FTC Inquiry Into PBMs | Luke Slindee and Benjamin Jolley, PharmDs

Speech to text: 

Mike Koelzer, Host: [00:00:25] Benjamin and Luke, for those that haven't come across you online, introduce yourself and tell our listeners what we're talking about today. 

Benjamin Jolley, PharmD: This is test

Luke Slindee, PharmD: I'm Luke Slindee. I'm a pharmacist. Who's very interested in pricing, how pharmacists and pharmacies are reimbursed for the services that they provide. And I'm also very interested in understanding the presence of any anti-competitive business practices that might exist in the pharmacy market.

Benjamin Jolley, PharmD: I'm Benjamin Jolley pharmacist. I work for Jolley's pharmacy, my dad's store. I work for CPS N now I consult with pharmacies across the country, but I'm not speaking for any of the people I work for just myself. And I write a blog about pharmacy and monopolies and pricing and all of the fun stuff. 

Luke Slindee, PharmD: Uh, today, we're gonna talk about the recent investigation by the federal trade Commission or the FTC into the business practices of the largest pharmacy benefit managers or PBMs.

That was recently announced. 

Mike Koelzer, Host: The last time we talked, Benjamin had his moment in the sun talking to the FTC 52 seconds. I think it was. But at the time we were kind of waiting for a vote to come through, to see if the FTC was going to look at the PBMs. And then it's like, no, that didn't happen. And then someone told me, well, it's not quite over.

They might do this or that. And then before I know it like two weeks ago, the FTC comes out to say that they've decided to do the inquiry into the. PBMs did a 180 or was this like a loophole that they could do, even though they voted it down, they could still do it. How did it go from not doing it to all of a sudden doing it?

Benjamin Jolley, PharmD: So what happened here is internal politics at the federal trade commission and external politics to the federal trade commission. So, um, the original study that was proposed, I think this was three, four months ago, um, was a two, two vote divided on party lines. The two Democrats voted for the two Republicans voted against the Republicans though did say this is a no, but I vote for it.

If it was a more detailed study, apparently from, from news reports, supposedly the. Um, the original study was not terribly well detailed, well thought out, according to those parties. And apparently the last draft it was, was circulated like 20 minutes before the meeting. And so 

Mike Koelzer, Host: You mean the first one?

Yeah, the previous one. Yeah. And 

Benjamin Jolley, PharmD: So anyway, so the two Republicans voted, no, the two Democrats voted. Yes, they were split. So that means no action. Um, in the interim, the FTC staff worked diligently on, um, developing a more comprehensive study, more well written out, more thought out, um, And then also the Senate confirmed the fifth member of the federal trade commission, Alva, 

Mike Koelzer, Host: Bedoya.

They usually only had four, but they decided to have five for this or one was missing at the time that one was 

Benjamin Jolley, PharmD: missing. Yeah. So, the prior commissioner RO Chopra took a job, um, with the consumer financial protection bureau, like in October. And so he could no longer be on the federal trade commission.

So, um, anyway, so there was just a two, two, it's normally a five member commission. It's now a five member commission again, and they voted five zero for the revised study. Um, which is that, that surprised me? I expected a three, two, I did not expect a five zero to be Frank. 

Mike Koelzer, Host: Did you expect the vote to come again that soon?

It seems like in politics it's like, well, once a year we'll do something, but this came like three months later. Did you 

Benjamin Jolley, PharmD: expect that? Honestly, not really, but, um, Apparently Lena con likes pharmacies or at least is really interested in the subject of medications. Um, it is. I mean, my, my point that I made to the FTC is that this is like, when you look at the, at the fortune 500, and this was Luke's ID originally.

So when you look at the fortune 500, the biggest companies that in that control, the most money are all in pharmacy. Right. And so, and, and most of them are PBMs or wholesalers. And so it's a very natural place for the federal trade commission to look [00:05:25] at. Um, they've got, you know, an enormously overwhelming job, but, um, if you're gonna start somewhere, it makes sense to start with pharmacy.

Mike Koelzer, Host: I was amazed at the depth of this thing. I think it was like 17 pages. They wanted, like every time you breathed, we wanna know about it kind of thing to all these PBMs. And I was just like Mr. Evil. I was just ringing my hands in delight, you know, because it's like, that's a kind of baloney that they give to us for audits, but I saw that thing and I'm like, thank goodness someone else is doing that because I would never know how to get into those details and ask the right questions, which as you said, it helped to pass this thing.

But then I realized that the FTC has like 300 attorneys or something like that. I'm like, well, you gotta give 'em something to 

Luke Slindee, PharmD: do. And I would just add that, you know, this, this, uh, situation is what the FTC has been meant to be for all the way back to the very beginning. Uh, the federal trade commission was created in 1914.

When the concerns about all of the detrimental effects of monopolies reached a peak. I mean, it started all the way throughout the Gilded age and the trusts you had the Sherman antitrust act in 1890, and basically the problem persisted and continued to get worse for the next 24 years after that.

And finally, uh, you know, the government, how to react to the problem of monopolies, has been said by some historians to actually have been the most significant issue of the 1912 presidential election. So this is something that was at, you know, the absolute forefront of political discussions during that time period.

And it was because of all of the power. That rested in the hands of a very small number of companies and all of the market distorting anti-competitive business practices that those firms held. So, you know, these are firms like standard oil and US steel and things like that. This is back in a point in time when we had very much an industrial manufacturing economy.

So at that point in time, the most important businesses in the country were the people that produced steel or oil or aluminum or railroads, right. And fast forward to today where we were, our economy is oriented around different things. We prioritize, you know, things at the forefront of our economy are things like software, um, internet connectivity, and because we've moved to a service economy and we're to a point now, You know, almost 20% of our GDP is in healthcare.

That's, you know, healthcare is one of the biggest industries in our overall economy now. So, uh, the same types of monopolization practices that occurred over a hundred years ago in the most important industries of that day have now occurred in the most important industries of our day. And so it's almost a little bit like history is repeating itself and, uh, this situation is exactly what the FTC was created 

Mike Koelzer, Host: to do well.

Have our listeners refer back to, I don't know, six months ago we had a great discussion. I learned a ton in the podcast entitled Amazon and PBMs and other huge businesses or something like that. Um, so I'll have our listeners go back to that for some of the, the real basis of the monopolies and so on.

I'm not smart enough to look at this thing and do anything I could maybe say, oh, I wish they would've used a little bit, uh, prettier shade of paper or something like that. but when you guys looked at that 17 pages, did you guys have the audacity to say, well, they missed this, or I would've done that. When you looked through it, were you comfortable with what you saw?

