CareTalk Podcast – Revenge of the Healthcare Wonks

In this special 99th episode of CareTalk, hosts John and David look back at the past 4 years of the show. Have they changed their stance on some of their hot takes? Which episodes resonated the most? And most importantly, what lies ahead for the future of CareTalk, as we get ready to tape our 100th episode?

 

David Williams:

Welcome to CareTalk, your happy home for incisive debate about healthcare business and policy. I’m David Williams, president of Health Business Group.

John Driscoll:

And I’m John Driscoll, the CEO at CareCentrix.

David Williams:

John, we’re still in double digits. This is episode 99, about to hit 100.

John Driscoll:

You’re looking kind of old, dude.

David Williams:

It’s like 100 in, what? Radio years, or CareTalk years. That’s where… I don’t know. I hope we make it to, I hope we live to 1,000, John, if not that long.

John Driscoll:

I’m still having fun with this. I’m still trying to educate you, and you’re still trying to educate me, and every so often, we have a little bit of fun.

David Williams:

A little headbanging, there, John. I went back to our first episode, from April, 2017, which coincidentally I think was during sleep awareness week. I think we were a little worried people would sleep through the podcast.

John Driscoll:

Wasn’t that when you had hair?

David Williams:

No, no, John. That’s older history than that. That’s episode -500.

John Driscoll:

It’s been a great run. It’s sort of amazing that with these kind of crazy, wonky topics, but that are super important to everyone who is around, as well as some of the people that are listening, that we’ve still got, our membership’s still growing, and our great listeners, that’s you folks out there, are participating and engaged in the conversation.

David Williams:

That is very nice, and I think even more surprising or positive is, we haven’t gotten sick of one another, and we haven’t run out of things to say, and we haven’t driven that many people away.

John Driscoll:

So, David, if you look back, what are the big topics, and have we made progress on any of them?

David Williams:

I actually looked back, John, at some of our top episodes, and what I found was that there’s sort of a balance between the wonky and the practical. So, things that affect people individually, and policy, like palliative care, drug testing, school reopening, Medicare for all. These are things where it has an impact on you and your family, but also there’s broader policy implications, and I think we weave that together pretty well, and that’s what people come back for.

John Driscoll:

What do you mean, wonky? Explain what you mean by that.

David Williams:

Well, see, that’s part of it, John. We actually asked people to explain, like palliative care, does that mean they’ve given up on me and I’m going to die? So, the palliative care one, for example, we talk about is palliative care part of health insurance, or is that something you do after health insurance, because there’s a different set of incentives? There’s all sorts of acronyms and technical terminology out there that sometimes can be helpful for experts, but also gets in the way.

John Driscoll:

Well, you know, I think that’s really right, David. I think a lot of the value of listening to CareTalk is having a no-BS, very clear view of what’s going on in healthcare, healthcare politics, and practice. And then, being able to break it down to pieces that you should either be asking your question about, or be aware of.

David Williams:

John, part of it is also, and I’ll say hats off to you on this one, is being able to talk beyond one’s own narrow interest. That’s part of the problem with healthcare. Everybody has their own kind of hidden interest, and that affects how they talk about policy. You’re willing to talk about things that aren’t necessarily in your narrow self-interest. I can do that, as a consultant.

John Driscoll:

I know. I think both of us are pretty good at that. I think part of it is just reminding everybody that healthcare is deeply personal, and whether it’s palliative care, or drug testing, or how to handle schools, that you’ve really got to ask your own questions if you’re going to be a responsible healthcare consumer. And in politics, I mean, gosh, with a budget that it’s one out of every five dollars of the entire economy is spent on healthcare, it becomes an economic as well as a political issue, in addition to being personal.

David Williams:

John, we’ll come back to drug pricing in a minute, because that’s the answer to you question about-

John Driscoll:

Well, I thought you were going to come back again about drug testing, whether you need to be testing for drugs.

