert Popovian, PharmD: you have to, because I don't think this is something you can write about. You can do social media, you can push it, but you still have to come talk and convince, because these are not simple things. These are not two sentence answers. I've never walked out of a meeting with a policy maker or anybody who is a doubter about the market.

If I had half an hour with them and I can just sit down and explain to them how that works, I'd never walk out of a meeting without being convinced that it needs to change. The problem is everybody wants an elevator speech that is not an elevator speech issue. It's too complex. 

Mike Koelzer: I love the long podcast format, because when local news comes either want a positive comment or a negative comment, you know, you're never just like discussing it, you know?

And they're just complicated. They're complicated things. Well, Robert boy, good to see you again. That 

Robert Popovian, PharmD: was fun. It was fun. I really enjoyed it. Yeah. We'll have to set up 

Mike Koelzer: an annual and we'll get another topic 

Robert Popovian, PharmD: going. Hopefully I'll get some hate mail.

Mike Koelzer: How's your podcast going by the way, it's going 

Robert Popovian, PharmD: well. I mean, we had the best week last week. Great. So it's going well. I mean, it's short, it's 15 minutes. We get into one topic, a policy topic. As a patient we're very patient focused. Some of them are complicated. Some are easier to digest. The one thing I don't like 

Mike Koelzer: So much about podcasting is that there's not a real great back and forth.

Like you would get with social, you know, it's like people listened to it and then like they can go to social and talk to you, but what often they don't. But the thing I like about podcasting is that nobody else knows your numbers, which I like, I just like to compete against myself. And I don't really want everybody to see how much of this I have.

It keeps me doing it for a personal goal and not trying to move up a rank kind of thing. 

Robert Popovian, PharmD: Even when you write something like an opinion, editorial and things like that. And I do that too, but podcasting is much more real time, right? Because by the time we write something, it was through the meat grinder of the editor and everything else.

By the time it comes out on the other end, this party, five other issues versus a podcast, you can think of something and you do a podcast on it tomorrow. And talk about it more. I got to do 

Mike Koelzer: It's real time, just so I can remember what I'm thinking about. 

Robert Popovian, PharmD: Exactly. Excellent. Robert, good to see ya. Have a good week.

All right. Take care.