Would you have done something 

Benjamin Jolley, PharmD: else? Um, I don't have the audacity to say that, but when I looked it over, it answered pretty much every concern that I've got about the pharmacy benefit management market. I wanna know about network contracts and differential rates. It had steering, it had audit practices.

It had, uh, rebate information, like all, all of these things that, um, you know, Little independent pharmacists, just complain about all the time. Um, it hit, it hit on like every single one of those points. And so I was, I was very pleased by [00:10:25] what I saw. Um, I will say that on a slightly different T the FTC more recently, um, also issued a policy statement in reference to rebates, um, that revived an act that has been dead letter law for 40 years, the Robinson Patman act, um, and specifically it's banned on commercial bribery, um, which is something that we haven't heard since before Reagan, which is just, I, I, I don't know that just made me happy to see that, like, because as long as I've been.

You know, politically active and trying to convince people. It's all my, my, my view of rebates has been well. We can't really touch them until health and human services decide that they're illegal because they're, they have a safe Harbor and they say, it's fine. If you stay inside this box, it's not, it's not a kickback under the anti kickback statute, but the federal trade commission said, well, I mean, it, it, it doesn't just have to be legit on the anti kickback statute front.

It also has to be legit according to the federal trade commission act. And according to, uh, the Robinson Patman act, which, um, which it bans commercial bribery, which basically means you pay someone off. To not, um, to prefer your product over competitors, for example, which is exactly what PBM rebates are.

They are kickbacks, they are kickbacks from pharma to exclude a competitor. Um, and so seeing that policy statement, I don't know, it was a breath of fresh air and makes me really excited that I don't know we're, I, I think the next five years are gonna be the most interesting times that the industry has had in at least two decades.

Mike Koelzer, Host: Here's my thought on some of these investigations: Michigan came up with rules for PBMs, and it's gonna go into effect in January. 2024. And one of my team members was kind of excited and I said, eh, don't get so excited. I said, they're gonna find some other way to screw us. But I said that the value of these rules is one step closer to removing the opaqueness , which makes it easier to explain to the Michigan legislature, which then maybe next year they'll do more rules because they understand it better.

And there's not so much shenanigans going on. I mean, there's still going on, but they're easier to understand. I said, it's gonna be like peeling back an onion, you know, like three or four layers. Okay. That's Michigan. Cut to the chase. What happens with this thing now? So the PBMs respond to this. I'm too much of a negative thinker to think it's gonna just solve it.

I'm thinking there's layers like this, which will gradually improve things, but not right away. 

Luke Slindee, PharmD: I would say that the most likely first layer would be that certain business practices, which are now the norm in the industry, may be ruled to be illegal. In which case those particular business practices would have to stop.

And if you know, they continued, then there could be lawsuits surrounding them, which then in theory would lead to enforcement, further enforcement of those particular business practices being made illegal. Um, and we've already identified and discussed some of those business practices like spread pricing.

Or patient steering to PBM owned pharmacies. Uh, you know, there's a, there's a long list of certain business practices, which are problematic and each individual one could be ruled 

illegal. 

Mike Koelzer, Host: When you say they're illegal, are they already illegal under a larger umbrella? And now they're just defining them.

And they're saying, guys, this is illegal because look, it's a, it's this, of course it's illegal. It's under this umbrella, which is already illegal. Are they kind of defining it or are they like making up new laws? I don't mean making them up like magic, but are they, are they making them up with new legislation or are they just defining something and saying that's illegal and it should have always been illegal.

You were just trying to get around it. 

Luke Slindee, PharmD: I would definitely say that the scope of the FTC is the latter. So the, no, the, the FTC is not going to be creating new [00:15:25] legislation. It would be enforcing. Legislation that has been on the books for a long time, you know, uh, decades, if not a hundred years. And for whatever reason there was selective non enforcement of those 

Mike Koelzer, Host: laws.

It's not even defining the loophole. It's like saying we're gonna finally enforce this. It's always been there. Correct? 

Luke Slindee, PharmD: Yeah. Correct. And so, uh, on, you know, as we are, not to get into that, but as we are learning lately, um, there's a lot of room for interpretation that occurs in the justice system and that has a really strong effect on what ends up happening.

So first of all, you know, you can have legislation around something. The justice system is still able to interpret it. And then there's even another layer on top of that, in that once it's been interpreted, there actually has to be. Actual enforcement or what I like to call teeth. There has to be a penalty for not following the law.

So you kind of need to have at least those three things in place. You need to have the, the, the legislation itself, the judicial interpretation of the legislation, and then enforcement through some form of penalty. And I think the onion metaphor is an apt one. Um, to me, there's lots of layers of the onion.

Uh, the deepest layer of the onion or the core of it would be structural breakups. There is a historical precedent for this, uh, standard oil was forced by the federal government to break into lots of smaller companies and T was forced to break into smaller companies. Uh, Microsoft was not forced to break into smaller companies, but just the threat in the nineties that it may be structurally.

Broken up, uh, basically prevented Microsoft. They got scared and they didn't do a lot of tactics that they otherwise could have. And that actually allowed for lots of other companies to come in, like Google, where, you know, if the FTC had not threatened, uh, punishment and, and structural breakup of Microsoft in the 1990s, it's possible, we would not have Google today.

And so we, I mean, I am always a big proponent of dreaming big. So the end game of this, or the biggest, the way to dream the biggest would be structured breakups where, um, basically we would dissolve some of the vertical integration that's occurred where the PBMs would have to be sold off from their holding companies, such that the PBM and the health insurer would not be the same company.

And then we also might see horizontal breakups as well, where the FTC could determine. You know, it's not a good idea to have three companies control 80% of the PBM market, even if they're not connected to health insurers. So we are going to force some of those companies to break up into smaller companies as well.

So to me, that would be the deepest layer of the onion. And there is historical precedent for this. 

Mike Koelzer, Host: I think it all has to go together because you could break things up and without the proper rules in place, these guys can all be playing games with each other and rebates and all that kind of stuff. So they had to be broken along with stricter boundaries.

I imagine Lena 

Benjamin Jolley, PharmD: con did a, I guess listening session with Michelle Belcher, the president of N CPA, a guy from the aids healthcare foundation, the, the CMO there, a patient advocate and talked about what the FTC is doing around PBMs. Um, just, I think this was just last week. Um, and in. Chair con of the federal trade commission gave her concluding remarks and said that, um, this, this process will take time.

Um, the original order gave the PBMs 90 days to respond. That doesn't necessarily mean that they're going to cough up all the documents in 90 days. It means that they're going to say hi, um, I'm disputing that I can, that I have to give you all this information, right? So it may take a year, two years for this study to actually play out and get final results.