David Williams:

I don’t have to be tested, John. You can just look at me. You don’t need to waste time on… When we go back to video, people can do their own test. It will be a cheap one. But John, I was going to say, on drug pricing, I want to come back to that, because that’s one where we’ve been beating the drum, but without a lot of success. But you know what’s an interesting one, and I would say I had forgotten about this to an extent, which is that one of our most popular topics is about Amazon, and Amazon’s role in healthcare. Now, we should come back to talking about that, but what are your reflections on why that one’s been so popular?

John Driscoll:

I think Amazon could be the terminal monopoly in cloud-based software, through Amazon Web Services providing web, cloud-based access for low-price and very flexible tools for any company that wants to do digital commerce, eCommerce. But I think the reason why Amazon is so interesting in healthcare is a two-part opportunity. One, they’ve got more money than anybody, and so if they go into a sector that’s as screwed-up and as high-margin, and as opportunity for disruption as healthcare really is, I think everybody’s going to pay attention.

The other thing is that Amazon gets right what most healthcare gets wrong around the personalization of service, surprising and delighting you with what you want and need. It provides a low-cost, high-value retail experience, where you feel, from a consumer perspective, seen. And if you think about healthcare, it’s high-cost, low-access, and often leaves you with a lousy sense of a retail experience. And so, I think both of those really matter. From the consumer perspective, it just reminds you of how different the consumer experience is in healthcare from any other part of commerce in America.

David Williams:

John, a lot of our listeners and viewers are healthcare insiders, and I think pretty much everybody in healthcare feels threatened by Amazon, if not today, then tomorrow, down the road. Historically, throughout our decades in healthcare, you’d take a look at something in healthcare, say, lousy service, high cost, but you know, it’s healthcare. You’re not really thinking it’s going to change. And you look at it any you say, well, from Amazon’s perspective, this may be ripe for the picking, and even if it’s not easy to nail it, it doesn’t mean they’re not going to go after it. And that can mean, similar to what you’ve seen with Walmart, where something can be really out of control in terms of cost and convenience, and they just take a hatchet to it in a way that nobody had. So, I think that’s where Amazon comes in.

John Driscoll:

I think you’re too much of the hatchet man, there. You’re about cost, cost, cost. You’ve got to think about the consumer experience, David. You’ve got to respect people as people. That’s one of the reasons why Amazon does so well, and the other is, they do things in a low-cost way, but part of that’s because they’ve got infinite access to zero- or no-cost capital through the public equity markets. But I think that the most important thing is, it’s just healthcare is lousy from a consumer interface perspective, and not everybody’s going to tolerate the kind of way they’re treated as patients.

David Williams:

So, John, you’re saying less hatchet and more ratchet, building up.

John Driscoll:

Yeah, I think so. I think the other thing is, you presume that healthcare should cost as much as it does. Amazon always assumes you can cut costs. Now, I think in general, they can take advantage of predatory pricing and proprietary information, since if you’re selling on the website, Amazon begins their own homegrown stuff. It turns out they’ve got access to the data on both sides of that wall. So, tear down that wall. They already have.

But I think what Amazon gets right is cost and consumer experience. I don’t know whether they’re ready for how complicated healthcare is. You saw recently that they were rejected by some employers and some health plans, who they wanted to participate in their network. So, I don’t know. I think Amazon… Well, what’s your view? Do you think Amazon’s going to take over healthcare, and provide it to you through your Kindle?

David Williams:

I’m going to borrow your Kindle, John, next time I see you. I think I still have it. Maybe I should return it. No, they’re not going to take over all of it. But like you said, it’s one out of five dollars out of the economy, so there’s a lot of places that are already very big. So, just think about it from the standpoint of a doctor’s office, and where they order their supplies from, their office supplies and other things. It’s just coming from Amazon anyway. They’re already in healthcare in a pretty big way, just by being part of the economy. So, no, they’re not going to take it over.

