Legal Fights Against PBMs | Greg Reybold, Atty, Georgia Pharmacy Assoc.

Speech to text: 

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

Greg Reybold, Atty: name's Greg Reybold I'm, uh, the general counsel and vice president of public policy for the Georgia Pharmacy Association. We do a lot of work in the Georgia capital advocating for the profession of pharmacy, for the protection of patient rights.

And a lot of that happens to be dealing with abuses and problems with pharmacy benefit 

Mike Koelzer, Host: managers, talking to good pbms. Usually the difference between the two is they say, well, Mike, we're a transparent PBM. We're not an opaque PBM. And that's where your problem is. And it's like, I'm not sure if I wanna be a transparent PBM, then I can just watch 'em screw in me.

I think I'd rather do that. I think I'd rather do that without seeing it right. it can't be that simple. Just that we wanna see stuff. Hopefully there's more protection for pharmacists than. Seeing what they're doing wrong. Right. 

Greg Reybold, Atty: Absolutely. And I, you know, and I think there's some implications when a pharmacy benefit manager says that they're a transparent PBM implicitly in that often is that they're engaging in practices that aren't manipulative as well.

Not always the case 

Mike Koelzer, Host: when the light shines on it, you're not supposed to just be doing terrible things still. That's supposed to clean 

Greg Reybold, Atty: things up. I think that's right. But now what I would say is when we think we see some light shining on something in the, in the prescription drug industry and pbms, we're seeing Slivers of light, we're certainly not seeing the whole picture, but it's sort 

Mike Koelzer, Host: symbolic of cleaning things up.

Yes. I think that's right in these movies, let's say there's a detective movie. Right. And every movie that they have a scene of these guys going to the dark strip club, you know, and having to pull out this guy and talk to him, you know, and again, symbolism it's like you think to yourself, that movie cliche of the strip club has to be the most degrading.

Uh, thing we can put on the screen of degrading women and drinking and smoking. And is that a walk in the park? Compared to working with pbms because the pbms have really screwed people over. We have these terrible views in our head, but is there anything more Cy than a PBM or do we just hate 'em that much?

Because it's our 

Greg Reybold, Atty: industry. That's a great question. An interesting analogy. Right. Um, so, you know, in my head, when you picture that movie scene, right. Where, where, you know, it sort of represents the, you know, the CD underbelly of America, right? Like that's, that's what they're trying to capture here.

Yes. And so, you know, with regard to pharmacy benefit managers, uh, you know, obviously they're, they are now amongst. Some of the biggest companies in the world, right? These are, yeah, these are monster size companies. Um, you know, I, and look, you know, there are big corporations, you know, across industries and, and the larger these corporations get, you know, the more aggressive they're gonna be, potentially the more comfortable with risk they're going to be, um, you know, certain practices get, you know, they get so large, there may be some guy at a PBM who flips a switch.

You know, who's a numbers guy who says, Hey, listen, if we engage in this practice, we can monetize this thing even more. Right. And so, you know, there are all sorts of businesses when you get to a certain size that get really aggressive, and big decisions have to be made. And I'll give you, you know, when I was in my first, uh, I think it was my first year of law school.

I remember something that was really eye opening. This is a digression, but I'll bring it back quickly. But it was, you know, it was a case study about an automobile manufacturer who essentially, they knew that of, and I'm gonna butcher this a little bit, but you know, of. You know, if, if they sold a million cars, a thousand, we're gonna spontaneously combust and explode.

And Hey, you know that, a lot of people are gonna die. Do we bring it back? And you do the math and, and it's like low and behold, Hey, listen, X number of people are gonna die. Let's call. 'em a hundred of that 50. You gonna Sue that 25 are gonna, you know, take a low settlement. We go to trial on some, but all in all, we're gonna sell X number of cars.

Let's roll. Let's roll 'em out. Right. Let's sell those cars. That was the old Pinto. Right? I don't remember you young 

Mike Koelzer, Host: kids don't remember that that's old farts. That was the old Pinto, but that's the example they use. It's a 

Greg Reybold, Atty: numbers game. Yeah. It's a numbers game. With prescription drugs, you know, look, it's, it's a massive market, right.

You know, prescription drugs are big business and frankly, uh, you'd be hard pressed to find bigger business. And so what I mean by that ispbms. Obviously you've got some, some huge, huge companies, you know, your CVSs, which bought Aetna, imagine that you've got express scripts, which was bought by Cigna, but look at wholesalers, right.

You know, wholesalers are in the, you know, the three big wholesalers are, you know, two of them I think are in the top 10, three of them are, are in the top 20. Right. And so you start looking at the prescription drug market and it's, and it's big business. Right. And then you've got obviously huge pharma companies.

Then you've got managed care companies that are, you know, think Sentinel now, which before the affordable care act, wasn't on the fortune 500. And now I don't know their most recent placement, but they're well within the top [00:05:00] 50. Right. So, you know, healthcare and prescription drugs in particular is big, big business, but what pharma, you know, what pharmacy benefit managers have done to me.

and I always liken it to my father being an old wall street guy and he engaged in arbitrage. Right. And so, you know, merger, arbitrage, convertible, bond arbitrage, um, and, and what is arbitrage, right? It's it's, you know, they're, they're capitalizing on imbalances in marketplaces. And what pharmacy benefit managers have done is, you know, arbitrage on the grandest scheme that it's ever been played, right.

They create imbalance and on every, you know, almost every section of the drug equation, right. They have found a way, the big ones to manipulate and create imbalance every step of the way. And to then monetize that. And I don't know of another industry. Where you have these, you know, just, just such giant companies with these just opaque and obscure practices that, that they've monetized it in the way that they have with prescription drugs.

And I think what makes it more acute frankly, is that this is something that's harming patients, right? It's certainly harming pharmacy. It's certainly harming the practice of pharmacy. It's certainly harming the business of pharmacy, but it's also harming patients. And, and look, I think you, when you look at larger healthcare insurers and, you know, I think folks are looking at pbms are like, Hey, you know, how can we replicate that elsewhere?

Right. Um, and so, you know, it's, it's, it's really truly a unique situation. Pharmacy benefits managers and sort of the system that they've built and we're playing in their world. 

Mike Koelzer, Host: I ain't no genius, but I learned a couple years ago about weather, more and about low pressure and high pressure. When you have low pressure, it allows.

The high pressure comes into the area and that's why you get a change of weather. So it'd be like if a balloon has high pressure, it's always gonna try to get its air out into lower pressure to equalize itself. Mm. And with the PBM, it seems like maybe every industry would do this, but. In pharmacy, there's such a difference between pressures.

You know, there's such a difference between arbitrage. It's just huge. And so, as it balances out, it just looks terrible because it's such an imbalance. 

Greg Reybold, Atty: That's a good analogy. I, I think, and, and there's just tremendous imbalance, but what they've done, you know, maybe better than any other industry and what I mean better, I mean, worse is, you know, it's so complicated.

It's so complicated and, and every sort of side is in the dark. Right? Right. This is what I do for a living. Right. I'm a healthcare attorney, uh, you know, public policy person, but it's, I mean, it is a tough thing to get ahold of because it's just, you know, it's so massive this system that they have built involving commercial payers, involving private payers involving governmental payers.

Um, and it's so incredibly complicated and, you know, they found a way to exploit that in EV you know, again, every step of the way, right. You know, they're getting rebates from pharma to develop formularies, you know, they're steering patients to pharmacies that they own. They're designing plans that do just that with regard to reimbursements, obviously we're all, you know, I'm sure your audience is well versed with spread pricing and some of the things that have come out in that realm.

Right. Um, and so, you know, every step of the way they're paying, you know, charging. They're clients more, they're reimbursing pharmacies less. Um, they're coming back on the back end. You know, even if you cut out spread pricing, that's all well and good, Hey, you know, no more spread pricing. Great. But guess what?

They're coming back on the back end and they're imposing fees, right? Um, and so, you know, every step of the way they manipulate that process and what happens is, you know, the business of pharmacy becomes more and more unsustainable. Every year, patients are being impacted in the pocketbook every year.

Their copies are manipulated because it's not the true price. You know, of the drug. When you get retroactive fees, payers are paying more providers like oncologists and pharmacists who see that patient care is being compromised. But year over year, over year, their profits grow and grow to the point where some of these companies are amongst the biggest companies truly in the world.

