Exposing the Hidden Costs Behind Prescriptions | Pramod John, VIVIO Health

Transcript Disclaimer: This transcript is generated using speech-to-text technology and contains multiple spelling errors and inaccuracies. It is only intended to capture the essence of the conversation.

[00:00:15] Mike Koelzer, Host: Pramod, for those that haven't come across you online, introduce yourself and tell our listeners what we're talking about today.

[00:00:23] Pramod John: My name is Pramod John. I'm the c e o of Video Health we were started in 2016, and our focus is [00:00:30] on this question of, Hey, why do these drugs cost so much? Why do they seem like they aren't necessarily helping all the people that we're paying all of these high prices for?

[00:00:40] Mike Koelzer, Host: Promote, we gotta start here. One of my sons just [00:00:45] graduated from mechanical engineering. And when we were at his graduation, there were some people there in electrical engineering. And Brian said those are the smart guys. He said, the ones that go into [00:01:00] electrical are smarter than us, mechanical ones.

Now, I don't know if that's true, but you're an electrical engineer.

[00:01:06] Pramod John: That's correct. I'm not gonna make a claim of being smarter than anybody I know some very bright mechanical engineers that are extremely smart, [00:01:15] so

[00:01:15] Mike Koelzer, Host: You're not biting on that one. I'll tell Brian that. He'll enjoy that. Pramod Electrical engineer. Does that also have to do with the computer coding and that kind of stuff, or is it truly just the electrical, the [00:01:30] circuits and all that kind of stuff?

[00:01:32] Pramod John: Yeah, no, electrical engineering is very broad. It has very little to do with that tradition, where it started out being electricity, for example, and magnetism, those types of things. And so my background was mostly doing a lot of computational [00:01:45] work. For example, I did work in some basic physics, physical chemistry, so it could be all over the place in optics.

So I've done work in all of those spaces, and so today it's a very broad space. It could include everything from basic sciences in some cases, to designing [00:02:00] computers, computer engineering, designing semiconductors, all of those things generally fall into aspects of double E nowadays.

[00:02:07] Mike Koelzer, Host: How'd you end up then in the pharmacy field from that?

[00:02:10] Pramod John: I didn't start out there. I started out in the computer security space. So I did a few [00:02:15] ventures in the computer security space. And after those were sold, I felt that, going back to your question about smart or not smart, my issue was always that we, especially, I live in Silicon Valley and we seem to work on a lot of problems that [00:02:30] make people a lot of money. But those don't seem to be the problems that really drive the biggest problems that we have in society. For example, education, healthcare, government, these types of big systems problems aren't the ones that we're focused on. And so after [00:02:45] I, after being in the computer security space, I decided that healthcare was our biggest national social problem affecting our economy.

And I wanted to do something about changing the healthcare system. And that's how I ended up going into healthcare. And I started out my career in healthcare at a company called McKesson, [00:03:00] which is one of the largest healthcare companies in the world. And it was one of those fascinating experiences.

'cause I went in with a lot of people who go into healthcare, especially as outsiders, thinking I know all about software and everything else. This is gonna be an easy thing. They just need more software, computers and technology. It's gonna [00:03:15] fix all their problems. And of course that's a very shortsighted and uneducated opinion.

And, working at McKesson was one of those experiences of the, everything you thought about the way the healthcare system worked was wrong. Type of experience. And it was how money [00:03:30] flows and how the system works. It's not a technology problem. It's this, it's how these large scale systems work and how money and the economics behind these systems are ultimately what drive what they do.

Our healthcare system doesn't have a lack of [00:03:45] technology. It's not a technology problem, it's not a, we just need smarter people from Silicon Valley. It's not one of those problems. It's a problem in which there are billions and trillions of dollars moving on a, on a monthly, quarterly basis.

 And as a result, there [00:04:00] are a lot of very interesting parties when I started out in healthcare. When I got into space, it was about two and a half trillion bucks.

Now we're almost four and a half trillion. And everybody thought that we could never make it past two and a half trillion.

And now we're not even blinking at two and a half trillion at about [00:04:15] 20% of GDP.

And so there's this whole sense in which At some point, it's almost like we don't even care anymore because it's so big we don't understand what we can do. And of course, the people who sell healthcare are all like, Hey, we're doing a great job.

We can't [00:04:30] really do any better. And the people who pay for healthcare are perennially asking the questions of Why do we pay so much for all this stuff? And why are our metrics so much worse than the rest of the world? Here's a crazy factoid for you. The United States represents [00:04:45] 4% of the world's population, 

if you look at our population divided by the total we're 4%. So I never realized how small we were. We're only 4% of the world's population. Do you know that we spend as much on drugs [00:05:00] as the rest of the world combined?

96% of the world's population pays exactly the same amount as we Americans do, representing only 4% of the world's population.

We're not living longer. We don't have [00:05:15] better outcomes. Our life expectancy has dropped post covid, opioid addiction, all those things that have happened that have been a result of drugs. As a matter of fact, unfortunately. But as a result of that same industry, we've seen in many ways, our life expectancy actually drop, not catching up.

[00:05:30] The, with the rest of the world, there're underdeveloped or third world countries that have higher life expectancies than the United States does, and we spend as much as all those countries put together in the world.

[00:05:40] Mike Koelzer, Host: A lot of people would hear that number [00:05:45] and say, that's crazy. We can do better than that. There's a handful of people, though, that hear that number and they say, we wish we were 97% of the healthcare costs, because that's what helps our bottom line.[00:06:00] What kind of people are saying that? Who does that 96% help the most? And I gotta just think offhand it's people that enjoy the arbitrage of higher costs. Some PBMs, some politicians [00:06:15] getting their palms greased, drug manufacturers, hospitals that maybe get more money, the more transplants they do, and so on.

Who wants to keep that number up?

[00:06:28] Pramod John: The healthcare industry. Look, if [00:06:30] it's 20% of G D P, if you were just look at our G D P and on a good day, the estimates are the number of people who work in the healthcare industry are about four to 5% or less of the US population, so if you go back and look at that means 95% of the US [00:06:45] population is actually consolidating dollars , that move to pay the 5% of the US population.

And so imagine you're the average median income earner in the United States. You have the privilege of working [00:07:00] two times, one or more minimum wage jobs just so that you can hit. Median income in this country. So you can make sure that your kids have food on the table. They have the basic necessities in life.

Look, median income, we're not talking about [00:07:15] people who are living well in this country. We're not talking about the middle class. And that's where the median income is. But if you look at where those dollars are coming from, it's dollars that those people should have had to be able to spend on the things that they want to, versus being forced to spend it on healthcare or their [00:07:30] employers forced to spend 20 grand, 26 grand per family a year on healthcare.