And I think that retailers in general are going to get more into healthcare. Walmart’s been kind of up and down, but I saw recently, Dollar General actually just appointed a chief medical officer. I think that means they’re going to offer dollar generic drugs?

John Driscoll:

Let’s focus on Walmart, because we’re not going to… It sounds like Dollar General may be one of your new clients. But if you think about Walmart, Walmart has systematically lowered the cost of retail clothes and food in a lot of rural parts of America. They were the first folks to offer $4 generics. I mean, why shouldn’t Walmart be able to succeed in healthcare, and why haven’t they, David?

David Williams:

Well, I mean, it’s America, so let them do whatever the heck they want. But I think what happens is they try it, but they’re still up against kind of the healthcare industrial complex, and you can’t just go and do everything differently. And it’s difficult to do it well. So, there’s just a lot of demand, which they can partly fulfill, but not completely. They’ve opened some big Supercenters, but they have to…

John Driscoll:

You’re meandering there. I don’t think you have an answer. [crosstalk 00:09:15]

David Williams:

Well, I think they know what they’re doing. I think they look at it, and it’s like, whoa, wait a minute, everybody wants us to fix this. This is a big dog, and nobody’s been able to fix it. We’ll take our sweet time.

John Driscoll:

Walmart has over a million employees. It’s as big as most health plans. They are really good at bringing costs down. I think they’re the sleeping giants. Let’s just hope they wake up, because there’s a huge opportunity in healthcare, and a focus on low cost and great consumer experience would, I think, be a game changer. And I think they’re in a better position, because they’ve got so many domestic employees, to actually test new solutions on their own employees.

David Williams:

Yeah. All right, John. Listen, how about drug pricing? You’ve been a real loser there. I can see a bruise on your head, because you’ve been banging your head against the wall. So, we haven’t made much progress on that. Let’s talk about what may be coming, what may be new in drug pricing.

John Driscoll:

Well, there’s some… But let’s be honest, the president came out with a bunch of executive orders the other day about anti-competitive behavior, and not allowing drugs that were going off-patent, to have those patented drug companies to be able to pay for a delay, so they could protect their monopoly even beyond when they were legally supposed to. And there’s some interest in doing more with generics, and making sure that their biosimilars, which are biological drugs that are like generics, are accelerated to market.

But I think that the administration has decided to kind of take the dive on whether they’re going to require or create the opportunity for Medicare to negotiate drug prices. And I was surprised by that.

David Williams:

Yeah. I mean, I don’t know. When you’re negotiating… I still don’t understand this about Medicare negotiating, because unless you have a threat where you’re actually not going to cover the drug, then what are you really negotiating? It’s like, what’s going to happen if I…

John Driscoll:

Price, David, price.

David Williams:

Well, say I want it for $50. No. Well, I’m not going to offer it. Oh, yes, you are, because you’re going to be forced to offer it by Congress.

John Driscoll:

Think about that hep C drug. I mean, it was eight cents in Egypt, $800 here. I mean, it’s not that we want an unfair price. We just want something close to fair. And it’s people like your friends who do not want to discount the drugs. I mean, I saw on one of your Trump blogs today, for example, that ex-president Trump, well, A, had suggested that he was talking to the Almighty. It also said that he is going to bring down prescription drug prices, at which point Bernie Sanders and Donald Trump are pushing out the same extreme ideas, that they’re going to shake down the price… shake up the drug companies, and bring down prices.

I think we’re at a cultural tipping point, David. You know, you make fun of my desire to bring drug prices down, but mark my words, we will have some form of legislation that will affect drug pricing.

David Williams:

So, I think there’s a couple of new things that may be happening. And I don’t make fun of you trying to do it. I make fun of the fact that there’s no progress. But there’s a couple of things that have happened that I think might be of interest. One is that this new approval of the Aduhelm from the FDA, which is just like an outrageously priced drug for something that’s not very effective. Now, they’re dialing it back. There’s all sorts of investigations.