How the 

Mike Koelzer, Host: hell did pharmacy get so complicated? Is it because of all the players or how did it get so opaque compared to let's say the car industry, for 

Greg Reybold, Atty: example, boy. Yeah. I mean, great, great question. Um, and you hate to, I hate to lay it all at the Fido pharmacy benefit managers. Right. But they have. they have E they've evolved.

Right. And they've evolved quickly. Um, and you know, you look at like the growth in DIR fees from, from 2010, right. To 2021. It's like, it's, it's make, make believe numbers. Right. Um, and so, you know, I, I don't know that I have a good answer for your question, frankly. O other than, you know, the system has been it, this is by design, 

Mike Koelzer, Host: It's been in the dark on purpose.

Nobody wants to talk. 

Greg Reybold, Atty: Yep. It's, it's been, it's been in the dark. [00:10:00] Um, and, and frankly in ways it remains in the dark. Um, and, you know, and, and look pharmacies in certain ways where the, you know, independent pharmacy in particular was the Canary in the coal mine. Right. They've been, they've been preaching about this stuff for, I remember when, you know, the first independent pharmacy I represented, um, you know, you know, shoot, they, that, you know, they, they were, they.

Preaching about the stuff for years before you saw really significant legislative action in ways it's a fascinating political story. And you know, it wouldn't shock me, look I'm into it. And I'm nerdy about it. I love, you know, I love the issues and the subject, but I, you know, look, it's, it's a, it's an amazing political story of underdogs, you know, small businesses standing up for their patients and, and, and for what you know their business is and what they believe and, and, you know, being able to make some significant strides.

Right. I mean, it really is amazing. It's not easy to pass any law, right? Period in any, any state it's really easy to kill a bill. It's really hard to pass a bill. And if you look at the last, you know, five to seven years, what pharmacy has been able to pass in in ways? It's a fantastic story of, of right.

It's David and Goliath. It's, it's these, you know, small, independent pharmacy owners and small associations. Um, and, and. You know, who, who are willing to come up against 40 contract lobbyists, 50 contract lobbyists, and it's, you know, folks who are on, you know, main street, America and legislators who are willing to listen to them and, and stand up to sort of these big behemoths, the problem is they evolve quicker than we do.

Right. Um, and, and what I mean by that is we're always, you know, for years, pharmacy fighting audits, right? We're fighting audits, which are certainly a pressure point. If you're a business owner. No, no question. Right. It's a pressure point in an audit. But while pharmacies are worried about fighting audits, you know, they're sucking.

You know, half your patients out of the back door and they're, you know, nine steps ahead implementing DIR fees and, and, and practices of spread, pricing, et cetera, et cetera, et cetera. And so in ways, you know, we've made amazing strides and there's a lot of work in Georgia and, and nationwide that I'm super proud of.

And it's really neat to see. Um, but that said, you know, pharmacy has to up its game more still because these practices continue to evolve and evolve and 

evolve. 

Mike Koelzer, Host: You followed the me too movement, a few years back or whatever, with these creepy Hollywood guys. I think that the only chance that pharmacy had of catching up with these scoundrels was the internet people talking and LinkedIn and the podcasts and all this stuff.

Like you say, you know, you've got the audits. And then in that few minutes, while we're arguing, they took 10,000 out the back door without us seeing them. And I think that the internet is the answer to shine. Like we talked about this symbolic transparency on this, and I don't think without the internet, we would be able to even come close to watching the back door.

Greg Reybold, Atty: I agree. It's a unique time in that we, you know, the internet is out there and the, you know, the social media and the ways to communicate and, and the, the, the spotlight that does get shined on these practices is, is really amazing. Look, your podcast has, has brought a lot of attention to this, um, you know, Antonio with 3 Axis advisors, right?

And like the, the, the attention that he's gotten to these practices has been amazing. And, and, you know, APhA is shining a light, right? So, so, and social media's spreading, right. But I think, you know, pharmacy and particularly not just independent pharmacy, but independent pharmacists have been amazing at really utilizing social media and, and technology to spread this message.

Mike Koelzer, Host: Speaking of Antonio, you kind of have that tough look. I look like an old fart, but you and Antonio are tough. Good looking guys. Remember the right stuff or one of those movies where they showed like those four astronauts walking at you, you know, it's gotta be you and Antonio at least. And there's probably a bunch of other guys too, but you needed to be the face of 

Greg Reybold, Atty: this.

You, my friend, just made my Christmas list. I could tell you that 

Mike Koelzer, Host: So we all just want bitch about pricing and we say, we want it transparent. And we talked about symbolism and so on. But now that I'm talking to an attorney here, what are some more specific problems with thepbms, rather than just a guy in the street like me saying, we want to get paid.

For example, when I looked at Arkansas, you know, it's like, oh, okay, well they're fighting, but Georgia had some talking points in there or something. What are some of the details of 

Greg Reybold, Atty: this? Yeah. So, you know, I think the big picture and, and we can go narrow, right. But big picture, you know, we've gotta start fighting big fights.

We've gotta fight the right fights. Um, you know, we're, we're never gonna outspend. That you know, that, that that's for sure. Right? So we've gotta pick the right fights. We gotta pick the right forums and we have to do it precisely. I always say this it's, you know, it's, it's precision beats power 

Mike Koelzer, Host: overall. We have to find a [00:15:00] method, whatever the method is, but it's not gonna be lobbying.

Greg Reybold, Atty: That's part of it, right? Advocacy is part of it, but whatever we do, you know, we have to, we have to pick the right fights and we have to do it aggressively and we have to do it precisely. Right. And, look, it truly has evolved when you look at, you know, in 20 14, 20 15, the world was looking at audits.

And when you start doing Mac pricing, you know, in Georgia, in 2017, we did at the time, what was first of its kind, this pharmacy patient protection act, which is, Hey, instead of going and talking about one really complex issue, let's get something on the books that's akin to unfair and deceptive trade practices, right?

That's Hey, let's get a code section that says pharmacy benefit managers engage in bad practices. Those practices need to be stopped, right? Maybe it's mandatory mail order, maybe it's gag clauses, uh, maybe it's copay, clawbacks, which you may remember those, you know, where a patient pays a $50 copay, but you know, the cash price of the drug was, was, was 20 and the PBM clause back 30.

Right. Um, and so we, you know, we got that on the books and, and you start seeing that happen elsewhere. And these, this then, you know, the next year, Arkansas does just some awesome, awesome stuff. Um, Ohio obviously has done amazing things in Medicaid, Louisiana. There's so many states. Um, and then, you know, what we started focusing on, I was really excited and I believe this was the right fight for 2019.

And we attack steering kind of from a two pronged analysis, right. Or from, or sort of two points. One is, Heypbms, you shouldn't be able to engage in steering. Right. It's harmful to patients. Um, it's, it's, it's, you know, typically in healthcare steering is persona non grata. You can't do it.pbms have done it again on the grandest scale it's ever been done in the world in healthcare.

So we attack it from the PBM side, but then we also attack it from the pharmacy side and we say, Hey, pharmacies, if you're affiliated with pbms, you know, if you share ownership, not only can the PBM not. Steer, but you can't fill it and bill it. Um, and so, you know, we started, you know, cause again, steering I think is, is one of the main issues 

Mike Koelzer, Host: and Greg, just for the listeners.

So the steering is telling a patient, you have to go to a certain pharmacy. And the pharmacies you're talking about is because of the vertical integration, thepbms own these pharmacies. So it's like, wait a minute because you own the pharmacy for sure. You can't steer 

Greg Reybold, Atty: towards them. Yeah, that's right. And so what, what we saw and, and again, you know, it it's, it, it was happening on a massive scale.

It still is, but pharmacies that are owned by or affiliated with a pharmacy benefit manager. Right. And, and you've got these pbms who are. You first, you know, and probably most insidiously they're, they're targeting the sickest patients across the country, right? Patients with cancer, patients fighting HIV and you know, who are on a lot of specialty drugs.

And thepbms are forcing these patients to, to get those drugs where at pharmacies owned by them often mail order pharmacies, right. It delays care. And again, I, I, I think if you look at like three access advisors, I've done amazing work on things like prices and reimbursements in the specialty market. And, and you know, what you'll find is, you know, that's where the biggest profit margins are.