But crucially in her remarks, she said that where we find, um, evidence of anti-competitive trade practices, and suppression of competition, and, you know, basically violations of the law, we will not wait till the study is published to take enforcement action. So as this study is ongoing, , they will use the information that they learn to [00:20:25] inform referrals to, um, the department of justice for, um, lawsuits, um, which could include criminal lawsuits.

The Sherman act, um, the Sherman antitrust act is a criminal statute. It's not just a civil statute that attempts to monopolize. The market are felonies 

Mike Koelzer, Host: and that's perfect because in my mind, you've got a guy making, you know, whatever they're making, you know, and they're worth, you know, a few billion dollars someone is or whatever, and you take away a billion, you know, you still got a two billionaire, so you gotta hit 'em where it hurts.

And that's probably sitting in the slammer for a while. Absolutely. 

Benjamin Jolley, PharmD: To Luke's point though. I think that, I think the core of this. So I think that we'll see as time goes on, we'll see, assuming that there's not some DETA or something like that. Um, I think we'll see that. The federal trade commission will find anticompetitive practices and issue enforcement, um, policies saying, Hey, um, this is what we view as out of bounds.

And you, CVS Caremark, your OptumRx, your express groups are out of these bounds. Um, we view this as commercial bribery or whatever, whatever statute they wanna find it under. And they will Sue them in court, get an injunction against that behavior, and potentially find them. And then probably over the course of time, maybe a breakup who knows, um, company breakups of companies.

Luke mentioned there is historical precedent for it, but it takes forever. Um, the breakup of at and T that Luke mentioned took 15 years. a, and we're at the very beginning of those 15 years, if it falls a similar course, breakups during the FDR years were a lot quicker because, um, the, the approach was very different.

Um, FDR, um, uh, department of justice, antitrust head was Thurmond Marshall who, um, Thurgood Marshall, excuse me. Um, who would issue companies, criminal and civil, um, uh, lawsuits at the same time saying, Hey, we're, we are, um, prosecuting you for violation of, of this criminal statute. And we are also suing you for the civil statute.

And, um, when he issued that notice, he would basically just walk up to a company and they would say, okay. Hand, hand me a settlement and I'll sign it because I don't want to go to jail. Um, and he, he also, he also had a lot more, um, public backing for what he was doing because a lot of the companies he was going after were literally selling to Nazis.

Um, and we're basically betraying the US government in its, in its war against, um, against Nazi Germany. And so he had a lot of ammunition to take people to jail. If they didn't play ball, 

Mike Koelzer, Host: who's threatened for jail on these things. Is it the CEO or is it down from there? I know like Madoff and stuff going to jail, but I don't really recall.

And I mean that school, you know, but I don't really recall like CEOs going to jail for something their company did. Is that. Does that happen? 

Benjamin Jolley, PharmD: Not recently. not in the 

Mike Koelzer, Host: last 40 years. That's why I don't remember 

Benjamin Jolley, PharmD: it then. Right. But it is, it is in statute that, um, the principles of a company can go to jail for what the company does.

Um, and similarly, um, that there are all sorts of acts that impose a ton of liability on, on corporate officers that haven't really been enforced. Um, IRISA which was the PBMs favorite act to say your PBM lies. It imposes a fiduciary duty on, generally , the chief financial officer to make sure that a health plan, its assets are properly managed and.

my, um, my status quo in my head is that if you've hired one of the big three PBMs, your health plan isn't properly managed. And so you are personally liable for losses to the health plan due to your mismanagement. But again, that hasn't really been enforced. Um, some employees of T-Mobile sued their CFO for mismanaging their health plan, [00:25:25] uh, like two years ago.

And they won, um, which is kind of fascinating, but that's the first case that I've heard of, of that sort 

Mike Koelzer, Host: that wasn't jail 

Benjamin Jolley, PharmD: time. No, it wasn't jail time. It was just, it was just a fine, but it was personal assets of the chief financial officer. Oh, was 

Mike Koelzer, Host: That right? Personal assets? Yes, 

Benjamin Jolley, PharmD: no kidding. The CFO was the fiduciary of the plan.

So, when they signed up, they were the one, when they signed the documents to say, I am in charge of the health plan that made them personally li. 

Mike Koelzer, Host: Why would they take on that responsibility? Is it just part of their contract? It's just expected that they'll take the fall. Is there any benefit to them except for the CEO not doing it.

And someone has to do it. 

Benjamin Jolley, PharmD: Someone has to be the fiduciary of a health plan. In every case, it has to be someone. And it makes sense that it's the guy who's responsible for the finances of the company. Right. Um, but it's not always, it's just, it depends on the company. It can be as varied as the number of companies in the country.

There are things that our law doesn't enforce or has not enforced for the last, my whole lifetime, um, that the Biden administration's appointees have decided are law that matters, which people hate Joe Biden. His approval ratings are terrible, but if he did one thing, right, it was appointed well, three things, right.

It was an appointment. Lina K Bedoya and, um, Jonathan con, as his antitrust people, because they have taken that job and they're already having an impact. 

Mike Koelzer, Host: I'm familiar with Lena Kahn, where do the other two come in? Are they on a different commission? 

Benjamin Jolley, PharmD: Um, so Bedoya is the other member of the federal trade commission.

He's under Khan. Yes. Yeah. So, so, so it's, he's one of the democratic appointees. Khan is the chair. There's usually two Democrats and two Republican appointees and then a chairperson. 

Mike Koelzer, Host: That's the five we talked about earlier. 

Benjamin Jolley, PharmD: Right. And, um, they served for seven year terms. So Lena Khan has just crossed her one year mark as head of the federal trade commission.

So she's one of the five. So she'll be there for another six years. The other members of the federal trade commission, I didn't mention. And who's the third 

Mike Koelzer, Host: that you mentioned. 

Benjamin Jolley, PharmD: The third person I mentioned was Jonathan Conor. He's the assistant attorney general for antitrust at the department of justice.

Mike Koelzer, Host: How many different divisions are there only two, the department of justice and the FTC, or is there another branch that sort of gets into this fight too? 

Benjamin Jolley, PharmD: Those two are the main ones, but, but, you know, we have all sorts of other similar kinds of entities in the government that all come from the same era.

Um, so the security is an exchange commission, the controller of the currency. I mean, there's, there's all these crazy little entities in the government that no one pays any attention to, but that can have enormous impact on federal policy. But the, but the two main ones for antitrust are, are the department of justice, antitrust division and, and the federal trade commission.