Compared to a 50 grand a year median salary in this country. You can make a strong argument that investment in healthcare actually drives up the cost of healthcare

too. 

[00:07:45] Because if you look at a lot of the investments that are coming out, private equity and others that are investing in healthcare, remember that pod is growing, which is why everybody's investing, nobody's investing in solutions that actually take dollars out of the healthcare system.

And pretty much every business model is based on [00:08:00] how do I move dollars from someone else's pocket into my own whether that's another healthcare company's pocket into my own, or it's the consumer's pocket into my own versus, hey, healthcare is a public trust, unlike many other things it's the public that pays for [00:08:15] healthcare.

If you're in a self-insured employer, your pooled funds pay for the employee sitting next to you. If you're fully insured, your funds are actually paying for the person who is next to

And so these are all public funds that are being used. And today, there is no sense in which we have a [00:08:30] public responsibility around healthcare because it's a public trust.

Rather, we treat healthcare as a public trust fund, that we can help ourselves do is really the way that it works today.

[00:08:39] Mike Koelzer, Host: And I know Pramod, that your company, and we don't see this a lot, especially in the heading, but your company is in [00:08:45] a public benefit corporation. Tell me the genesis of that. Was that from the start and why that versus a regular C corp?

[00:08:57] Pramod John: Yeah, I mean we, we originally incorporated as a C corp [00:09:00] and that was largely because there were still some questions about this public benefit status. Most states don't have such a thing as a public benefit corporation. Delaware, just not too long ago, actually put into place a Delaware Public Benefit Corporation.

A lot of companies, for a lot of [00:09:15] reasons are headquartered out of Delaware as we are. And so the Public Benefit Corporation piece was very important, because it reflects who we are as a company and what we set out to do. 'cause our mission is to take dollars out of the healthcare system.

So the way [00:09:30] we measure our is how many dollars have we taken out of the healthcare system? And, one of the biggest problems that we have is that this is about money. And money is really about business models, it's about how do you make money? For example, if someone [00:09:45] comes and cuts my lawn, It's pretty clear on what the exchange is.

I pay the person, he cuts or she cuts my lawn, I'm happy. I pay somebody. There aren't any intermediaries involved. Or if it's a company that I hire, for example, they pay their employees, and [00:10:00] it's a very clear arbitrage on what we pay for, what we get outta the equation And not only that, if I want to pay more, I expect more. If he asks me for more money, it's gotta be that he has a legitimate reason or he has to do more work. He can't just come up to me or she can't come up to me and say, I [00:10:15] just want you to pay me more.

And you're like, why? But in healthcare, that's not the way that it works in healthcare, if you look at the way the system works today, almost everyone makes more money when prices go up and when more people [00:10:30] use more healthcare, I. As a result, if you have a business model in which you make more money by people consuming more, then I want people to consume more.

It doesn't necessarily have to be good or better or anything. It just consumes more. And in the same way, when you've got a lot of intermediaries, health plans, PBMs, [00:10:45] just a list goes on and on, even providers, I was talking to somebody who was a physician last week. And if you look at what's happening physicians used to be able to be an entity that could exist on their own, have a decent business, and none of them were making billions of dollars, 

[00:11:00] they made decent money. But decent money is compared to other, professions, they're not making a bazillion dollars compared to their neighbors,

 And today it's very hard for a physician to be independent. That almost all the physician practices are being bought up by larger and larger systems.[00:11:15] 

And remember, the physicians aren't necessarily making more money when this happens. Often, they're actually making less money when this happens. But our cost of healthcare still is going up. As the people who actually provide healthcare services are paid less, we go in and crank down. [00:11:30] For example, imagine you're a rheumatologist.

You get paid a hundred bucks for a visit, and you barely have five minutes or seven minutes to talk to somebody because your reimbursements have been cut down so much, but the drugs they prescribe have gone up from being, 10 or [00:11:45] $15,000 a year to 60, 70, $80,000 a year. Nobody's complaining about that, but everybody thinks that doctors make too much money.

We need to crank it down from a hundred bucks to 95 next year [00:12:00] and we're trying to save $5, $10 on the people who actually do the work. And the solutions that are in intermediaries have nothing to do with it. We're fine with them charging more and more.

[00:12:11] Mike Koelzer, Host: Pramod, when I think about [00:12:15] some of the people, as you talk about the money conversation going on, it always makes me think of like a. Car lot where you can put the lipstick on [00:12:30] the pig however you want to by saying the new model is, a bigger rebate and you're getting this invoice thing done and this warranty and this many features and so on. Though, through all that, you're not gonna walk out two [00:12:45] years later, less expensive than you were two years earlier. And when I think of all the money flying through the medical system, all these talk about costs and rebates and the vertical [00:13:00] integration is gonna save such and such it's like when it gets down to the end of it, you can talk it all you want.

But I think the key is what are we individuals? Offering up in payment, how much of [00:13:15] our paycheck is going to health and is Grandma doing a little bit better that we can take her to the zoo, or is the overall death rate going down? Those kinds of things. And you [00:13:30] can paint it any way you want to, but I think the truth of the matter is, and I know your company touches on this, what does it mean to really decrease the cost?

And it's easy to decrease the cost just by removing services, but what does [00:13:45] really mean to decrease the cost but have an enjoyable life on the other side of it?

[00:13:51] Pramod John: Why Do we pay for healthcare at all, We pay for healthcare because we wanna improve quality of life, like for grandma, to go back to your example, or grandma or any of [00:14:00] us, 

How do we improve our quality of life and how do we improve our life expectancy?

Those are the two reasons why we pay for healthcare. If we didn't need to do that, then we wouldn't need to pay for healthcare. And so if we're to go back and ask, then how should healthcare be measured? It has to be measured [00:14:15] on how it is improving our quality of life and our life expectancy, Because that's why we pay for healthcare. And today, for some odd reason, so much of healthcare, there is no tie. To the question of how has that improved my quality of [00:14:30] life or that patient's quality of life, or how has that improved their life expectancy? We have drugs that come out today, which show zero benefit.

We're not talking about some marginal benefit that we can't figure out. We have drugs that have been approved, like [00:14:45] the Alzheimer's drug last year, agile? there was zero evidence of any benefit. It was a surrogate endpoint that this drug showed that it improved and there was no correlation on that surrogate endpoint on whether it actually improved your quality of life or your life [00:15:00] expectancy.

And we were gonna be paying billions of dollars for this drug. And the argument for why it should be approved was that hope is better than nothing.

Okay. And that would be like going back to your car, for example, that all of [00:15:15] us in America would be happy paying for cars that don't run. And we would justify to ourselves, 'cause we have a car that won't start.