That's why they're steering those drugs there. Right. And, and, and they're, they're, you know, engaging in those practices. And of course then it goes not just from, you know, the very specialty drugs, but also your maintenance meds. Right. And so from a business perspective, if you're a, if you're a small pharmacy and independent pharmacy, heck if you're a large chain pharmacy that's not affiliated, what are you left with?

Right, right. They've taken, they've taken your sickest patients. They've taken your chronically ill patients and they've left you with, with, with penicillin and ADHD. Right. You know, I mean, that's, that's that's so from a business perspective, obviously steering is incredibly anti-competitive, right. It's not, it's not allowing pharmacies to compete based on the care they provide, it's steering patients against their will.

Um, and that's what they're doing. And then from a patient care perspective, you know, and I, I talk to oncologists weekly and we work really closely with, you know, like the oncology association here in Georgia and my God, right? I mean, you wanna talk about sad and compelling stories of patients who, you know, had to wait three weeks to get their drug.

And then by the time it came, their blood levels were different. And, you know, they had to wait another three weeks to get their drug and the adverse impact of that, or patients trying to self-administer a drug or brown bagging. And so, you know, the, the. You know, it's look, it's an incredibly insidious practice.

And it's an example of, I think the larger problem, but I would say when you start TA tackling issues of, you know, obviously you had, you know, the Mac pricing, great, you know, you know, you see audits being, being tackled, and then you start, you know, playing kind of in a, in a bigger, you know, let's go after more material things.

And there's a lot of action in steering. There's no question about it. And so I, you know, that was great. The 

Mike Koelzer, Host: audit and the Mac pricing was maybe low hanging fruit, something like steering 

Greg Reybold, Atty: deeper. And why is that Georgia? You know, we've done a lot of work with audits and we've done a lot of work with Mac pricing.

You know, we passed a, I think in 2015 or 16, we passed a Mac pricing bill and, and so it's not to. Devalue that [00:20:00] work, right? I mean, it's all, it's all progress and it's all moving forward. Um, but again, if you're, if you're worried over a $500 audit recruitment, which is maddening and wrong, but they're taking, you know, all your chronically ill patients and, and all your patients fighting for their lives, what's left, right.

What's left when they can create a market. It's a bigger deal. I think it's more insidious, but here's the thing it's, it's fighting the right fights. And I think steering is a step towards that, towards that evolution. But to me, the big news out of, you know, PC Navy Rutledge was, was huge. Right.

But my takeaway isn't, Hey, everybody, let's go out and pass Mac laws. Mm-hmm , it's significant, right? If you have a Mac law in the books, all of a sudden, you know, for the first time we've got a green go light, Hey, this can, this can get enforced in the commercial market. Cause that's what Rutledge 

Mike Koelzer, Host: was. That was 

Greg Reybold, Atty: more of a Mac thing.

Sure. Right. That was, you know, that was, you know, Arkansas's. Mac pricing law preempted by Rissa. So you've got the, you know, the fully insured market and then the self, you know, the self-funded market. And, and so it gets complicated, but the takeaway was, Hey, listen, states can, you know, a state Mac law Arkansas's Mac law was enforceable in the Rissa market, including the self-funded market.

Right. And so, you know, think large employer plans that are self-funding and is that Preen by risk or isn't PCMA, the PCMA B Rutledge, the Supreme court says, Hey, states can regulate that, but, but the takeaway isn't, Hey, go pass a Mac law. You know, if you look kind of deeper, you know, that holding is, Hey, listen, states can, and you know, states can regulate costs.

States can regulate costs. And so as a, you know, as a, as a person who spends a lot of time thinking about this. It's great to regulate Mac pricing. If that's, if that's what you've done, we've done it. Or if that's what you wanna do, that's fine. But at the end of the day, we're still living in their world.

Right? And so what I would propose is, you know, nationwide, if, if, if we're going out trying to pass Mac pricing, we're fighting the wrong fight, right. We're fighting the wrong fight because it's the deeper issue. It's not that, Hey, you know, they're not updating pricing. They're not, they're reimbursing pharmacies.

There's no question, but you know, if they evolve, right. So if it's not Mac pricing, it's Geer pricing. If it's not Geer pricing, it will be something else still. Right? So I think pharmacy wide, we have to look bigger, right? Because you know, you stop the practice of Mac pricing. It's gonna be something else.

It's gonna be something else. As long as pbms are able to engage in sort of trade secrets, reimbursement, methodologies, we're gonna lose. And we're always gonna be a step behind. 

Mike Koelzer, Host: You're not saying that we just have to take on something different now, because they're going to change. You're saying that just the same as audits were maybe not as important overall as Mac pricing, you're saying now there's something deeper than Mac pricing and that's something else.

And then this can keep going deeper and deeper. What's the 

Greg Reybold, Atty: deepest. I was joking around with my wife the other day. I was like, I knew everything when I was 20. Right. You know what I mean? Like the O the older I get, the less I know. Right. right. Um, and so I, I certainly don't propose to have all the answers, but what I can tell you is, you know, we've got to fight the right fights and we've got to, you know, we've gotta think bigger.

And so we gotta think bigger than audits. And we, you know, just two years ago, we just completely rewrote our audit bill of rights. It was great. I think it's super strong, but we've got, we've gotta think bigger. Across the board. And so to me, you know, as a, as a policy guy, as an attorney, I, I look at PCAV Rutledge.

I'm like, Hey, you know, we can engage in cost. This is much broader than just Mac pricing, right? This is, this is cost regulation. And so if you, you know, if, if everything that we do should be about almost deconstructing the system now, right. The system is so flawed and it's so broken. And I think we're at a unique time because pharmacy has a lot of integrity to its voice right now.

Right. Right. The things that we've been saying for years, as folks look in and they see a little bit more. it's like, wow, Hey, pharmacists were right. Right. The spread pricing is nuts. Right. You know, the spread in Ohio was huge. The spread in Georgia was 50 million in a small Medicaid managed care market.

We had one managed care company that had a 25% spread. So there's integrity. Think about that 25% markup. Right? So there's integrity in pharmacy right now. It's a powerful voice. Pharmacy is always a powerful voice. Even if you look historically, pharmacists are held in really, really high regard.

Um, you know, and, and so there's always power in, in, you know, pharmacists care for people , they're professionals and they're held in high regard. So it's always a powerful voice, but pharmacists helped expose these things. And you see these, you know, look at the work in Ohio with the, with the large settlement with Centine.

Right. Yeah. And look at the spread pricing that we've uncovered. And so I think my thing is we've gotta stop living in thepbms world. And so, and I, I, I always use this. Right. But you know, like Plato's allegory of the cave. Right. You [00:25:00] got these folks looking at shadows and, you know, and, and, and they, they see a little bit of light.

They don't like it. Right? Yeah. It's, you know, the shadow is, is their reality. And I think, you know, the, the, thepbms have created this world of shadows, right? Yeah. It's, it's, it's a world of shadows. It's a world of opaqueness. The fight shouldn't be, Hey, update your Mac pricing. The fight should be there.

Shouldn't be Mac pricing. That's the fight, the fight. Shouldn't be, you gotta update your Mac list. The fight should be, there should be no Mac pricing. And again, we, we, and we've, I've fought those fights, right? I've fought for Mac pricing. So I'm not, I'm not trying to disregard the work that's been done because it's been awesome and it's exciting, but I think pharmacies need to start looking bigger and I think they need to start fighting bigger fights.

So for example, 

Mike Koelzer, Host: on the Mac pricing, you would. We're in the wrong fight. It shouldn't be how much you're gonna allow this and that it should be let's open it up. What 

Greg Reybold, Atty: is the price? Yeah. Right. And, and you know, what, what, what's the answer and those are, those are hard questions. Um, you know, I, I would say, look, Hey, you know, how, how about you having a NADAC is not a bad start, but it's certainly imperfect.

Right. But, when you go into markets, you know, like Alabama, I think, you know, has sort of its own state specific, you know, like NADAC right. NA and NADAC nationwide and Medicaid is not mandatory reporting. So what, what do you have? You've got chains that don't report often and independence that do.