Those are the two that primarily have, uh, Have their job as, as dealing with monopolies, 

Luke Slindee, PharmD: it's probably an oversimplification, but the federal trade commission is kind of like the, the researchers and the gather, the data, make the case. And then the antitrust division of the department of justice is the actual.

Legal hammers. Like they're, they're the ones that the lawsuits are brought by the FTC. And then they go through the judicial system, ultimately arriving at the antitrust division of the department of justice. And then those are where the final legal decisions are 

Mike Koelzer, Host: made. I reference back to the last podcast we had and you guys did such a great job of saying that it's important that we get out of our own little groups and that the pharmacists get out of that.

And the book sellers and the shoemakers and all these things, they get out and they join forces to say that these monopolies are not good for the whole country, not our little segments. That's what we talked about. And now a couple months later, it is a pharmacy. I know healthcare is a $4 trillion industry and so on.

Did pharmacy somehow rise to the top because it was so bad. Or how about these other industries that we said it would be good for all these industries to conglomerate, to go up to the FTC, but pharmacy did rise to the top 

Luke Slindee, PharmD: because people die. 

Benjamin Jolley, PharmD: Hmm. Everyone goes [00:30:25] to a pharmacy. That's the biggest thing.

They maybe 

Mike Koelzer, Host: don't care about the pharmacist as much, but everybody goes to a pharmacy, like 

Benjamin Jolley, PharmD: 90% of Americans take a Medica, a prescription medication, at least once over the course of like a two year period. So, the influence that pharmacy and pharmacy benefit managers have is touched. Every person in the country.

Um, E even if, even if, you know, you're a healthy, young, glad that doesn't have any problems at all, and you just get a, you know, you just go to get your COVID shot. Like you've interacted with a PBM in a pharmacy, almost certainly in the process of getting your COVID shot or your flu shot, or you get a strep throat and you go get an amoxicillin you've interacted with that system.

And so it, it touches so many people, um, the federal trade commission, isn't just doing pharmacy. The they're doing all of the things. 

Mike Koelzer, Host: There's other industries that are maybe getting the same 17 page documents that the PDMs are getting. 

Benjamin Jolley, PharmD: Yes. I mean, just as, for example, an action that happened, that's still in healthcare, but not in pharmacy.

Um, David a dialysis here, uh, tried to buy, um, the university of Utah's dialysis clinics here in Utah and the federal trade commission said, uh, not so fast. Um, that's an illegal merger. You're gonna monopolize the Utah market for dialysis. And the two companies just backed down. They just said, okay, fine.

Um, and the, the FTC I think has issued, um, when, when they've had these mergers like this come in front of them, cuz under antitrust law, if you're making a purchase of more than I think $80 million of one company of another, you have to, you have to tell the department of justice and the federal trade commission so that they can think about it before you actually buy 'em.

And then they have like 30 days to respond and say, Hey, no, you can't merge. Um, yet we want more information, a so-called second request anyway. In the last year when they've, when they've made these second requests, every time the companies have just said, yeah, Nope, nevermind. Uh, we're not gonna try. Um, and so it's been pretty incredible to just watch the, watch the government actually stick up for herself and say, Hey, no, you can't.

And they didn't even have to litigate 

Mike Koelzer, Host: it in court. There's been a deterrent because they've seen that they've toughened up. Yeah. 

Benjamin Jolley, PharmD: The companies knew what they were doing was illegal. They just hoped to slip it past the federal trade commission and the department of justice and they didn't slip past. And they're like, okay, fine.

Well, we'll not do it. 

Luke Slindee, PharmD: It's, it's a total, total shift in, in policy. Like, like the, the whole ship has been turned around and is going back in a different, in another direction, which at the federal government level is a small 

Mike Koelzer, Host: miracle. It's gotta be kind of fun for you guys, cuz this was like your hobby, you know, thinking about the FTC and then this.

Gal came in and here it is changing. And yeah, 

Luke Slindee, PharmD: It's been a very interesting time for people that are interested in this stuff. I would say there's investigations that are ongoing and pharmacy is one such investigation that they're doing, but there's also all kinds of other changes that are going on.

And it was mentioned, um, you know, they're rewriting wholesale, their merger guidelines. So the FTC is currently in the process of completely revamping the way that they review and either approve or deny all mergers, all, you know, every industry above a certain size threshold that, uh, Benjamin referenced.

And so just the effect of that. Going forward is going to be immense. Now some industries, unfortunately, are already monopolized to the point where just affecting the future merger guidelines isn't necessarily going to be enough. So that is the point at which they're going to need to do these investigations and then basically go back and, you know, you can think of a structural breakup.

More or less like a retroactive denial of a merger because these companies got to be the size that they were and attained the market power that they have most of the time because of mergers and acquisitions that happened in the past. And so, you know, pharmacy is no different. You look at all of the large PBMs that are coming under scrutiny.

All of them went through several mergers and acquisitions to get to the point where they're at now. So, um, you know, it's, it's important to kind of understand that, [00:35:25] you know, the merger process and the guidelines for approval or denying a merger going forward is going to change. But they're also now going to retroactively look at some of the mergers that were approved in the past and ultimately decide, you know, was that a good idea?

And if not, that is where the structural breakups come from. 

Mike Koelzer, Host: When I think about laws, And where the PBMs have been able to go, not so much through mergers, but just through their practices. It always seems to come back to money. And it always seems, the conversation always seems to come back to lobbyists, you know, that the lobbyists have so much money, that they do their thing to the legislators and then low and behold, nothing changes in your guys' opinion.

Is that true for this whole FTC thing in the past, but the legislators don't really get involved so much. So it was some lobbying of the trade commission and so on 

Luke Slindee, PharmD: What's the term you use Benjamin the shield of boring. 

Benjamin Jolley, PharmD: Yes. Yes. The shield of boringness. Um, there. It's actually, I think a term from, uh, a great, a great little comic for kids, but sort of like Calvin and Hobbs in this, in this comic series.

There's this little girl who has a friend who is a unicorn, but, um, instead of like in Calvin and Hobbs, Hobbs is a stuffed tiger, not a real tiger. Um, but Calvin imagines him to be a real tiger in this. It's a real unicorn, but she has a shield of boredom that she can turn up so that her parents don't recognize that she's a unicorn.

Um, in the context of, um, government policy, like when we talk about banking policy and PBM policy and stuff, this stuff is so boring, right? Like what we're talking about, Mac prices. And like, I remember going to legislative day when I was in pharmacy school. In Missouri in Jefferson city. And it was sponsored by the Missouri pharmacy association and they got all of the students in my year to go.