And we went and paid full freight for that, saying that in one day we might have a car that runs, therefore let's pay for cars that don't run and fill our [00:15:30] garages with them. Now, you're laughing, I'm laughing. Everyone in America would look at them and say, that's the dumbest thing I've ever heard of.

Who would do something that stupid? Because that clearly is stupid and it's a joke, but in healthcare, for some reason, we pay billions of dollars for things that don't work. [00:15:45] And we know that they don't work.

And not only do we know that they don't work on the AAL case, The majority of the committee, the F D A committee quit the physicians on it saying, this was the stupidest thing we've ever heard of.

Because I forgot to mention another thing. If you look at side [00:16:00] effects, remember there's no zero sum game or it's not free when you take a lot of these drugs. It's the side effect cost that nobody's factoring in. Also, 'cause technically you should have to weigh the benefit minus the side effects. Guess what?

None of our models do that. [00:16:15] In this case, about 30% of the people on the drug had severe side effects, including brain bleeds. And we approved that drug with no benefit whatsoever. And by the way, that story is not singular. I can give you example after example.

Primarily [00:16:30] oncology drugs that have been approved, that have shown no benefit. We're not talking about it, give you 30 days of life or none of those questions we're talking about. None whatsoever, we have drugs. Not only that, about a year and a half ago, G A O came out with a study.

Was talking about [00:16:45] drugs that have gotten accelerated approvals. And these were all oncology drugs. So accelerated approval basically means, hey, to show some kind of promise, We're not really quite sure whether it does anything useful, but we're gonna prove it anyway. So we all get to pay billions of dollars on an experiment, And in this [00:17:00] case just Medicare alone, if I remember my numbers correctly, it was something like $18 billion is what they spent over three years on drugs that failed in all confirmatory trials in the future. So these were drugs [00:17:15] that were approved saying, Hey, they may do something. And then there was never a confirmatory trial or a negative confirmatory trial, which proved the drug did nothing.

And just on those drugs alone, just Medicare alone spent $18 billion in three years.

[00:17:29] Mike Koelzer, Host: Pramod. Let's go [00:17:30] back to the example of the Alzheimer's drug, and let's say you're in charge of the fdA or whatever. let's Say you've just taken charge of that over this quitting of the members of the [00:17:45] board.

What are you changing and what happened there in the most blunt words, what happened on that board and what are you gonna do to change that?[00:18:00] 

[00:18:00] Pramod John: So number one, let's go back to why does the F D A work in the way that it does? And so it turns out it's also a business model problem. And the business model starts with a lot of, you've probably heard this before about a lot [00:18:15] of our regulatory agencies and how they work. About half the funding for the F D A comes from fees that are paid for by pharma.

Okay. So who's your real customer here? It's pharma. It's not the American people.

[00:18:26] Mike Koelzer, Host: Are there shenanigans going on like, if I do a favor for [00:18:30] pharma, they are going to pay me more fees? 

[00:18:32] Pramod John: It's actually a really good question that you're asking, but it's slightly different. It is that, take a look at most of the people who worked at the F D A. Look at what their next stop is when they leave the f

d a. Okay? [00:18:45] And Scott Gottlieb lost no time at all before ending up at, on the board of Pfizer,

 And so you look at that and that almost all of these folks end up going into industry. You can't piss off the hand that feeds you, and ultimately it's not about [00:19:00] wherever they're there. It's about how they get extremely high paying jobs in lobbies and in pharma, the day that you leave the f d a.

And that's what happens. And all the pharma companies hire you because your job in life is to figure out how to get around the F

D A now. 

[00:19:14] Mike Koelzer, Host: Primo? Is that what [00:19:15] happened on the Alzheimer thing? Is it that simple? That the people that remained on it had their future investment, they were looking into what else was 

there for this 

[00:19:26] Pramod John: unfortunately the story doesn't end there. If you remember [00:19:30] a few weeks ago, there was a new drug that was approved by the committees inside the F D A that did the statistical analysis on this. A l s drug from Sarepta Pharmaceuticals all said that there was no evidence that this drug did anything.[00:19:45] 

And the person who heads up that division with the F D A, along with everyone on his own teams arguing that this drug showed no benefit, approved it

with all of their disapproval, and this person has a [00:20:00] record of the only other time he also went against every committee and approved. It was also for another Sarepta Pharmaceuticals drug earlier.

You ask how in our process can this type of thing occur Because the people who are the [00:20:15] regulators or in government are supposed to be economically disinterested, people who ultimately represent the American people, not business interests within the country.

[00:20:26] Mike Koelzer, Host: What's the answer to that question? Why is it happening?

[00:20:29] Pramod John: [00:20:30] Because we allow it to happen and our system works that way. Our system doesn't have a restriction that says, Hey, you can't go work in that industry

was gonna say

[00:20:39] Mike Koelzer, Host: that it'd have to be Like a lifetime non-compete kind of thing.

[00:20:43] Pramod John: Exactly. It's got to be where [00:20:45] you can't have an economic interest, or they need to bring in people who are dispassionate, who have no economic interest in the industry. 

[00:20:51] Mike Koelzer, Host: The F d A, for them to certify a drug, they have to certify that it's different.

They don't have to [00:21:00] certify that it's more effective than what. We currently have, they have to look at safety and it has to be different. But they'll give a patent to something even if it's not better.

 Is that true? 

[00:21:14] Pramod John: [00:21:15] Yeah, it is true so the F D A has no objective standards on effectiveness. But it has standards on efficacy. Now you probably hear that word all the time. Efficacy, 'cause everyone uses it. You hear physicians using it, you hear it on the radio all the time. It turns [00:21:30] out that efficacy didn't mean what I thought it meant.

'cause of course everybody uses that word all the time. I thought it meant what the drug actually does. It turns out that efficacy is the population response rate. That means how many people out of a hundred got the [00:21:45] response? Or in the clinical trial terms endpoint that they were measuring, it does not have any statement about what the endpoint is.

The endpoint could be completely worthless.

 Because the F D A does not have any standards on the endpoint. So going back to [00:22:00] your thing, you know how we started out the conversation talking about something like agile?

 It turns out there are a lot of oncology drugs that look at what's called progression-free survival.

And it sounds, if you listen to a term like that, it sounds reasonable, if a tumor not [00:22:15] growing, if it's not progressing, that must mean that it's good, and that the cancer's not getting worse, is what that means, it turns out that's not true. It turns out that in some cases life expectancy can be correlated to [00:22:30] progression-free survival.

And it turns out in a lot of cases it can't be, and there is no correlation. Which means that even though the progression-free survival was positive, everybody died on the same day,

 And it didn't actually improve your life expectancy. And so then you've gotta ask [00:22:45] yourself the question of, look, if I'm gonna die on the same day and something's not gonna improve my overall survival, then isn't it better for me not to be on a drug?