And then that allows the chains to exploit the price based off of NADAC. But, if you have some sort of transparency. You know, a transparent start that's a great start. Right? So, Hey, all, all the drugs are gonna be reimbursed on a, on an actual acquisition cost plus model. Right. You know, something like that.

I'm not inventing that to say the least, but that's a heck of a lot of a smarter fight then, then to be arguing over, cuz again, if you get Mac, it's gonna be called something it's gonna be whack and then it's gonna be tack and then it's gonna be sack. Yeah. I've lived through it all. We've gotta start fighting bigger fights in the system as long as we're sort of playing in their system and letting them define the terms.

Um, I used to have a great contract professor back in law school. I would always say, Hey, don't let you know. Don't let anybody else define the terms. Right? You, you define your own terms and, and what we've done in pharmacy is we've let them set the field and we're playing in their world. And as long as we do that, ultimately they're gonna keep growing and growing and growing.

Remember Michael 

Mike Koelzer, Host: Jackson, his super bowl performance. So he got out there and he stood at midfield. He popped up from wherever Michael Jackson pops up, but he popped up with the smoke and so on. And he just stood there for like 45 seconds and the crowd was going nuts, you know? And he didn't say anything, he just stood there and then he moved his head and then the crowd went wild again.

And he did it for another 45 seconds. All right. So we've talked about the next thing we've talked about. Don't make it Mac pricing, make it just actual pricing, maybe under NADEC or something like that. All right. So you're Michael Jackson and you're standing up there at halftime and you get your first head move at 45 seconds and then another head move, 45 seconds later.

What's your first thing you're gonna say on that first head move? What's the next thing after pricing? And then what's the final deep thing? So you got two chances to go deep. What are they? Can I have more 

Greg Reybold, Atty: then two? Come on, give me, well, how 

Mike Koelzer, Host: many do you want? No, two. I want this narrow. What's the final one?

You wanna go for the deepest? That's your head turn at 90 seconds. And what's your first head turn at 45 seconds? You get 

Greg Reybold, Atty: two. On top of sort of deconstructing the whole reimbursement model being trade secreted. 

Mike Koelzer, Host: Yes. Let's say the whole reimbursement thing of the Mac pricing. We're not doing Mac anymore.

We're doing whatever we want to do. That's one, what are your next two? I'm gonna 

Greg Reybold, Atty: Give you a caveat because we've got, you know, Georgia specific and then national, right. And so you, and so there's some things that we've done in Georgia that I think we're poised to do, to do some really exciting things.

And then nationally, I think there's some difference in what you want, but you only get two, you tackle sort of the reimbursement model. Great. But you got two other problems you got, I think, I think rebates that's one is a huge problem and, and rebates need to be addressed in a, in a huge way, right? Because ultimately they're paid to play and they're, they're a major leg that they stand on as a profit center, as a way to, you know, exclude competition and, and, you know, patient suffering.

And the whole system suffers. I think rebates is a major issue where there needs to be a lot of 

Mike Koelzer, Host: work done. That's the 45 second one. What's your deepest one? You might have to skip over a few here and we can come back to 'em, but what's your final, like you're gonna break into, uh, Billy Jean. You're about to break into that.

What's your final answer? 

Greg Reybold, Atty: on a national scale. I think addressing DIR fees, but in a very different way than we than the current solutions proposed have 

Mike Koelzer, Host: been DIR fees. All right. So that's the deepest, that's the biggest 

Greg Reybold, Atty: problem. If you talk to any independent pharmacist, certainly DIR fees. And I talk to a lot that have closed a lot that have sold and DIR fees are a huge, huge pressure point.

Well, 

Mike Koelzer, Host: [00:30:00] One of the reasons is because it's infinite. I mean, they can do it when they want to, as much as they want to. So that seems like a big hole too. 

Greg Reybold, Atty: Sure. Sure. And I think, but I think if you look broader than just the impact on a pharmacy's bottom line, right. Because I think, I think you've gotta look broader and, and it's, it's a cancer to the, to the whole system.

Right? It allows them to manipulate drug prices, to payers with co you know, to, to payers, because guess what? That money, most of that money, isn't going back to, isn't going back to the feds. Right. They're they're keeping 

Mike Koelzer, Host: That's right. They can tell them what it was and then they can legally then tell someone else what it was seven months later or something.

Greg Reybold, Atty: Sure. Right. So it, so it manipulates, it manipulates the price to the, to the pharmacy. It manipulates the price to the payer and it manipulates the price to the patient. And then on top of that, you know, and I think this is a, really, another important reason that doesn't get addressed enough. Right. But as long as we're fighting the fight.

That, Hey, as long as we're living in their world and we're saying, Hey, let's move it to the front end and not the back end. Right. Again, I think it's the wrong fight. The price of a prescription drug. This is the business of pharmacy podcasts. Pharmacists do a lot. There's no question about it and they can improve care.

And there's a lot of exciting work to do there. But as long as you tie the price of a prescription drug to patient outcomes, it's arbitrage, right? It allows them to manipulate the cost of a drug. So you asked me for two things, but really when you look at all three of these things, it's, it's one and it's, we have to, what we have to do is break the system down.

So they can no longer profit on ambiguity. Right? So that, so they can, you know, so they can no longer profit on imbalance. And, you know, and, and how do you do that? You change the way prescription drugs are reimbursed. You take away rebates and you take away DIR fees. You deconstruct the system and the fight isn't.

In my opinion. And again, everybody's working hard in states and, and nationally, and I don't begrudge anybody anything, but if you're a business owner, right, do, is it is, is the, should the fight be, Hey, these ERV should be on the front end or should the fight be? You shouldn't tie the reimbursement of a drug to amorphous patient outcomes.

Mike Koelzer, Host: Is there any value in that of tying results to 

Greg Reybold, Atty: price, not to the price of a drug, the drug is the commodity, right? It has hard costs. And as long as they're able to sort of tie the price of a drug to amorphous patient outcomes, whether it's on the front end or whether it's on the back end, it allows them to manipulate the cost of drugs.

And that's what has driven their growth. And that's, what's been, you know, the detriment to the pharmacy industry as a whole, right. We have to cut out. Their ability to play arbitrage, their ability to, to capitalize off of these imbalances, get pharmacists to get paid for the care that they provide, right.

Pharmacists or healthcare providers. And so if you wanna improve outcomes, and I think they're, I think it's an exciting time in that, in that area as well. Right? I think folks are starting to open their eyes and they're realizing that, Hey, you know, pharmacists can play a central role in the great diseases of our time, right?

Cardiovascular disease, diabetes. There is so much work that there is for pharmacy to do there that can improve these outcomes, um, in Georgia and nationwide. And that's fantastic. But guess what? Pharmacists should be reimbursed. For being a healthcare provider, right. Reimbursed for outcomes. That's fantastic.

That's great. That's what happens with every other provider, as long 

Mike Koelzer, Host: as you don't have a thousand dollars medicine, the person already 

Greg Reybold, Atty: took. Right, right. Don't tie don't tie reimbursement to a drug to patient outcomes. Period. It's a simple thing, right? It's a simple concept, but that's not what pharmacy is.

We've not really been fighting for that. Right. We're we're Hey, don't don't do it on the back end. Right? Don't do. . And so again, I think pharmacy wide, we've gotta start fighting the right fights. We've gotta fight big fights. Right. And we've gotta rethink, we've gotta stop playing on their field. Right. They started the, you know, they started the conversation they're dominating with, Hey, they're gonna tie patient outcomes to, to drug reimbursement.

Right. And so where does pharmacy go? Pharmacy says, Hey, don't do it retroactively. I think, I think pharmacy should say, Hey, don't do it, 

Mike Koelzer, Host: period. It's kinda like my kids swimming and I've got my youngest two now are 10 and 13 and they start fighting out in the water, you know, and screaming back and forth.

And I'm like, listen, you two, I'm not here to say who was right or wrong. If you guys are fighting. We're gonna play a different game. Yeah. You're both getting out. You're both gonna get out and sit there. And so if you don't want to both get out, find a way to work it out. No, and I get what you're saying.

It's like, they've got us into this weird game, you know, they said, all right, here's the rules now talk amongst yourself. It's like, no, that that's the wrong conversation. We're having one. Not based on that anymore. 

Greg Reybold, Atty: Well, put, we need to change the game, right? Not, not try to put bandaids on sort of ex and we've done this and again, it's not it.