So there were, there were 150 pharmacy students on Capitol hill and they had put us all in a room with all these pharmacists from the Missouri pharmacy association. And this, this old pharmacist gets up there and starts talking about Mac pricing. And he pulls up all these spreadsheets and how they've got multiple prices on the same day.

But man, I was bored and this is like my thing, all, all of the rest of the students, they were asleep. Um, even though the guy's describing like these ridiculously terrible, um, business practices, it's just so boring to your average, Joe, that, you know, when the guy starts going into detail, your eyes just glaze over, 

Luke Slindee, PharmD: You know, a lot of terrible things are possible.

Brought, you know, into existence because they're boring, you know, you can get away with a lot of these financial crimes, uh, because you know, first of all, as you've alluded to earlier, it's very difficult to understand. So if you can't even understand it, it's really hard to, you know, to get angry about something that you can't understand.

There's a, there's a word that I come back to a lot called and it's one of my favorite words, it's pernicious, which is defined as having a harmful effect, especially in a gradual or subtle way. And I mean, that is, I think the perfect word to kind of describe this multi decade evolution of PBMs that's basically, you know, caused us to arrive at the point where we are now.

It's been very subtle and little changes here and there, but those changes compound on themselves. and then, uh, so you end up having this very pernicious effect that arrives us to where we are now. 

Benjamin Jolley, PharmD: Uh, I think, I think we gotta go back like 50 years here, um, to, uh, a gentleman named Robert Bo and several other people in the Chicago school of law, um, who founded this movement that was called law and economics, which basically said that antitrust law and other similar kinds of laws should not be seen as protecting companies from each other, but protecting consumers from companies in part.

And also basically it challenged the concept that big companies are bad, which is in statute attempts to monopolize are in the Sheban act felonies. Um, But the brain worm as [00:40:25] Cory doctor puts it, um, that big companies can be more efficient and deliver lower prices. And that the antitrust law is really about lower prices and about consumer, uh, welfare, it just completely changes your mentality.

And what happened is that Robert Bo and his allies wrote all of these articles and books in particular, the antitrust paradox, which then, um, they also hosted seminars for judges and for lawyers that explained their way of thinking. And over time, this caused the federal bench, all of the judges, pretty much all of the judges to be in that line of thinking that, you know, this is about efficiency.

This is about lower prices, not about. Harms to competition per se. Um, and the same thing happened to the head of the department of justice at that time. So I talked about Jonathan contour as being this phenomenal, um, gentleman who has, you know, basically resurrected the concept that, you know, we should actually Sue people.

Um, one of my favorite stories about him is that he, um, he got in front of a bunch of lawyers at, at the department of justice and, and said, how many of you have never lost a case? And a whole, whole bunch of people raised their hand and they're all proud of themselves. I've never lost a case. And he is like, you all.

And I'm quoting him. Here is the chicken club, because what, and what he's saying is that if you never lose a case, that means that you are choosing not to prosecute cases that you might lose. . Yeah. And so even if the government loses cases, that means that they are trying right. They are actually choosing to enforce the law.

If, if someone never loses a case, that means that they, um, that they're only choosing to prosecute the easy wins. Um, and so he's told all of his staff to listen to, uh, what's that rock song that he told them to listen to. Um, oh, I don't remember like me never, gonna, not, not ever gonna give you up, but like 

Mike Koelzer, Host: Benjamin, you just, Rick-Rolled us.

Benjamin Jolley, PharmD: My brain 

got Rick-Rolled there. Cause I can't remember the name of the darn song. 

Mike Koelzer, Host: Come on. 

Benjamin Jolley, PharmD: I won't back down. That's the song, 

Mike Koelzer, Host: Tom petty. 

Benjamin Jolley, PharmD: Yes. 

Tom petty, 

Mike Koelzer, Host: Tom petty. 

Benjamin Jolley, PharmD: I won't back down. He told him to listen to that on repeat until they're excited about 

Mike Koelzer, Host: just 

Benjamin Jolley, PharmD: fighting the big companies. 

Basically the opposite happened in 1980, a new head at the department of justice.

The Antitrust Commission came in and said, Nope. We're, we're just not gonna force the law anymore. That's what happened, 

Mike Koelzer, Host: who Robert stamps sees. Imagine the, the head of the FTC doesn't look at every merger. So who's soft? When you look at the FTC, who's deciding whether these things are okayed. This is 

Benjamin Jolley, PharmD: why Lena con is such a controversial figure at the federal trade commission.

Is that, um, for the last 40 years, the federal trade commission, basically, hasn't been doing their jobs and her, her coming in and basically saying that offended the entire staff, um, who thought we're doing good jobs. We're, we're taking care of consumers. We're doing all the right stuff, but she's like, look, you guys have been letting through all of these mergers.

You've been doing a terrible job. and that really ticks off the two Republican commissioners, Noah Phillips and Christine Wilson, who have, they were both staff at the FTC at one point for, and they've been in there for like 20 years. And so she's coming in and saying, you guys have been completely botching your job.

And they're like, this is my whole career you're talking about 

Luke Slindee, PharmD: here. It's also worth pointing out that a lot of the, I think what you could call the pro big business media that's out there, uh, namely the wall street journal, but there are others that have released quite a bit of articles that have been critical of this new administration.

And that kind of stands to reason. Right? I mean, if, if you're. The art, you know, the journal of wall street and big, big business. Uh, if all of a sudden you have the federal trade commission, actual enforcement, and, you know, uh, cops on the beat, if you will, they're not gonna like that. And so there's already been several what I would characterize as like hit pieces, uh, written about the new administration, because, uh, you know, they don't like them.

They view them as an annoying HIRA in their plot to get all the money in the world. 

Mike Koelzer, Host: I'm guessing every merger over a certain size of company. Does that go up to that five member commission? It seems like they wouldn't see [00:45:25] everything. There's gotta be a ton of mergers that they wouldn't see all of them.

Benjamin Jolley, PharmD: I think it's called the Hart. Scott Rodino act. Um, HSR requires companies that are, I think it's over 80 million. It might be 84 or something. Um, that is merging to file a notice of intent to merge with the federal trade commission and the department of justice to allow those, those E those, uh, government entities to respond.

Um, and last year it sure felt like all of the companies were trying to just completely overwhelm the federal trade commission staff. So they wouldn't be able to respond. 

Mike Koelzer, Host: When you say staff, do those five people actually vote on every merger over 80 some million. I don't know how the 

Benjamin Jolley, PharmD: process honestly works.