'cause every drug has severe uh, take oncology for example. There is not a drug that doesn't have severe side effects. I. That's a trade-off that you make [00:23:00] when you have cancer. Side effects. And so why would you put yourself on a drug with extreme side effects when it shows that, on progression-free survival, it's positive.

And one way to think about that is that it progresses more slowly, but then it progresses [00:23:15] faster and more quickly at the end. And you die on the same day. And at the end of the day, you died on the same day and you had to go through all the extra side effects of the medication. All of us would look at that and say that doesn't make a lot of sense, does it? but that's the world we live in, where the F D A can approve a drug on [00:23:30] progression-free survival, saying it might help. And then we learn later that it didn't help or that it actually harmed more people and that it lowered life expectancy. And so all of those circumstances occur today because again,[00:23:45] that's the endpoint. So the endpoint is I got better progression-free survival. That's effective. What did the drug actually do? And efficacy is how many people out of a hundred got what's the population response rate?

So if you have 30% efficacy, [00:24:00] that means 30 out of a hundred people actually got to that endpoint, but it does not describe whether that endpoint itself was useful.

So you can have drugs that sound great with high efficacy that are not meaningful at all, and do nothing to improve your quality of life [00:24:15] or life expectancy.

[00:24:15] Mike Koelzer, Host: Lemme see if I have this right. Pramod. So let's say with this Alzheimer's drug, it could be that the people that let's say certified it just to make it look good. They might have been measuring like some [00:24:30] gray matter in this part of the brain or something like that, and they prove that this did such and such to that.

But in the long run, maybe there's four or five different reasons for Alzheimer's. And maybe even if you did cure this, everybody's gonna get bad [00:24:45] at the same point and they can cook the figures up, but they may not mean anything in the real world.

[00:24:51] Pramod John: And you brought it, so it turns out to be a gray matter plaque. It was, in fact, the amyloid plaque is, in fact, what the thesis was that by reducing that would [00:25:00] actually reduce Alzheimer's. Right now, that's a theory. It's never been proven. And not only is it a theory, there's more and more evidence to support that theory isn't even accurate or true.

So how do you spend billions of dollars on unproven theories in which there's now not even [00:25:15] strong evidence? Not even mild evidence. The evidence is now leaning in the other direction toward it not being an adequate hypothesis to explain Alzheimer's disease.

[00:25:23] Mike Koelzer, Host: Alright, so Pramod. Obviously the average person can't be thinking about [00:25:30] this. I'm a pharmacist and won't even be able to follow this. 

It's hard to trust the government. It seems there has to be somebody that's not incentivized with this or correctly incentivized. [00:25:45] I'm thinking that's where Vivio might step in.

[00:25:49] Pramod John: Yeah. And so that's a really good point. And we started our discussion about business models and why they're important. One of the key things that we started out with is, we charge a flat fee. So we don't actually [00:26:00] care what drug somebody's on.

It makes no difference to us. We don't get paid more or less. So whether someone's on zero drugs or 50 drugs, or it's an expensive drug or a cheap drug, we don't care. We just care about the underlying data, and our job in life is to look at data, we care about data and on top of [00:26:15] that, we don't own anything.

You know that you brought up vertical integration. So guess what's happened with all this vertical integration? So the people who control your money, who are supposed to represent you, the insurers, the PBMs, and all these people who are in this [00:26:30] role, guess what they all started doing? They started buying service providers themselves.

1. They bought hospitals, they bought pharmacies, they bought doctors, they bought everything else. And guess what? We put in these laws, like you've probably heard of the medical loss ratio. And so when the Affordable [00:26:45] Care Act came out, we put in requirements that for every dollar you collect, you can't just spend all of it on administrative expenses.

And as a result everybody who's at any scale has to have at least an 85% M l R,

which means that for every dollar you bring in, [00:27:00] you have to spend at least 85 cents on actual services. You only have 15%, 15 cents on the dollar left for your profit or your fees or whatever else. So everybody got really smart and they decided that's dumb, 

so [00:27:15] how do you get around that? You pay yourself because it'd be 85 cents on the dollar. So for example you're a health plan, you buy your own doctor, and you pay that doc, you can pay whatever you want. Because you're insource it to yourself or you're P B M, you buy your own pharmacies, 

and you [00:27:30] pay yourself. And now you get around the M L R requirements 'because you can pay yourself whatever you want, there are no restrictions on it. And so our laws are antiquated when it looks at these things like what was the point of an M L R? It's to prevent a vendor from controlling those dollars [00:27:45] directly.

And one could argue that, hey, if it's dependent organizations that you own, they have a hundred percent control over that. You've broken the whole model by doing that. So vertical integration is killing us and the other sort of analogous situation is that in the rest of the world, what's [00:28:00] happened is that we've gone through cycles of centralization, decentralization, 

and now we've gone through this decentralization model and cycle. And what's happened in those cycles is that, for example, you were FedEx. FedEx owns a lot of things, including logistics, transportation, [00:28:15] all these different pieces, and the reason you had to buy them was because of their scale.

Nobody else could offer a solution, without buying that vertically integrated solution. Now you can buy APIs where you can outsource your logistics to one party, and its software and the transportation is [00:28:30] something else, and you can stitch together whatever kind of solution you want. You don't need to buy one size fits all.

You can buy a solution that costs you less by stitching it together. But what's allowed us to stitch those together is access to data.

Party who's paying for things owns the right, and [00:28:45] they can access and do whatever they want. In healthcare, we've gone the opposite direction. Not only are these institutions vertically integrated, they control the data, they control that.

You can't use any other third parties. They control all these things, which have gone exactly the opposite of [00:29:00] pretty much everything else other than healthcare. And they've made the data inaccessible. They've made the data that, hey, we own the data. It's not your data. Your data on what you paid for that drug isn't yours.

And we've done all these things that are exactly the opposite to insulate the system. [00:29:15] Rather than saying, no, we wanna open up the healthcare system so any willing provider of a service can now offer a better service. And now we allow data to be the underpinnings. By the way the government has taken efforts like the health exchanges and things to do [00:29:30] this.

Go take a look at how they've been implemented. I. They built exchanges and there's nothing being exchanged. And you're like, why? Because there's no incentive to exchange, and you've made it difficult to exchange. No consumer can go and say, Hey, give me all my data today. I want it [00:29:45] right now. Not available on the exchanges.

[00:29:47] Mike Koelzer, Host: The exchange I've heard the word always is that synonymous with exchange being competition so you can decide to do this, or that. Is that what 

What does that word mean? 

[00:29:57] Pramod John: That was the point of the exchanges by [00:30:00] opening up data, it'll increase competition. It'll increase choices for consumers, by making their data available. So we built exchanges, but we never made the people who have the data, we never forced them to put their data on the exchange and make it available.