It's all great. It's all [00:35:00] progress. And, and there's been great work done in a lot of states and there's been great work done on, on a national level, but ultimately we've gotta stop having bandaid solutions, right? We need to, we need a different game. And if you look again, like me, I always brought it to Ohio.

I think, I think, you know, Tony has done, you know, and others have done an awesome job, the coverage out there by the reporters. But you know, if you look at everything we know now nationally, there's one conclusion to me and it's obvious one, the system is. and, and we can't stop, you know, again, look, George has done amazing work, right.

And, and it's, and I'm proud of it, but the game goes on because we're playing their game. Right. And so nationwide, we need to play a different game. And that means we've gotta rethink things. And, and it's, it's hard. Change, change is hard. Change scares everybody. Right. It, it, it, you know, it's, it's the world we live in and that's why I go back to the allegory of the cave.

Right. We're comfortable with the shadows right now. Right. We're, it's a world that we're familiar with. And so, and so that that's the world where, where we play. But, but I, I think it's time nationwide to start fighting bigger fights, uh, maybe more coordinated and, and let's stop it. Right. We know all the games that's going on with rebates.

We know all the games that go on with reimbursement methodologies. And we know all the games that go on with DRR fees, right. Let's stop playing those games. 

Mike Koelzer, Host: Let's say we all agree and they make sense to me rebates. And then DIRs how do you make that jump then? Are those two a pathway to getting out of the game?

Or are those just like, well, let's just do these two, but we still need to jump. How does that jump take 

Greg Reybold, Atty: place? One thing we can take hard in is if you look at the work that's been done nationally and I'm from Georgia. So I use, you know, I'm the most familiar with Georgia, right. But, but if you look at 2015 to 2021, and you look at states like Arkansas, Ohio, Louisiana, New York, Georgia, uh, you know, I, I, and I know I'm missing states, California, you know, there's, there's states that have done awesome work, you know, Iowa.

So I, I, I don't want to leave anybody out in that regard, but, what we've proven nationwide is pharmacy. can impact and, and change in one year. It can be a different world in a, in a state things naturally move faster at the state level. Right. But again, we have to start picking, picking big fights.

And again, I think steering was a big worthy fight and, and, and I think that that would also be part of it, if, if, if, if you haven't achieved that already. Right. But, but, but fight big fights, you know, don't be afraid to lose, don't, don't go for bumps, right. Swing for the fences, fight, big fights, do it, smartly, do our homework, but the data's there, right?

The data's there, the system's broken, I think, thanks to, you know, the media and thanks to the work of, of, pharmacists nationwide. People know it, right. Legislators know it, they know that there needs to be change, right. FTC, you know, all, all of these things. And so, you know, we've gotta keep fighting, you know, we've gotta keep driving those conversations.

We've gotta keep driving the narrative, but we've gotta introduce legislation that tackles big issues. 

Mike Koelzer, Host: Things. So Greg, would it be fair to say that these bigger fights, even if they don't get us out of the game, what they're doing is they're announcing to the world how screwed up everything is. And then it's saying, look, we showed you how screwed up this was.

We showed you how screwed up that was. Do you finally trust us enough to? Say that we're not gonna play this game anymore. And then someone says, ah, alright, you showed us how messed up it was. All right. What is your new game? Is that kind of like, it is, maybe these fights are not getting us into a new game, but they're showing the world how messed up 

Greg Reybold, Atty: this is.

Yeah. I mean, I think the fights expose the practices, right? There's no, there's no question about it. And so the fight should be fought, win, or lose. Those fights are out there. They're big fights and those fights should be fought. But I do think, you know, if, if you're in a world where all of a sudden rebates aren't driving formularies and you don't have pay to play, and you've got sort of a, a, a transparent acquisition cost that everybody knows, and folks are choosing pharmacies based on the quality of care, not based on, you know, these narrow networks and, and rebate games.

And, and you take away, you know, these, these DIR fees or whatever you wanna call them, where performance is it you know, performance and patient outcomes are tied to reimburse them for a drug. Guess what? Those are fights that do change them. Period, right. Ppbms, you know, Hey, they, they, they wanna be, they're comfortable if you're, if, as long as you're living in the world of trade secretive methodologies, and you're talking about, Hey, let's force them to update it.

Even if they lose, they still win. Right. If we're saying, Hey, you can engage in D IR fees or, you know, performance tied to pay, you know, drug reimbursement, tied to patient outcomes, but you have to do it on the front end. They're still gonna win that game. And, you know, the rebate game, they, you know, they, they [00:40:00] Lord knows they win that one too.

Right. And so, you know, those fights will change the game as does steering because again, what is steering, but, but another way for them to, to, to cloud things, right? Is it, we always, we see this in lots of states, these conversations of, Hey, we should be able to incentivize a patient to use our pharmacy.

Right. You know, if we offer zero copay at our pharmacy, that's an incentive, don't take that away. Well, you know, no, it's, it's not an incentive. It's a penalty. If you, if you know, it's a penalty for them to use the pharmacy of their choice, right. It's not, it's not an incentive, it's a penalty. And so steering is, is just another example of that, right?

It's they, they utilize it obviously to steer business, but also to manipulate what is the cost of a drug? What is the price? And so we, we've gotta, we've gotta take that playing field away from them. And I think those are, those are the ways to do it, to fight those big fights. Broadly, 

Mike Koelzer, Host: we level things out.

We make. More transparent. We get rid of all the games and all that kind of stuff. Then thepbms keep dropping the reimbursement. You can see everything now and it's more upfront and all that. Tell me where that link is to say, all right, but it's not this game anymore, even though it cleans it up. How does that jump us to not having it based on the product versus the care?

Is it because. Customers then, because they're not being forced to go anywhere. I can see. Well, if they're not being forced to go to a chain, maybe they'll come to my pharmacy, but if I'm not getting paid enough for it, they might see some of the services, but not all of them I could give. How does that get us to the new 

Greg Reybold, Atty: game?

Keep in mind one of, you know, what one of, sort of the, the, the, the pillars, if you will, that they stand on is these sort of obscure trade, secreted, reimbursement methodologies, right. And so, you know, if you have a simpler cost plus system, And, and, and pbms have to reimburse at, you know, you know, whatever the, the state average acquisition cost or actual average acquisition cost plus dispensing fee.

Right. You know, that's gonna, I think that's going to take a lot of the, uh, you know, a lot of the problems in terms of just absurd underwater reimbursements out. Right. You know, it's not a perfect world, but if you go to, like, if you look at Medicaid fee for service, where, where a pharmacy is paid NADAC plus a, a fair dispensing fee, right.

It's a simple concept, but you don't see those pressure points. You don't see pharmacies getting, getting killed with the underwater reimbursements. It's, you know, when you take away the trade secret methodology, that's what empowers them to just kill on the reimbursement side. 

Mike Koelzer, Host: Gotcha. So if there's a little bit of breathing room there, then pharmacists can maybe start to do their thing.

And come back to life 

Greg Reybold, Atty: a little bit. Yeah. And it's a hard thing to imagine, right? Because the system is so skewed right now. Right. But there, but there are other ways of doing things. And let me, let me add this, right. I, I'm not proposing that these are the sole answers, but what I can tell you is we need to think bigger.

And we need to be more aggressive and we need to think differently, right? We need to find different angles. And look, I, I, I don't know these guys, but I'm a, I'm a fan from afar, right. But like blueberry pharmacies right out in, out in Pennsylvania, right. They reimagined a different way to do it. Right.

And they took pbms out and there's a way for them to make a decent living, provide fantastic patient care and save patient money, patient's money. And, and, and why, because, you know, every step of the way in the current system,pbms have the ability to manipulate and, you know, and profit off of that uncertainty.

So when you get a, a, a transparent, you know, model for reimbursement, and then you take away their ability to manipulate that on the sort of on the DIR fee patient outcome side, and you take away their ability to manipulate formularies, etcetera, on the rebate side, and then you don't let them steer. I think what we're gonna see is pharmacy practicing pharmacy.

Again, 

Mike Koelzer, Host: I had Kyle on the show from blueberry back a couple months ago. And once a lot of this stuff is cleaned up and then finally people have freedom and then he's $3 more than someone else it's like, he probably won't lose that person for those $3. He would've lost them. If CVS or someone came in and said you had to leave, but for those three bucks, a person probably won't leave.