Mike Koelzer, Host: I'm trying to figure out who's dropping the ball. Who's soft or who's getting bought 

Benjamin Jolley, PharmD: out. So, the staff reviews every one of these HSR and either lets it go or sends a second request. And I think that my view of how this works is that probably it does go to the five member commission to say, yes, no, yes, no, yes, no, but I don't actually 

Mike Koelzer, Host: know with maybe a lot of input and, you know, they might almost know their answer before it gets to 'em kind of thing.

Plus it's really 

Luke Slindee, PharmD: important to understand the difference between the pre ideological shift versus now, right? So, you know, a lot of the things that were happening for, you know, 40 plus years from 1980 through last year, um, you know, the directives were coming from the very top. So it wasn't like there was like some rogue group of people at the FTC that were, you know, causing something.

It was the whole, the whole agency ideologically was not really enforcing the laws because of the precedent that had started in the 1980s. And so now the ship has been turned around and that's why there's a lot. You know, uh, consternation and disagreement internally and coming from the outside, because everything has changed.

Mike Koelzer, Host: Let's say that both of you guys were out of a job and you're not losing an opportunity, cost and different levels of these FTC jobs open up and you're getting paid the same as they are. Would you take the top position or do you think there would either be too much pressure getting too many attacks from, you know, the press that you wouldn't want it for your family or this or that?

How far up would you go if someone offered you one of those jobs tomorrow? 

Luke Slindee, PharmD: Well, I would, I would, I would be happy with being the chair. You would take it. Yeah, my, uh, my wife always tells me that I'm like one of the most immune people to criticism in the whole world. So, uh, I don't, if people wanted to hate me because of my positions and decisions at the FTC chair, I think I would be okay with 

Mike Koelzer, Host: that.

I forgot this question though. Luke, would you feel confident to take that job? Well, 

Benjamin Jolley, PharmD: I 

Luke Slindee, PharmD: mean, , I don't have, first of all, I'm not a lawyer and that person should be a lawyer. So that kind of instantly discredits me 

Mike Koelzer, Host: there. Why should they be so they know the law or just so they have that stamp behind their name to have some power.

I, I 

Luke Slindee, PharmD: think this is a very complicated subject and I, I like reading about it, but I mean, my, my knowledge is pretty much reading, you know, 10 books about the subject, and then thinking about how, what I learned from those 10 books applies to the things that I see day in and day out in the pharmacy space.

Mike Koelzer, Host: You know, the movie, Dave, you know, where the guy looks like the president and he has to be the president. And so on, let's say you end up there. Could you fake it for a while? They got 300 lawyers that are working for you. I mean, it 

Luke Slindee, PharmD: would be pretty easy to just deny every merger for a while and see what happens.

Mike Koelzer, Host: That's true. , that's true. All. How about you Benjamin? 

Benjamin Jolley, PharmD: Um, well, I wouldn't feel competent because like most of what we're talking about here is people management, right? If you're in charge of, if, if you're a member of the federal trade commission or you're the head of, of the department of justice, antitrust division, most of your job is not, not per se the, um, The like making the decisions, doing the work, right?

It's convincing your staff that this is how we're doing things. And that is not my forte. That is not, that is not what I'm good at. I, I, I am not good at people management at all. I'm happy to ablate about subjects at length. Um, but working through the minutiae of who gets what job that is not my, that is not my thing that I'm good at.

Mike Koelzer, Host: [00:50:25] That's a pretty full plate that someone has, I mean, they gotta have the smarts and they gotta have the tactics and they gotta have the administration. I mean, that's a full-time job, it? It, it 

Benjamin Jolley, PharmD: literally is. 

Mike Koelzer, Host: I might have to work 40 hours a week if I were in that job. this is an 

Luke Slindee, PharmD: agency that we, as a, as a, as a nation need to expand their resources.

You know, we need to give them more funding, hire more people, you know, all of that. Uh it's you know, it's kind of analogous to the whole IRS concept where I know nobody likes to pay their taxes, but if we have an underfunded under-resourced IRS, it makes it that much easier for people to cheat on their taxes.

So if we wanna have an agency that's performing well, it has to be, you know, well resourced from that perspective. 

Mike Koelzer, Host: Now going to the evil side, if you guys were both heads of the PBMs, all right, now we wanna make this true to life. So take all your morals away. you can't bring any morals into the job, but you do want to avoid ending up in jail.

I'm not saying you're gonna do everything right. But you can't get caught. And one of your biggest goals is just improving your stock value. What are you gonna do for the next, you know, five years as head of the PBMs? And let's say you guys are each ahead of your own PBM and you're one of the top three or whatever.

How do you defend against this? 

Benjamin Jolley, PharmD: Well, 

I can tell you what JC Scott, the head of PCMA is doing. 

Um, 

and that seems to be just lying through his teeth about what they are doing. 

Um, 

just saying, no, that's not what we do. We save people money. No, we don't, we don't take bribes. These are good for people and just repeating the same talking points over and over and over and over again.

All right. But now I'm Benjamin. You get this 17 page. Document, how are you gonna play out the next five years to still end up on this evil mountaintop? 

The first thing that I would do is, uh, try to get a court to throw out as many pieces of that order as possible. If I'm writing express scripts, I've been through.

More lawsuits than I have hairs on my head. And so I know which courts are friendly to me. I know which courts are not. So I'm gonna go to whichever court is the most friendly to me and say, Hey, I need you to say no, they can't do this. No, they can't do that. Try and gum up the works as much as possible, just like 

Mike Koelzer, Host: in two small businesses suing each other are family.

They've got the discovery and half of 'em the attorneys come back and say, you don't need this. This is overstepping. And then things like that. So that's what you would do. You would cloud 

Benjamin Jolley, PharmD: that up as much as possible. That's that's the first thing that I would 

Luke Slindee, PharmD: do. It'd be very effective for them to continue to deflect as much as possible.

Right. So, uh, point out, you know, hammer the point home over and over again, that manufacturers are the ones who raise the prices. Right? So deflect as much of the negative energy as you can towards. The manufacturers then when you run outta steam with that, then make sure that you place all the blame at the planned sponsors that hire 

Mike Koelzer, Host: you.

Are you saying, do that in the document or are you saying turnover? What you cannot ignore and then in the court of public opinion, do these things, or maybe once you've already sent this in and you start taking the next step, 

Luke Slindee, PharmD: I guess that those are two different strategies. So in terms of turning over the documents as part of this official investigation, there's this term that's become really popular since like 10 years ago.

And it flooded the zone with shit. 