So all it is it's an [00:30:15] exchange in which there's no traffic on, because nobody can access anything through it, because the laws did not require people to open up the data.

[00:30:22] Mike Koelzer, Host: Pramod, is there any other industry even close to this? And let's just focus on federal funds because[00:30:30] whatever self-insured this or that place wants to do with their money. Maybe I'm not smart enough to understand it, but let's talk about federal funds where we're all paying into that.

Is there any other industry that comes close to the smoke [00:30:45] and mirrors and the non exposure of their. C costs and so on. Back to the government who is funding this 

business.

[00:30:55] Pramod John: No, and the easy way to convince yourself of that is ask yourself, what are the [00:31:00] largest government paid institutions in the US the government pays for healthcare, number one on the list. The defense and all these things that we talk about are dwarfed, education, dwarfed right by this, and so nothing else is even close.

I

[00:31:13] Mike Koelzer, Host: So it's the biggest, so there's [00:31:15] nothing close. But let's say everything was comparable. Let's say all these were equal distributions of funds. Healthcare, is that like far and above the smoke and mirrors? Or is there any other industry that is as [00:31:30] hidden as that is?

[00:31:32] Pramod John: So the, it is a really interesting question because if you look at, what are the most hidden industries in America, government, it's a non-competitive industry, government education, non-competitive industry. Again, IT [00:31:45] education, and healthcare at its core, it's a non-competitive industry.

And everybody who tells you about competition in healthcare does not understand competition, how competition occurs or what competition means. These are largely non-competitive industries that we've created,

Healthcare and education, both could [00:32:00] be more competitive, 

if we wanna change the structures on how they work. But today, we keep allowing these systems to work. It's like the PBMs have a safe harbor on rebates, we've granted them safe harbor, that a rebate will not be considered a [00:32:15] kickback. Now ask yourself a really simple question of, hold on.

But why would someone be granted safe harbor? It's because by all definitions, it meets the definition of a kickback.

And because it meets the definition of a kickback, we've said that you are special because [00:32:30] you bring so much more benefit because of all the aggregation and the prices and all the things that you do.

We're gonna give you a safe harbor. So it's not really a kickback anymore.

Ask yourself how ridiculous that is, and not only ask yourself how ridiculous that is. What are we [00:32:45] having across the country now? Debates on PBMs, laws, restrictions, what they're doing, it's everybody's talking about it. Why do they still have a safe harbor for rebates?

When it's clear to every person on the planet who is not a P B M, [00:33:00] that this should be illegal and it is illegal.

[00:33:03] Mike Koelzer, Host: Pramod.

As soon as you start talking about competition and maybe you've convinced the legislators that there has to be balanced competition and so on, [00:33:15] as soon as you do that, everybody tries to put up the smoke and mirrors again. You don't understand, Mrs. Senator, because you know this and this, and that's different from this and this.

Where does the [00:33:30] rubber hit the road of competition? Is there any place where you can compare apples to apples a little bit more than all this smoke and mirrors of policy and all that kind of stuff?

[00:33:43] Pramod John: That's a really good question. I'll give you a really [00:33:45] simple example of something that's been gaining a lot of attention in the public arena, which is Humira. It's a fascinating issue in the case of this whole question of competition.

It's the biggest selling drug in all of history. Biggest selling drug in the [00:34:00] world, annually, currently the biggest selling drug in the United States. And so if you were to ask yourself, okay, let's talk, let's just think about competition for a second. For something to be in that position, what would it take?

In a competitive world, that would mean that it's gotta be better [00:34:15] and much more cost effective than everything else. Assume that there was competition. Let's just for a second, assume. Okay. In a competitive world, what would that mean for this drug to be the biggest, best ever? That would mean that drugs just blow everything else away.

Okay. Lemme tell you, give you some facts. [00:34:30] Humira is a drug that, there have been many competitors to, it went off patents several years ago. We represent 4% of the world's population for which the biosimilars or generic versions of it have not been available. They're available everywhere else.

And it turns out that even if you took a condition like ra, [00:34:45] take a rheumatoid arthritis, which is the first indication for which Humira was approved, there are already before the biosimilars came out, there are already over a dozen different drugs, some of which are newer, some of which are better, some of which have better numbers, some.

[00:35:00] Lower side effect profiles than Humira does, for example. And in real life what ends up happening is that you realize that hey, there are some drugs that are effective for different people. And as a result, you basically want more drugs because some different people [00:35:15] respond to different drugs. And so if you go back and look at even Humira's numbers on its best day in its trials it achieved in less than half the population, there was a mediocre response, less than half.

And in about [00:35:30] 25% of the population, there was actually a reasonably good response. And about 10% of the population, a great response. One out of 10 people is how this drug, shaped up in the trials. And again, we can talk about the limitations of the trial itself, different conversation, but assuming those numbers, [00:35:45] you're at about 10 to 10 to 25% that had a reasonable response out of a population, how could that drug become the biggest selling that means that it didn't work for 75% of the people. That means that those 75% of the people still have something wrong with them right at this point.

Unless there are other [00:36:00] medications that actually helped them

 Which is what we'd expect. There are different mechanisms of action, different drugs, for example, that help those other people who weren't helped by Humira, for

example, and so it turns out they're more than a dozen other drugs, some cost less than Humira. [00:36:15] Okay? In that world, how could Humira blow all of the other drugs put together pretty much away? There's no way that's possible, other than market manipulation, just do the simple map. It's not possible if it were in [00:36:30] in a competitive environment. So that goes back to the fact that that's how they won because of the PBMs, Enbrel was the first drug in that space.

The second drug was Humira. Humira. And the folks that were back before AbbVie owned, did the folks there [00:36:45] realize, we'll just pay back bigger rebates to the people in the middle. And that way they will put our first, think of it as grocery store shelf space. It's Hey, I put the ones who pay me the biggest rebates on the top of the shelf, 

but they went a step further and they said that, and we won't [00:37:00] even put other people's cereal on the shelf and you can't buy other people's cereal. Okay? And that's what happened. And as a result, Humira ends up becoming the biggest selling drug in all of history. The one that drives most of the rebates, 

So then everyone's oh no, what can we do? [00:37:15] We have to wait until a biosimilar comes out, because there's nothing we can do. We have no alternatives. Again, not factual, but that's the belief that people have,

 So Humira bio sims finally, and by the way, I don't know if you're the reader, your listeners are familiar with this, but.

AbbVie threatened to sue all the biosimilar manufacturers, [00:37:30] and so all the biosimilar manufacturers agreed not to sell for another couple of years, even after the patents expired, which should be illegal, it's anti-competitive. And that's what happened. And as a result, we had to wait for years after the rest of the world had the biosimilars [00:37:45] available.