I always use the example of getting cancer. It's like, let me hold on for six months and something might happen, but it sounds like these big fights are kind of at least giving some life before everybody's wiped out. Yeah. Giving some life and giving a chance. Then neither you nor I have the answers right off hand, but give us at least a fighting chance to get into a different 

Greg Reybold, Atty: game.

Yeah, I think so at a state level, I think, you know, what Arkansas did with PCAV Rutledge was really important. And I think we need to see more fights there, [00:45:00] right? Like us, George has passed a lot of things. Some of them are great. Um, some of them, you know, not, not all of 'em are great, but some really interesting things.

Um, and we are seeing them adhere to, and, you know, 50, 60% of the market. So I think there's also a lot of action in fighting to ensure that state laws get passed or enforced broadly across other markets as well. And so, um, and I know that's a little bit of a digression, but it's a point that I wanted to get out because it's, it's one thing to kind of pass these things and get these things on the books.

And it's another thing to get them enforced. And there's a lot of work to do there as well. But boy, the PC of Rutledge was an awesome, awesome, awesome, you know, major step in the right direction for that. 

Mike Koelzer, Host: Once a state brings something and they win like in the Supreme court, is it best for you? Like with Georgia to say, Hey.

That's already one, let's not go back and do that. Is it better for 50 states to all fight something different because we can all benefit from the win of an individual state. 

Greg Reybold, Atty: So that's a really good question. I don't know if I have a great answer for you. What I can tell you is the PC, maybe Rutledge was really unique because it made it all the way to the Supreme court, which is a big deal, right?

Not every case does. And so, you know, something that happens in the eighth circuit, which is where Arkansas is, is not binding precedent in the 11th circuit. Right. And so, um, but obviously a case like that for the Supreme Court case, I think what is decided for certain is that, you know, states can engage in cost regulation beyond just Mac pricing.

And so again, I think we need to think bigger than just, just a Mac pricing law based off of that precedent. Right. But, you know, look. PCMA and, you know, who's the, you know, the PBM association and, and pbms, they're gonna, they're gonna construe that decision narrowly. Right. And so, and pharmacy is probably gonna construe it broadly.

So there's a lot more fights, right? Are PBM regulations across the board, not preempted by Arissa or is it just cost regulation? And so, you know, we're, you're gonna see some, you're gonna see some significant fights. Right. Um, and keep in mind that Arissa, you know, piece of a Rutledge at the Supreme court level, they were looking at the issue of Arissa, right?

Self-funded, you know, employer plans, right. Whether they're fully insured, whether they're self-funded the Arissa market, they weren't looking at the Supreme court at the Medicare market. Right. And our state law is preempted by the Medicare act if a state Outlaws or prohibits DIR fees. Right. Does, does the Medicare act preempt that the Medicare act preempts, um, you know, where there's established standards, is there an established standard on DIR fees?

Isn't there, um, established standard on audits, a standard established standard on steering. And so there's, there's a lot of. To fight. And so certainly, you know, the issue of cost regulation that's been decided, and it's been decided by the US Supreme court cost regulation in the ERISA market. But, but there's a lot, you know, I think there's great work to do in Georgia and other places in terms of, Hey, let's get some of our laws enforced in, in broader markets, right?

Can we get it enforced in the Medicare market? Um, you know, what, beyond Rissa et cetera. So there's a lot of work to do. It's really, I, I, you know, to my mind, it's a really exciting time. And pharmacy has enjoyed, you know, fantastic success when you look at the, you know, the fights and like the, the, the dollars that pbms can spend and the number of lobbyists that pbms can, can hire.

It's, it's a, it's a fascinating, if you kind of take a step back, it's a fascinating political dynamic, and it shows the power of advocacy and the power of pharmacy to be able to bring, you know, the biggest companies in the world, you know, to their needs and, and state legislators at times. Rutledge 

Mike Koelzer, Host: and your wins have changed.

I mean, can you point to something and say, our state now is doing this because we say we bring these pbms to their needs. I know legally we do, but can we point to any 

Greg Reybold, Atty: changes? It's a great question. And, and when I say that I don't, I don't want to be hyperbolic. Right. But you know, for, for pharmacy too.

PBMs in the US Supreme court, that's a big deal, right? It's a big deal. And, and we're gonna grow on that and I 

Mike Koelzer, Host: I want it to be a big deal. I'm just like, so pessimistic against those 

Greg Reybold, Atty: bastards. Yeah. I can point to a lot of examples where patients are coming back into pharmacies. Patients are coming back into oncology clinics in Georgia because of Georgia steering law.

Are all of them coming back? No, but you know, what, if oncology clinics are able to treat 50% more of their patients now and care for them in a better way because of those laws, you know, you're darn right. That's worthwhile. It absolutely is. When 

Mike Koelzer, Host: We were talking about steering, I was thinking, all right, we're talking about goals and so on, but you guys have won some steering laws.

Greg Reybold, Atty: Yeah. Yeah. So, so in Georgia, we've, you know, in, in 2019 and 2020, we did expansive, you know, some expansive legislation and steering was a big part, a big part of what we tackled. Um, and so those laws are on the books and they're strong. And there's other states that are, that are, that are also implementing steering laws.

And so does it make a difference? Yes, it does. We also did, you know, one of the big issues going back like 5, 6, 7 [00:50:00] years. And it probably still is in some states if you pass a law, but there's no hook, there's no enforcement. Yeah. And if, and if you wanna go and complain, the PBM can point to, Hey, guess what?

You know, we've got an arbitration clause and we've got a choice of law clause and, and it ain't Georgia. If you're in Georgia, right? It's gotta be fought in another state. Right. And so that's a way for them to get away from different state laws. But so we've, you know, we've done a lot of work on getting the, you know, in Georgia, the commission of insurance has oversight.

He has the ability to, you know, he has equitable powers to stop practices. He's got powers, you know, to, I implement fines licensure also to order reimbursement, to pharmacies, as well as pay fines to pharmacies. And so, you know, there's, again, there's, there's always a lot of work to do. We're certainly not getting our laws adhered to in a hundred percent of the market, but we are gaining them adhered to in large swaths of the market and that, and I think that means something.

Um, and so, and we're not the only state, right. There's other states that are doing that. So these fights have to be fought, um, and. You know, now, now there's other fights we can have in terms of what's the scope of it. You know, if Arkansas had never passed their Mac law, they wouldn't be able to get to the US Supreme court to, to fight over the scope.

And so, you know, what we should see is these Mac laws. Now, you know, these prices are being updated in the commercial market, the Risa market as well. Um, and so that's a, that's a really good thing. Again, my, you know, my premise is states shouldn't go past Mac laws, but they should think differently now that we know that, that, Hey, we can regulate cost in the ERISA market.

Mike Koelzer, Host: It seems to me that the states and a lot of times people bitch about this, because it's something against them like, oh, they made me get a, you know, a license for this or to do that. But if something passes in the state, it seems they have a lot of power over a business to say, well, I don't care who you are or you can be the biggest company in the world.

But if we don't allow this to happen in our state, we don't now. I suppose the company I'm thinking of is like Amazon, I suppose the state could make a law against it. Any Amazon purchases coming into a state, but I suppose then Amazon could probably Sue the state. Right? 

Greg Reybold, Atty: Sure. And, and, you know, and ultimately that's what PCAV Rutledge was, right.

PCMA sued the state of Arkansas. Um, but in healthcare, you know, and particularly in insurance states could move quickly when you have, and again, we've had great champions in Georgia. Representative David Knight is just an amazing pharmacy advocate. Um, and you know, Senator Burke and Senator Watson representative Cooper, and, and what we're seeing is in more and more states, there are folks who are fighting for pharmacy, right in your Arkansas's all, all over the country, New York, there are folks who've picked up the man and they're fighting those fights, but you know, thepbms are, have, have armies of lawyers and they're expert at, you know, trying to argue preemption arguments, whether it's Arisa, preemption, whether it's Medicare, preemption, whether it's Tricare, preemption, but they find ways to not adhere to it.

And so there's a, you know, Part of the battle is getting the law in the books. Part two is getting it enforced. Right. And so, but coming off of PCMA V Rutledge, there's never been a better time to try to get right to, to try to get state PBM laws enforced. Yeah. 