Mike Koelzer, Host: give 

Luke Slindee, PharmD: too much. Yeah. Give them, uh, an unbelievable amount of information mixed in a ton of stuff that is false. Um, make it really, really complicated so that it's as hard to decipher as possible. Make it. Half of the information is true and half of it isn't and just basically, you know, it, it's a lot, it's a lot more effective and, you know, unfortunately we've seen that it's really effect over over the last 10 years and a lot of different arenas to, instead of hiding information or obscuring it.

Um, sometimes it's more effective to just basically just spew out as much information as you possibly can and make sure that enough of it is [00:55:25] false, that you plant the seed of doubt into everyone's heads. Nobody knows whether the information is correct or not. They are the experts in what they do. Uh, there's an informational asymmetry.

So basically think about the amount of effort that would have to go into disproving information that they provide. You'd have to round up every other counterparty. You'd have to go out and get all the pharmacies on board and all of the health plan sponsors and everybody else that interacts with them and cross reference all of the information across all those different places, and then make sure that that corroborates with what they gave you in their official submission.

Just think about the sheer amount of effort that would have to be involved in all of that. And so, you know, that's why it's really easy for them to put out misinformation because in order to disprove it, the onus is on you to disprove it. But the amount of effort that has to go into that is 

Benjamin Jolley, PharmD: enormous.

I'm just thinking, as Luke's talking here, if I'm a PBM, I just take all of the claims data that I have from the last five years. Just every single line item. You know, we've, we're talking probably a te bit multiple, multiple paid a bits of, of Excel spreadsheets and just don't send a data dictionary of what the column headers are.

Delete, delete one of the columns. That's like the index to be able to say, okay, this goes with this, like delete the prescription number or the, or, or something. So that now, now you've just got like these two spreadsheets that are like a paid bit each. And the unique reference number that links this spreadsheet to this spreadsheet is gone.

So. Good luck, have fun. This is actually kinda fun to think about how, how annoying you could be if you really wanted to. If anyone at express scripts is listening, please don't do that. Please 

Mike Koelzer, Host: comply. When I was in college, I was in this house and computers were relatively new. It was the late eighties and someone had shown me how to save something to the disc.

And so I told some of the guys, I knew how to save it. I saved it all like in the hieroglyphic font and there was no way to reverse it. so that kind of thing, that kind of thing. All right, so you hand all this crap over and they can't disprove it really 

Benjamin Jolley, PharmD: well put on my optimist hat here.

There's enough crap going on that I, I cannot imagine that like taking even a cursory glance at all of the contracts with any fraction of knowledge of what's happening, it becomes immediately apparent that this. This is BS. 

Mike Koelzer, Host: I take back what I said about disproving it, because I know it'd be hard to go to like individuals and individual pharmacies, but you could probably get stuff from insurance companies and the manufacturers that they could do a similar thing.

And pretty soon you could pretty quickly, you could line up that it's baloney, 

Benjamin Jolley, PharmD: just a standard template. PBM contract probably contains at least five violations of law. In my opinion, just the contracts just, just the like 20 page template contract. Just that alone. If you look at it with understanding of the industry, I'm fairly certain that offering to reimburse a pharmacy at WAC minus 13 has to be illegal under some statute somewhere.

Um, especially if they get a copy of my contract and they get a copy of the contract, that's offered to Walgreens and mine says WAC minus 13, and there says WAC minus four. Um, that, that has to be illegal. Somehow I wrote a blog post about this last night. I read that the structure of brand name drugs is that pharma pharmacies buy drugs on average at w minus four, but really wholesalers buy it at WAC minus two and a half.

And, PBMs buy it from pharmacies at w minus 13. In some cases, this is not the way that supply chains work. Things don't get cheaper as you go from one end to the supply chain to the other. Right. Um, but that's the way that the pharmacy brand Mar market works. Everything gets cheaper. The farther you go down the supply chain until you get to the last step, and then it goes way through the ceiling.

I'm pretty. 

Mike Koelzer, Host: We maybe skew the database and then you're the CEO still, you turn it into them. And then do you just sort of wait or do you pack your bags for, uh, Tahiti or what do you do? Do you put the best spin you can on things until you're either fired or you're put in jail or you retire happy? I mean, 

Luke Slindee, PharmD: isn't that just every corporate executive's mindset all the time.

You're 

Mike Koelzer, Host: right. The CEOs [01:00:25] that have risen to the top, that's how they live. This FTC thing is they've got a hundred of these things going on, different lawsuits and crap like that. That's how they live. I, I, 

Benjamin Jolley, PharmD: I think that for this, there's an attitude that is. in government and in big corporations, um, that's referred to, as I B G Y B G, I'll be gone.

You'll be gone. yeah, that you do, you do whatever you're gonna do, but by the time the crap hits the fan and the government comes to get you you're, you've already retired, 

Mike Koelzer, Host: you're gone, or else the person following you retires and someone new comes in and kind of forgets about you. Most of the mergers 

Benjamin Jolley, PharmD: that we're talking about happened.

Say if we take CVS, as an example happened under the auspices of Larry Merlow, he's no longer there. It's Karen Lynch now, right? By the time the, the crap hitting the fan at someone else, who's in charge who was not responsible for the decision to merge with Caremark was not responsible for the, the, for the decision to merge advance in PCs and advance PCs with Caremark.

Is there anything 

Mike Koelzer, Host: else you would try to do it as a CEO? Well, 

Luke Slindee, PharmD: I think you would want to continue to make it as hard as possible for the general public to get access to real pricing information. I would also reach out to every pharmaceutical manufacturer and continue to encourage them to only develop drugs for basically orphan D diseases.

And, um, because that business model has worked out tremendously well for everyone involved, uh, effectively we, as a society have said that no, there is no expense that we won't pay. Um, if someone has a certain medical condition and there is a drug that at least shows that there is some benefit for that medical condition that you can charge literally any price and it will get paid in one capacity or, or another.

There are fewer patients there that have a condition. It's an easy justification to just raise the price. And I would disincentivize and try to get pharmaceutical manufacturers from never again, making something like the next Lipitor 

Mike Koelzer, Host: reverse that hat. Now, what might you do to try to neutralize some of these evil CEOs 

Luke Slindee, PharmD: voting is important?

Uh, I think one really positive change is that the FTC has now made it a lot easier to provide comments. Uh, that's, that's something that we didn't particularly address earlier is that, you know, why was there such a change in, you know, from the previous vote that was two to two and now it's five to 

Mike Koelzer, Host: zero.

Yeah. It's like 24,000 comments. Right. And there's only 20,000 independent pharmacies. 