And as of this July, finally, there was one biosimilar that was available earlier from M g vda. It was the first biosimilar available this year. And then July 1st was when the floodgates opened up, where all the other vendors, suppliers were allowed to bring their biosimilars. Now you would [00:38:00] expect that with the biosimilars, that you're gonna see a lot of change, and cost. And lemme give you a couple of examples of why you should legitimately expect this.

If you were to look at Humira, it now has a list price of 80,000. It's actually a little higher than [00:38:15] $80,000 a year. But now they have these big rebates that they pay the intermediaries and other things, and our estimates are the net cost after the rebates.

That's, this is where you go to the employer and they're like, look, we're gonna give you a big rebate. And everyone says yes. I want that rebate and everything I want, it's bigger than my last rebate. [00:38:30] Everyone gives me a rebate. They sign up the net cost after all that, on the best contracts that you can get in this country is about 35 K.

30 to 35 k. Okay? That's after the best rebates that you can get on a drug that started out like in the, in north of 80.

Okay. [00:38:45] Sciri is one of the new biosimilar alternatives that came out, and you may have heard about Sciri through Mark Cuban. Mark Cuban Cost plus drugs is selling Sciri at a discount.

Even for Sciri, it's the lowest price available anywhere. It's [00:39:00] just north of $500 in change, 600 bucks, okay? For one year of Usci. It's about just a little over $8,000 for a year of sciri. Okay. For a year of Humira with the best rebates on the planet, starting out [00:39:15] with an $85,000 drug, you're at 35,000 bucks.

Okay? And it doesn't matter how you slice it, how good your consultant is, you know how your consultant can make up numbers in Excel, doesn't make any difference. You're not getting [00:39:30] far from 35 versus eight and a half, $8,000, however you slice that. So any average American could look at that and say $8,000, $35,000, even with all the smoking or rebates and everything else.

It's not $8,000 on [00:39:45] the other side for Humira. It doesn't matter how you slice and dice this equation. Okay? And if you look at AbbVie's earnings, you can also figure out it can't be $8,000. That doesn't make any sense, with the amount of money that they're making, the doses that they sell,

 And so every average person, including every average [00:40:00] politician in this country, should be able to look at that and say, I. Look, I don't understand the whole healthcare system, but I understand $35,000 for this. I understand $8,000 for this $8,000 is less, I don't have to be a math genius or be above, kindergarten math to figure that

out.

That low [00:40:15] cost drug coherence from coherence biosciences is not on any PBMs formulary all the market expects to get, expects it to get no demand and sell nothing, basically, is what the whole expectation of the market is. [00:40:30] If that isn't broken, if that doesn't tell you that competition is broken in this country for things like basics, things like drugs, then nothing will.

 That's a kindergarten level example of why that's broken. Because if we were a competitive market, that drug would be flying off the [00:40:45] shelves. It would be depressing the price of all the other people, and we would see a crush in the inflammation market on cost today.

[00:40:51] Mike Koelzer, Host: A couple of years ago we were about ready to lock our doors at the pharmacy 'cause we were getting reimbursed from our brand name drugs, 90 cents on the dollar. [00:41:00] So in a year's time, I'd lost like a 

quarter million dollars. So I 

was ready to lock the doors.

So I said to myself, I made this decision in 15 minutes. I said to myself, we either locked the doors 'cause I don't have 10 grand tonight [00:41:15] to lose a thousand on it, or we just got rid of the brand names. And we got rid of all of our brand names. There's not many pharmacies that do this.

And. Someday I'm hoping for someone to say, boy Mike, you're wise. I'm not [00:41:30] wise. I just know that it's better usually to have the business open than to lock the doors. That's the only wisdom I had. But the reason we've been able to stay afloat is because it's a very easy picture.

Someone comes in and they [00:41:45] say, why don't you have brand names? And I hold up my hand with the five digits and I say, the brand name of this is $500. And then I hold up one finger and I say, the generic, which we have is $100. [00:42:00] Wouldn't it make sense that Medicaid, the government and all that would want to pay a hundred versus 500?

And they say yes. And I say, that's not the case. They want to. Me to sell you a drug for [00:42:15] $500. And the people just start agreeing. They know what's going on. They know a slick sales play going on when they see it. 

 There's no way you could not understand that.

Just like the Humira. It's like you can say whatever you want to, but when it's 30 verses eight, [00:42:30] there's no way to explain that away. Now, promote, how is that explained away? Is it because of the lobbyists? Is it because people just roll their eyes back in their head? When these brokers keep talking to the HR of [00:42:45] these big corporations, how are they able to keep this going?

[00:42:49] Pramod John: I think Mike, ultimately, it boils down to we don't treat other people's money like our own. And we don't care about other people's money. Now, one of the [00:43:00] differences about us is that we always talk about this in the company. It's Hey, would we spend our own money on this

And that we always have these conversations, which are always couched in the way we spend our own money? If we wouldn't? Then why would we spend someone else's money in a way that we wouldn't spend our own money? And so if you go back and [00:43:15] ask the question of Mike, would you or any one of those people who walked into your store pay $500?

At that point?

They'd all look at that, that it's the dumbest thing I've ever heard of. I'm gonna pay a hundred dollars. Because it's obvious. We've taken what's obvious and [00:43:30] we've convinced people right there, there are all these people convincing the politicians and lobbyists saying that, for example, that rebates have helped more than they've harmed.

That is a lie. That is nothing more than a dastardly lie, because they're comparing the [00:43:45] wrong things. And I'll give you an example of that. They look at that and say, Humira would've cost a lot more if we didn't have the rebates. And you're like yeah, then Humira wouldn't have been the top choice that everyone's on.

There would've been five other drugs in this country that people would've had access to, that would've been [00:44:00] on formulary, for example, and they would've had access to. So you're looking at the problem and analyzing it incorrectly rather than saying, yeah, we would've had a competitive market. Instead we say, yeah, but everybody needs to be on Humira and therefore it would've cost more.

And so now what we ended up [00:44:15] with was fewer choices in the market. A monopoly over a drug that is a so-so drug instead of a thriving market in which a company like COHEs Biosciences can release a drug that costs literally a quarter of everything else, and everyone would [00:44:30] be buying it.

Instead of everyone saying, no, I still am gonna buy the AbbVie one because I get a better, bigger rebate on it, even though I pay four times as much.

[00:44:38] Mike Koelzer, Host: Primo. Now let me think this through a second. Alright, so you go to companies [00:44:45] and you tell them this story and you tell 'em, we're not making money on this. It's a flat fee, but let's say that. Then they go back to the top three [00:45:00] PBMs.

Does somehow that get changed or do you then bring in other P B M options and so on for them? Where does the change take place given that everybody is [00:45:15] incentivized to keep doing things as they've been doing them?