Mike Koelzer, Host: I read an article last week and I was actually pretty enthused by one of the states.

The court said that the contract that they signed was a bad contract and thus the PBM could not enforce it against the pharmacy. Now I'm always thinking, I don't think it's fair this, and I don't think that's fair. I don't think it's fair that the PBM is making us do this, but it's like, well, I'm the dumb schmuck that signed the contract, you know, maybe it was through a PSA or something.

Right. But I'm the dummy that signed it. And so I gotta live with it. And that was. Very strange to me, thinking that even though a pharmacy signed something, the court said that they weren't held to that because it wasn't a fair contract. And I was like, I didn't even know that existed. I thought if you signed a contract, no matter how unfair it is, you're just 

Greg Reybold, Atty: screwed by it.

Right. And so look, you know, there's so many different angles and advocacy and legislation is certainly one angle regulatory work is, is another angle, which you see like the national groups doing with CMS. Um, but there's a lot of really good lawyers out there too, who are tackling this from a litigation angle and contract is certainly one of them.

Are there arguments that these are contracts of adhesion? Certainly there are arguments that there's no meeting of the minds because the pharmacy didn't even see the contract that it's being bound to. Yeah. Right. And so, you know, there's, there's really neat work being done, you know, in courts right now, there's, there's at the regulatory level.

Um, and then of course, advocacy, you know, at, at state and national level too. And so those are all, those are all really good things. And, and, and so, you know, overall, I think it's, you know, if you're an independent pharmacist like, Hey, Hey, or, or pharmacist period, right. If you're in [00:55:00] pharmacy, because you have, you know, chains that are non PBM affiliates that also wanna see a lot of these changes.

And so I think boy, you know, it's gotta be in ways of breathing fresh air, but the flip side is you're a pharmacy owner who's behind that counter. And, and are you feeling change? And, and, and, and I don't know the answer to that, right. For me, these things are, I know that they're wrong. And I, I, you know, I feel it in my bones, you know, and I believe it to my core, but some of these things are esoteric because I'm not.

I'm not behind the counter filling prescriptions at losses, or having to tell patients, Hey, you have to go to this mail order pharmacy to get it filled or having, you know, a quarter, you know, a hundred thousand dollars recouped, you know, because of retroactive, right? Like I like, I'm not, I'm not. Behind the counter.

And so it's easy for me to say, Hey, look at all these great things going on. We should be encouraged and pick up the manhole and, and, and, and go forth. Right. Be because you're behind the counter and I, and I, and, and you're feeling it and you're seeing it. And hopefully some of this stuff is translating, but you know, what I would point to you is, you know, this is the time to push, right.

And, and this is the time. And I, I, I always say this too, you know, I think it was an old plumbing adage that turned into an old boxing adage. And I use it in, in politics a lot. Right. But pressure burst pipes. And, and this is the time for pharmacy and patients and oncology and other providers. This is the time to apply pressure and, and, you know, and let's get as, as much change as we can.

This is the time that is ripe. I've been 

Mike Koelzer, Host: around a long time. And in my mind, pharmacy is getting more wind right now than ever. Then I say to myself, all right, let's look at this critically. Is it because I'm talking to more people with a podcast? Is it because of social media I'm seeing it more, but more's not being done, but I'm just reading more about the different pharmacy associations.

Is it because pbms have gotten so nasty exponentially, we look like we're exponential, but we're actually at a lower curve than they are but it seems to me like we're making progress more than let's say three years ago. Is that true? 

Greg Reybold, Atty: yes. Yes, absolutely. Right. I mean, I think, I think we're evolving and, and, and we, we are seeing progress more and more, and I don't know that you can point to one or two things, but I can, I think you can certainly point to the work that is being done.

Right. It's being done by associations. It's being done by, by, by, you know, some other organizations, some buying groups, um, you know, the work is being done. And, and I think another factor is, is, you know, thepbms have agreed at the level that, that maybe we've not seen in healthcare. Right. Mm-hmm , and what's, what's the old pigs get fed hogs get slaughtered, right.

Like they're not sympathetic. Right. And, and the work that's been done to expose these practices. It is starting to pay dividends, but again, there's, there's more, there's more work to do. Right. And, Georgia too. Right. We've had a, we had a fantastic 2019, we had a fantastic 20, 20, we rewrote the PBM code.

Um, you know, we, we prohibited spread pricing at the, at the state level, um, for state plans for counties, for cities. Right. But, but again, that's still a band aid, right. Because we're, we're still in Georgia living in their world, um, in a lot of ways. Um, and so, and so, yes, there's progress being made, but there's a, there's a lot more work to do.

There's a lot of momentum, but this is the time to push. Right. And, this will have a direct impact on patients. It'll have a direct impact on payers. This is the business of pharmacy podcasts, right. It'll have a direct impact on the business of pharmacy, right? If there's, there's no question about it.

Mike Koelzer, Host: I think that the natural extension of social media, it doesn't just happen by us getting on here and bitching to each other. I think the connection though, is it lets people know they're not alone, that there is a fight and maybe 10% of it, or 20% of it helps find an address or talks about let's meet down at the capitol today or, you know, something like that.

I think there's some mechanical help for it, but I think 80 or 90% of it's just people feeling like they're not alone. And me seeing, oh, Georgia won and the Supreme court thing won, you know, and things like that. I think it brings some hope for people to hit the ground and do something with their legislatures and so on.

You bet. So Greg, 10 years from now, where are you personally? 

Greg Reybold, Atty: Hopefully healthy. Right? 

Mike Koelzer, Host: I already told you that you've got the magazine cover with Antonio, so I'm not gonna give you another compliment. There you'll be 

Greg Reybold, Atty: healthy. No look, you know, in terms of this industry, I'm, I'm not going anywhere, right. I mean, this is, this is where my career is and, and, and my passion is, and so I, you know, I don't know what fights we'll be fighting.

Um, but, but I can tell you that there's no finish line in this, right? There's, there's, you know, we've talked a lot [01:00:00] aboutpbms and, and their relation to, you know, the business side of pharmacy, but there's, there's just a lot of exciting work to do, you know, whether it's, you know, getting pharmacists reimbursed for, for outcomes and, and, and improving patient outcomes.

Um, there's, there's a, there's a, there's a lot of great work to do. Um, and I, I always, because it's a business pharmacy podcast, I, I always used to tease when I was in private practice. I represented a lot of pharmacies and, um, I, I, wasn't one of these lawyers. Right. But, uh, you know, most lawyers don't pick up the phone if they're not billing for it.

And I always laugh because there's, to me, there's not an industry that gives away more than pharmacy, right? Like, it's funny, but it's not funny. Right. Pharmacists do so much. And, they don't monetize. Anything, right? Yeah. A 10th of it. Right. And, and so I, that's why I get excited when I see blueberry pharmacies and some of these other things out there, because you know, like in Georgia, you know, you, a pharmacist can absolutely it's in the pharmacist can bill for pharmacy care services.

Right. But, but do they, right? Like, like pharmacy gives away so much. And so on, on top of fighting these PBM fights, I think there's great work to do in, in getting pharmacists to figure more centrally in these big diseases and getting pharmacists reimbursed for that work. And I think that's a win-win-win.

Right. It's a win for pharmacy. It's a win for payers and it's a win for patients. And so there's there's, and there's great work being done nationally on that too now. Right. Um, and so it's an exciting time to be in pharmacy from that perspective. And, and, you know, in, in, in, in 10 years, again, I hopefully we will affix some of these things and, and we're working on some more of the fun stuff too, but there's no finish lines.

Mike Koelzer, Host: Yeah. On your point about charging, I was talking to one of my podcasts. Guess, and they were saying that there was this very obvious thing that a pharmacist should charge for. I forget what it was. It was very obvious. And the pharmacist actually likes to quit or something before they would charge for something.

I forget what it was. 

Greg Reybold, Atty: it's crazy. Free delivery, free consultations free, you know, like everything, every, everything is free, whereas like in the law and you don't know this yet, but like, I'll be sending you a bill for this, right? No, I'm just kidding. Nice talking to you, Greg. Take care. but everything is right in most businesses, you know, everything is monetized, but it's funny, but it's not right because pharmacy needs to be getting better, needs to get better and evolve in terms of billing and getting reimbursed for their expertise.