John Driscoll:

Well, again, context, context. There was a big new drug approval about a biogen manufactured drug that allegedly helps folks with Alzheimer’s, even though the facts and the data don’t show it. So, how did it get approval, David?

David Williams:

That’s what’s going to be investigated. Janet Woodcock from the FDA’s called for the OIG to actually do an investigation. And maybe the people at the FDA were too close to the company, because supposedly, it surprised even the top folks at FDA. And it’s another one of those things where people have said, well, maybe nobody’s looking, and we’ll just put it out there and see what happens.

John Driscoll:

But it’s pretty amazing when the acting administrator calls for an investigation of her own evaluation teams that approved this Alzheimer’s drug.

David Williams:

But I think what will happen is, nobody likes to talk about the fact that the prices are so high that they’re going to bankrupt us, and now this is a clear example of something that’s very expensive, it could potentially be used in a very widespread manner, and it’s not that effective. So, that’s the type of thing that helps to drive the discussion.

Now, John, everybody also blames the drug companies for drug prices, which sort of makes sense, but I have to say, through a couple of recent experiences, I’ve seen where hospitals and physician offices have taken expensive drugs, in this case, one that’s supposed to be a list price that’s $3,000 a dose, which is supposedly much more than it’s worth, but just take that for a minute, $3,000 a dose, and the hospital I saw charged $25,000 for it, and the physician practice charged $42,000 for it. So, somebody’s trying to get in on the action too, and it’s not just the drug companies.

John Driscoll:

Well, I think while you’re trying to hide the margin of the drug companies, the excessive margin of the drug companies, I think it’s worth calling out the fact that there’s outrageous markups at every step of the chain around drugs. It’s also worth calling out the fact that a lot of nonprofit public hospitals put people in bankruptcy for not paying bills, cash bills that they can’t afford, that are for prices of services that are quite a bit higher, and they negotiate prices with commercial payers, or Medicare, or Medicaid.

It’s just extraordinary how many margin-grabbers there are in the healthcare kind of stack. I mean, there’s a lot of great people in healthcare, but the way we pay for it and how much we pay for it is nuts.

David Williams:

All right, John, so I think we’ve already discovered that we’re still going to have more to talk about on some of these favorite topics, like Amazon and drug pricing. I really would like to see something happen there, so maybe we can do that. And as we think about resolutions for our next hundred episodes, or next 99 episodes, one of the things we’ve done in the pandemic, John, is go from a monthly frequency to weekly. I’d love to keep that up, even as we can see one another again. You agree?

John Driscoll:

I think that’s a great idea, David.

David Williams:

Yeah. We used to do something also where we do kind of a quick, we called it lightning round back in the day, where we’d go boom, boom, boom. And it’s hard to get you to talk quickly, but sometimes we can do it. But I think we should-

John Driscoll:

I think a better way to go at that would be to look at, maybe have a quick feedback on some trending items, or identifying what’s an important story that you missed? I mean, you miss a lot of things, David, even if it’s right under your nose, but I think the overwhelming waves of information, being able to call out one or two things each week that are trending, and one or two things that should be trending, would be an interesting add to the show, and we can try it out.

David Williams:

All right. That’s a tall order, but we can try it. And John, I’m looking forward to, you know, we missed Health 2020, because it didn’t really happen. We had a great time at Health ’19, down in Las Vegas. It’s going to be in Boston this year, so I’m looking forward to doing that, getting some good guests on at that point. To getting back together, and hopefully having ideas from listeners. People can leave comments if they have ideas about what they would like us to do.

John Driscoll:

That would be awesome. I think that would be great, and I look forward to that show, as well, and to doing many more shows with you.

David Williams:

Well, John, that’s it for yet another edition of CareTalk, in this case, episode number 99. I’m David Williams, president of Health Business Group.

John Driscoll:

And I’m John Driscoll, the CEO of CareCentrix. Thanks for listening, and if you liked what you heard, please subscribe.