[00:45:19] Pramod John: So I mean it, I have to tell you, even though this is common sense, we're all having this conversation. It's common sense, if you're a politician in Washington, if you sell the price of Usri versus Humira and number one, you should be [00:45:30] asking I wanna know what the net cost of Humira is.

Until then, I'm not gonna have a conversation with anybody. And at that point, why would you as a politician have a conversation about drug pricing without understanding drug pricing? So the first step would be, get educated on drug pricing, how this stuff actually works, how much it actually costs.

That'd be step number [00:45:45] one, step number two would be doing the common sense approach of saying if this drug is, $8,000 a year and this drug is $35,000 a year, common sense dictates that everybody should be on this drug, and at that point, you would be how do we create our policies and change them to prefer the lower cost drugs?

That's not [00:46:00] what anybody's doing. And in the same way, we see the same sorts of things when we go to employers with the, Hey, your problem isn't, your problem is that your people are on the wrong drugs and you're overpaying for them, what you wanna be able to say is no formulary. Your people should be able to access any drug they need.[00:46:15] 

But every decision in life should be driven by objective data. It's not my opinion. It's not your opinion, it's not the doctor's opinion. It's not the patient's opinion, it's not the pharma company's opinion, it's not the government's opinion. It's either there's data or there isn't. That's how the rest of our lives work.

And if it's a great option for [00:46:30] somebody, there should be data to support it, and if it isn't a great option, there's also data to serve that isn't, it isn't a great option, that's how it should work, but it's not how it works. So in our world, that's how it works. But when we go to employers, 

we have, obviously, we have a lot of customers who carve their specialty out of the big three PBMs, [00:46:45] all the major PBMs in this country. But what we're really saying is that, look, specialty, something different. It's a very small number of people who are on a very complex data problem, it's not like a atorvastatin, 

give away an atorvastatin, who cares? It's a buck, a couple bucks a script, five bucks [00:47:00] a script, for example, for a month. But when you're on an expensive drug, in a complex condition, that's where you wanna make sure, hey, is there data to support this? Is this the right patient for this drug?

Is this patient benefiting from the drug? It's all about care. The cost is a [00:47:15] secondary issue, and if you focused on care, you end up with lower costs, but I have to tell you as, as obvious as this conversation is, The number of employers who immediately say, this is common sense, we should do this, is still significantly lower than you'd think.

Because you know what happens? [00:47:30] They go back to their consultants. Their consultants are all paid by the suppliers. They have their own coalition contracts. This whole game is rigged, and then the consultant has a spreadsheet which says, who's gonna give a bigger rebate? And so imagine that drug for $8,000, which [00:47:45] has a $0 rebate, and Humira, which has a $4,000 rebate, which one should you buy?

The $4,000 rebate sounds larger than zero.

[00:47:53] Mike Koelzer, Host: All right, so Pramod, let me backup just a little bit. So if somebody does understand and they buy [00:48:00] into the data, I heard that you said there are ways to carve that out, so let's leave that to the side. There are ways for this to happen. I'm curious though, about these people, whether it's a c e O or HR head or [00:48:15] something that gets bamboozled into the broker's attempt to re educate.

Then what happens? Does that get under your skin? 

[00:48:27] Pramod John: oh, it goes to our, I mean, to be fair, [00:48:30] it's the system. It's not personal, it's not that broker. It's just the system and everybody's been spreading disinformation, misinformation over and over again, and after a while they believe it and they think it's facts.

And those people who are talking about that $4,000 rebate versus [00:48:45] zero, they truly believe that this is bigger. And they're right. 4,000 is bigger than zero, but they're asking the wrong question and they don't understand. The question they should be asking is, but how much do I spend on specialty in a year?

I don't care how, what [00:49:00] rebate or what drug or any of these things I care about. Did my people get the right outcomes? By the way, nobody's asking that question. No one collects outcomes assessments or anything. They don't know. They just pay for a drug, so number one, they don't actually know whether the drug does anything useful for the person or, and if so, what is it that's doing for them?[00:49:15] 

And the second is that they're overpaying because they're asking the wrong question. They're not putting them on the right drug. And it, what? And what's worse is even that. Like in the Humira example, they have limited formularies instead of a person having access to all the drugs that they might [00:49:30] need.

So it also limits competition. It prevents 'em from getting access to the drug they need and they pay more. So on every axi, this is pretty anti common sense, because we're common sense people.

[00:49:41] Mike Koelzer, Host: So you do your job and you tell them all [00:49:45] this, they go to their broker and we're not gonna, crucify their broker 'cause that's their job and so on. What happens then? Do you try to get a hold of these people again or is it a lost cause? Because they've [00:50:00] known their broker and probably played a few rounds of golf over the last 10 or 15 years and they trust you sort of. but you

guys are newer to them than their broker.

[00:50:10] Pramod John: You realize that why the whole C-A came about was because of that trust that is no [00:50:15] longer really trustworthy. You don't need to create rules and laws to open up things if there is transparency and trust and actual fairness, when the laws come into place, laws come into place when something is so fricking broken that we need to put a [00:50:30] law into place.

It doesn't come in at the beginning of, Hey, we might have a problem. Mission control. It has a, I think we lost the mission. We need to do something where the laws come in. So what does that tell you about where we are 

with 

Broker compensation? 

[00:50:40] Mike Koelzer, Host: So is this part of the conversation that you have with people when they [00:50:45] come back 

to you 

[00:50:46] Pramod John: Technically our. Our world and our love is about the question of do these drugs do something useful for this person? And is it a fair price? we just give 'em the information. But there are a lot of people for the first time asking those questions about, Hey, [00:51:00] what does c mean? Am I a fiduciary? Am I responsible? Let me ask you a question, if you are a benefits person, Number one, should you know what the actual net cost of Humira is? go back and do the same exercise you probably can figure that out. Or [00:51:15] ask your broker for, Hey, what's the net cost of Humira?

Even with the best rebates, putting in whatever you want doesn't matter. Put in any number you want of what you got for rebates and everything else. Then compare that to usri.

It doesn't matter how you compare sciri is gonna be cheaper. So at that point, does the [00:51:30] employer have a fiduciary responsibility to require their P B M to make sure that everybody's on sciri? And if not, what does CA or fiduciary mean? What does fiduciary mean? In that case, yeah, it costs four times as much, but we still [00:51:45] went ahead and did it because the broker told me to. 

[00:51:46] Mike Koelzer, Host: I've had in my mind That you had a need to convince people, but your job is done once you share the information, because you're not the sales person for this $8,000 drug. You've done your [00:52:00] job by explaining it to them. And that's where yours ends. 