Cuz the expertise that pharmacists have is immense and it's central to improving outcomes, Georgia, if you look at Georgia's like Medicaid managed care patient outcomes, right? Like all these CAs, there's so many CA not all, but you know, there's a, there's a number of categories where Georgia is in the bottom 25% in the nation dealing with things like cardiovascular disease and, and diabetes and, and asthma.

Right. And so like, but where patients are struggling. Just so happened to be where pharmacists are. Great. If folks start to really utilize and unleash, you know, the skill that pharmacists have to battle these, these, these big diseases. So 

Mike Koelzer, Host: I tell my team this, the biggest killer of people is let's say heart disease and cancer, you know, I mean, and so it's like, there's a lot that can be done and a lot that people will pay for if you do it right.

Yeah. How many state associations have a full-time attorney on staff? Do you think it's a 

Greg Reybold, Atty: lot? I don't know. I'm sure there's some, but, um, but I think when you, when you get to like the nationals, that's where typically, you know, more consistently you'll see, you'll see attorneys involved. Certainly 

Mike Koelzer, Host: It was interesting.

I'm not gonna say the religion, but I was just on TikTok last night and they were going through this one denomination and they were saying, look at this historian for this denomination, he was an attorney. And now. The previous historian for this denomination, they were an attorney. And now look at the previous one, they were an attorney and he said, isn't it odd that for the historian role, they didn't have a historian on there.

So , there was a reason why they had attorneys, you know, cuz there was probably something they didn't want to come out about. Yeah, that's right. The denomination I'm not looking at Georgia's shifty just because they have a full-time attorney in there by any means well, Greg, keep up the fight.

Thanks for what you're doing and the Gusto and the hope that you're bringing to the conversation. And I think that's needed as much as 

Greg Reybold, Atty: anything. Yeah. Well I, I appreciate it. And, and yeah, I mean, I, I think that's, you know, there's, there's no one thing that I think points to pharmacy success, but we have to.

You know, keep, keep fighting hard. We've got momentum in a way that probably we've never had before. Um, and again, I think sort of the games of pbms have been exposed, you know, amazing work out of Ohio in Antonio for that. Right. But like their practices have just been so exposed now and it's just, and then you, you come off PC, maybe Rutledge.

It's an exciting time. We've gotta fight hard, but we've gotta fight big fights and smart fights. And it's gonna be, it's gonna be a neat few years. I think that's something. 

Mike Koelzer, Host: Someone listening to this this [01:05:00] week, they could do, you know, let's say they're hearing this right now and it's a pharmacist. What could they do?

Whether it's learning something or writing to somebody or supporting something, what's the word of advice you could give? Just so someone doesn't say, oh, that's great. And then they're not doing anything. What could they do? 

Greg Reybold, Atty: Yeah. And I'm gonna, I'm gonna be broad, not myopic and, and, and it's right.

Find, find a way to fight. And so if you're in a state that doesn't have a lot of PBM laws, you know, talk, get involved in a state association, talk to a legislator, have a pharma, you know, have a legislator, visit your pharmacy. I hate saying it. Because it sounds cliche. Right. But that's what, that's what drives this stuff, right.

When you get, you know, you get somebody who's willing to, to, to come and listen and they see it. And I don't know too many folks who've actually taken the time to see. You know, to see what pharmacies deal with and see what patients deal with. Who've walked away and not wanted to do anything. Right. Right.

And so, and so maybe that's how you fight. I, I, I always say this, right? Like so many pharmacists, this isn't specific to pharmacy. Right. But everybody wants to fight until it's time to fight. Right. And, and so whether it's, you know, being willing to go down and, and offer testimony, right. It's just a handful of folks who are willing to come down and share their experiences.

Um, and we've been lucky in Georgia. We've, we've had a lot who are willing to, when we get the law on the books, Be willing to file a complaint, right. Be willing to fight that. Right. Because it's, it's, you know, there's, there's a million different ways to fight. Maybe not a million, but there's a lot of different ways to fight, but you've gotta be willing to do it.

Right. And the folks who step forward, they've been a part of great change. Right? We, we, we had a pharmacist, gen Shannon Lily's pharmacy who's, you know, just awesome and a good friend. And, you know, she came down to the CVS Aetna merger and she was willing to share her experience and testify. And we got some really, really significant preconditions as a result of that testimony.

We've had a ton of pharmacists come down to the Georgia capital and share their experiences. And it's those, those experiences, those narratives that drive change. And so, you know, if you're a pharmacist. Get involved and, and find a way to fight. And it may be as simple as, as the pharmacy visits, it may be filing a complaint.

It may be willing to testify. It may be writing a letter. Um, and you know, what else is being willing to speak up and disagree with? Right. You know, pharmacy, one thing I think industry wide pharmacists are like the nicest people, right? And, and so, you know, when, when we go one direction, everybody goes that direction and nobody wants to say, Hey, maybe we should turn.

Maybe we should. Right. And if, and if you see a better way of doing things, or if you have ideas, share those, right. Don't, you know, because you know, your perspectives are really, really valuable, but it's just willing to do something willing to take that step and willing to, to fight the fight in whatever capacity you're willing to do it.

If you, you know, if it's, if it's a, you know, donating to a pack, if it's donating to a legal defense fund, um, you know, all of those things are, are. Help move the ball forward. And so if you wanna see change, be willing to fight for that 

Mike Koelzer, Host: change. My wife was a teacher, so I always tell teachers that the reason they've got such good unions and such good benefits and so on is because they sit around the teacher's lounge and they complain to each other.

And you know, in a closed door teacher's office is like, oh my gosh, we got the best career in the world, but let's not let anybody know about it. Let's go out and say that we actually take work home at 3:00 PM and we don't get to actually stop till five because we're working from home. You know, it's like, well, yeah, no other profession does that.

They've got this whole thing set up, but. Pharmacists. I like that one about filing a complaint. So instead of maybe pharmacists just bitching to each other or bitching online, they'd say, Hey, this PBM doesn't seem to be following this new law that our state has. I'm gonna write to the state. 

Greg Reybold, Atty: Yeah, absolutely.

Right. I mean, look, you know, and I'll, again, Georgia is what I know. So we'll use Georgia, right. But we've, you know, we've got a commissioner of insurance oversight. We've got, you know, really strong regulations on the books on top of the laws, the commissioners in power to take action. But you know, when I talk to somebody from the commissioners of insurance and I say, Hey, you know, I'm, I'm hearing lots of examples, still of steering or underwater reimbursements.

And, and they'll say, Hey, we're not seeing that. Right. Like we're not, we're not the complaints aren't coming in. And so, and you know, again, pharmacists are incredibly busy and it's, it's a, you know, and, and I, I get that. You know that that's part of it, right? That's part two to the equation. Right? You get these laws on the books, but again,pbms are sophisticated operators and they may say, Hey, if we engage in this practice 5,000 times, but we know historically that there's gonna be.

Three pharmacies that complain and we can oops me cope with it, or, oh, sorry. Here's a reimbursement. Well, they still did really, really well. Right. And so until their feet get held to the fire, um, you know, they'll keep doing these things oftentimes. And so again, you know, if you, if you're in a state where you're, you're lucky enough to have some laws on the books, hold their feet to the fire, who does a pharmacist send a complaint to?

So obviously it may be different in different [01:10:00] states, right? But in Georgia, we've got wide PBM laws on the books and regulations and they can go to the commissioner of insurance's website and they can, you know, they can go to the consumer complaint floor, they can file a complaint really easily. We also have, again, like steering on the board of pharmacy side, you know, so, so they can file a complaint or a patient can file a complaint with the board of pharmacy.

Also, if they're being steered and, and having their prescription filled by an affiliated pharmacy. So, you know, there are places to go in Georgia, certainly, but, you know, are there a lot of complaints being filed? Not, not that. 

Mike Koelzer, Host: Yeah, I think I found my new purpose. I can be a professional complainer. All right, Greg.

Thanks for everything. 

Greg Reybold, Atty: Yes. Been my, my pleasure. And thank you for having me and the work you're doing. We'll be watching 

Mike Koelzer, Host: and thanks for George's leadership. We're all behind you. 

Greg Reybold, Atty: Thank you, sir. Thank you very much.