Luke Slindee, PharmD: Exactly. So, you know, the FTC has created avenues for people to make their voice heard on very specific issues. And it doesn't have to go through the mediation layer of your local re uh, you know, Congressperson. You could, you can directly make your feelings known to the FTC and they're giving people avenues to do that.

So I strongly encourage people to do that. And, uh, to the pharmacy owners out there, I would suggest, uh, sharing as much information as possible with other pharmacy owners. Uh, I really can't stress that enough. Um, the. There are these very large organ multi-billion dollar organizations and they are doing their thing.

And I think that if we're going to get traction and understand how to influence political power, it's, it's, it's critical that pharmacy owners share as much information about their operations with other pharmacies as possible. Because I would say that there are a ton of bad things that happen to pharmacies that are done by multi-billion dollar organizations.

And it occurs because. This pharmacy owner is not aware of what's happening to the pharmacy owner and then town in the next town over, or the next state over, or what have you. Um, there is an incredible amount of harm that comes to pharmacies, small pharmacies, because they are not aware of what is happening to their counterparts.

So I would really, really strongly encourage pharmacies to share as much information with each other as possible, including contracts. Um, Pricing acquisition costs, all that kind of thing. Uh, I know that that might seem a little revolutionary, but [01:05:25] I think that it is in the interests of pharmacy owners to basically be as communicative and informational sharing with each other as possible.

And that is a way that you can start to, uh, fight against some of these anti anti-competitive business practices that are done by large companies that are intentionally designed to splinter all of the smaller pharmacy groups apart from each other and keep 

Mike Koelzer, Host: them in the dark. Once in all you hear about these guys, and these guys have gotta be idiots that they're these business guys and you find out they have.

A wife in like four different cities. I mean, I love my wife, but I only want one of 'em. Are you saying that these pharmacies share this because they're all kind of getting screwed, but they don't really maybe see all the ways they're getting screwed and they kind of say, Hey, did you look at this? Do you understand how this is hurting you?

Is that what you're saying? Kind of commiserate and really understand how terrible this is for you. Well, I 

Luke Slindee, PharmD: think to follow your metaphor, if I was one of the four wives. And I didn't know about the existence of the other three wives and what was happening to them, with our shared spouse. I, I think you would be greatly benefited by communicating with the other wives and sharing as much information with each other as possible, 

Mike Koelzer, Host: But doesn't every pharmacy already know that they're getting screwed.

No, they don't because it's something in the contract, they don't realize it. Or maybe they don't realize how bad the DIR is because they don't put two and two together kind of 

Benjamin Jolley, PharmD: thing. In my experience, in talking to other pharmacy owners, the amount of crap that goes on that people don't realize just as, for example, here in Utah, um, our state law prohibits PBMs in audits from auditing more than 100 claims.

PBMs interpret that as prescription numbers, but that is not what the law says. And so they will issue an audit that is not in compliance with the law. If the pharmacy knows their rights and pushes back, then the PBM will back down. But if you don't know, then you don't know, and you get audited on this much larger audit.

A and the number of pharmacy owners that I've talked to and pharmacy managers that just don't know that that law exists and that they have such rights is, is a surprising number. Like I, I, I talk to a pharmacy owner, just 20 miles south of here who got an audit of 300 prescriptions from a, from a major PBM.

And, um, and I told him, Hey, just send them back, Utah state code this, um, you can't do this and they'll have to cut it back. And so he did and they did, but he had no idea. I didn't know this four years ago. And that's just one very small example, but, um, there's, there's so much stuff that happens. I mean, the number of price lists that the big companies and not just the PBMs, but also our wholesalers have like the big wholesalers have as many price lists as they have pharmacies, it feels like, and the big PBMs have as many price lists as there are people in the United States.

Right. And so if there's, if there's one price for every person, then there's not a price. 

Mike Koelzer, Host: Couple weeks ago, the FTC came out with this letter. Two days later, I gave a talk to a rotary club and I said, by chance, I'm up in front of you people here. And this is the best news I've seen in pharmacy in 25 years.

True. 

Luke Slindee, PharmD: Yes. Yeah. I would agree in terms of, uh, directionality we're we're, we're at an inflection point. I think you could make the case and to be honest with you, it, you know, this is personal for me because you know, it, uh, I graduated in 2008 and I've been a pharmacist ever since then. And. I hate to say it, but I feel like our profession has just steadily gotten worse every year, year over year, since that time.

And, uh, and my father, I was a pharmacist for 42 years and that means that for probably at least the last 22 years of his career, everything was getting progressively worse. Uh, and then he retired. So, you know, psychologically that's pretty difficult. Right. Uh, but, but to your point, uh, in terms of the best news, I would agree because I think we are at finally an inflection point where things could be there, there at least is a way now that we can stop the bleeding.

and start to move in a different direction. 

Benjamin Jolley, PharmD: I, I, I'm thinking of this in terms of like a double derivative that the, [01:10:25] the acceleration has changed. We've, we've made the change in acceleration from constantly going worse and worse and worse, faster to things are starting to slow down how quickly they're getting worse and maybe starting to move back the other direction.

That doesn't mean that things are getting better right now. I think things are still continuing to get worse and I think they will. For the next couple of years, margins at pharmacies will go down staff staffing conditions at big chains. Pharmacies will continue to get worse for a couple more 

Mike Koelzer, Host: years.

They're not getting as bad 

Benjamin Jolley, PharmD: as quickly. That that's what I'm thinking is I, I think that it's, I, I think that we're about to turn the corner here where things start to get better, but it's hard to keep that optimism, 

Luke Slindee, PharmD: but the seeds of that are being planted right now. 

Mike Koelzer, Host: Well guys, golly, Benjamin on SNL.

They've got like a five timer jacket and you're at four now. So next time you're on here. I've gotta get you like a five timer you're in the lead. The reason you're in the lead is because you bring good information. So thank you. You're 

Benjamin Jolley, PharmD: welcome. I, I, I expect a, uh, five years of service or something pin 

Mike Koelzer, Host: you got it.

Something like that. Something of high value? Yes. . 

Benjamin Jolley, PharmD: I want a little pin that says the business of pharmacy podcasts. Five timer. I'm gonna put it on my white coat and wear it next to my five gallons of blood or whatever it is, 

Mike Koelzer, Host: Luke. You're at two now, but, uh, you'll get there. 

Luke Slindee, PharmD: I mean to your comments earlier, you know, this is going to be an ongoing thing for quite some time.

So, I mean, I think it probably makes sense to at least have an annual check in to be like, all right, where are the pharmacy antitrust issues at now? Absolutely. 

Mike Koelzer, Host: Thanks guys until next time. Thank you. Thanks. Talk to you soon. Bye bye.