[00:52:03] Pramod John: and Our whole job is to make sure that happens for every patient. They're on the right drug, it's at the right cost, et cetera. And that's our job. But ultimately what people are saying is that We don't care. We don't care [00:52:15] that the drug is 8,000 bucks and all of our people are having to overpay. people who 

i don't care. 

[00:52:20] Mike Koelzer, Host: So Pramod is your service . I'm picturing two things. I'm picturing, one is a yearly look at the formulary in this and that the other service is [00:52:30] actually dealing with individual employees or their families of this employer. Which one is that closer to what you

do?

[00:52:39] Pramod John: The second one. We have no formulary. So there's no issue with formulary. It's all about drug data. Our people, like our [00:52:45] chief science officer, as I told you, was from Genentech. Drug discovery. So our whole focus is on understanding drugs better than anybody else on the planet, because how can we help people by understanding drugs better?

And the party who understands drugs better than anyone else will be able to help more people. [00:53:00] 

[00:53:00] Mike Koelzer, Host: Not that you have a desire for this . What other industry could this business model transfer to? Like I know that it almost seems to me like [00:53:15] you're an individualized consumer report for medical stuff. In the old days I'd go and now you do it online, but you'd buy the consumer report, to find out your best double cassette tape deck and things like that.

What [00:53:30] other business is out there that would need someone as deep as you? Is there anything out there? Or is this the one that's

a 

cloudiest? 

[00:53:39] Pramod John: So we've seen these transformations occur in other industries, take financial services. So imagine [00:53:45] that we're on the cusp of where financial services were a decade or two ago, where you had only experts, brokers who understood, all these sorts of things, and fund managers who were better than everybody else.

There's no data to prove that they actually did anything better, And [00:54:00] there's a lot of smoke and mirrors in all these industries, so you can draw a lot of analogies to what happens in healthcare, and what's changed? Every one of these industries access to data, the one thing that's changed, access to data and transactions being commoditized, anybody [00:54:15] can do a transaction. and again, the data dictates your performance, either you're doing well or you're not. There's no ambiguity on it. Either a drug is helpful or it's not. There's no ambiguity. An f d, an approval or a committee of people, for example, like the, NCCN guidelines are [00:54:30] the, cancer guidelines for example.

A lot of those people on those committees are compensated by pharma, how can you have a fair guideline for example, that you have economically interested parties who are part of it. And if you're like how far does this economic interest go? If you're an [00:54:45] academician today in academic medicine, what's your most common medical intervention?

Drugs. 

If you ever are on a trial and you say, this drug doesn't work, how many trials will you ever be on in the future? So imagine that it's physicians and people who are in research. You also have a, and [00:55:00] then academic medical centers. What's their number one thing? They sell? Hope. What is hope? Hope isn't about data.

Hope is actually about, Hey, if you come here, we do research on many things. We're a hundred percent pro research. We think that's where new developments come from. be [00:55:15] treated as a research if you need a drug and someone else's, it's someone else's research.

They're the ones who make the big bucks when that drug gets approved. They should pay for the research or you should own the rights for it. It can't be that you own the rights for paying for it, and they own the rights for [00:55:30] ip. It doesn't make any sense in today's world. That's where we are. 

[00:55:33] Mike Koelzer, Host: I had this guest on the show a couple years ago and I asked him a similar question. He said the closest this got was back in the eighties with milking and all this stuff. [00:55:45] And, the government had to step in because the companies that were the wealth advisors were basically writing the magazines to tell people that these are great 

things and stuff 

[00:55:57] Pramod John: It's 

the same thing. 

[00:55:58] Mike Koelzer, Host: and he said [00:56:00] that is nothing compared to the smoke and mirrors of this industry. 

[00:56:04] Pramod John: Yeah. It is so much, we're one of two countries that allow direct consumer advertising. You're doing consumer advertising on a product that a consumer cannot purchase. Remember, only a physician can prescribe, a consumer can't purchase anything. [00:56:15] What country allows advertising to somebody who can't buy something?

Think about how crazy that is. It breaks what advertising is unless it's being done for something completely different reasons. 

[00:56:25] Mike Koelzer, Host: Alright, Pramod, let me get Some questions in here. How big's your company? 

[00:56:28] Pramod John: We're, about [00:56:30] 60, 60 to 70 

people. 

[00:56:32] Mike Koelzer, Host: Do you like being the c e o? 

[00:56:33] Pramod John: Love 

1. Love working on this problem. And I chose to do this. It's one of the hardest problems I've ever worked on. For all the other businesses that I've done. And it's because it's a very hard problem, all [00:56:45] the issues that we've talked about.

But it's worth it, right? I've got three kids and there's no reason that their future needs to be that we spend 20% of our G D P unnecessarily on healthcare and call it that a good thing. All it's doing is ruining. Our next few generations. And so it's wrong. [00:57:00] It's morally reprehensible for us to stand by the sidelines and say, 

This is okay.

It's not okay. 

One thing I would recommend to every listener. Next time you go see your physician, don't ask them for their opinion.

Ask them to show you the data.[00:57:15] 

Ask them to show you the data behind why they're making a decision and why that's the right drug for you and why all of those things, and ask them, what are all the things that you've compared it to, and tell me why out of all of those things, this is the best option for me.

Ask them to 

explain 

every one of [00:57:30] those things to you. It

[00:57:31] Mike Koelzer, Host: they gonna hem and haw because they know that they're under the claw of vertical integration with the formularies?

[00:57:37] Pramod John: could be, their answer could be as simple as, Hey, it has nothing to do with someone else's formulary. That could be an answer, it could be that I don't know these [00:57:45] details because I haven't compared them, it could be all of the above, but it starts with consumers requiring data behind the decisions

rather than just tell me your opinion.

[00:57:56] Mike Koelzer, Host: In an oppressed world for time and [00:58:00] resources most professionals don't just offer up everything they know. When someone asks, then they're put on the spot to answer those kinds of things. So it starts with a question.

[00:58:11] Pramod John: Yeah and then ask specific questions. Don't ask general questions that are [00:58:15] answered by television advertising. Ask those specific questions about, Hey, what specifically, and how have you 

compared these drugs, and what specifically about my data 

indicates that this 

is the most cost 

effective therapy for 

me? 

[00:58:26] Mike Koelzer, Host: Pramod, boy, thanks for joining us. [00:58:30] There's a lot of talk going on about theories but it's really cool when somebody keeps, Forcing the issue of data and data and data with the ultimate goal of having grandma around to take her to the [00:58:45] zoo

[00:58:45] Pramod John: Hey, thank you very much. Thanks, Mike, for the chance to speak to your listeners. Really appreciate it, and hopefully they've learned something that they can use practically in 

their 

everyday lives. 

[00:58:54] Mike Koelzer, Host: Pramod, we'll keep in touch. 

[00:58:56] Pramod John: Thanks, Mike