Transcripts For CSPAN2 The Hill Holds Forum On Prescription Drug Costs 20170721

Civic [inaudible] this morning we are focused with the United States expenditure is on Prescription Drugs rising faster and reacting to the concern the warehouse is expected to unveil the executive order even as we wait for direction with a Prescription Drug Delivery System and with those that are being explored we will hear from government leaders and Patient Advocates and here in the studio we our lives dreaming please keep your phone on silent the we encourage you to join the conversation on social media follow less on twitter or comment. We will take questions throughout the program. And before to get under way with affordable Prescription Drug description. Good morning. Was in is very important conversation today with the speakers and panelists and watching on line there is nothing else that you could be focused on some things for the years all kidding aside of the very real issue of rising drug prices and the impact they have American Families and employers, a taxpayer the Health Care System and could not be more timely and of those patients rely of the drugs. With the substantive dialogue across the whole system and with the affordable Prescription Drug the members are and to bring together pharmacy benefit managers and with the stakeholders that they partner with. And that the real value to provide to their members with sustainable drug coverage and half of all americans get their coverage through the system far more than any of other systems and employers and unions have had to find ways that the employee members and families could access the medicines that they need for that they choose to partner including in a survey of 2009 only 47 percent of employers were partnering to manage the of benefits. Four years later it hit 61 percent but they are working to find ways to have access but the average list price grew by a nearly 10 but fell to around 3 and a through the negotiations of manufacturers. So with that sustainability a of Government Programs a recent study found that this would save Medicare Part d 896 billion so beyond a the value of the Health System Pharmacy Networks through negotiations with pharmacies with the deep clinical expertise with the most effective medicines that can achieve the same health cocoms out, and to avoid unnecessary costs such as hospitalization. Very appropriate that the for todays event is whatsnextrx. We believe that solutions and what should be working for the Government Program employer unions and other organizations they rely on for health care coverage. There is the immense opportunity with the effective use of medicine to improve Health Outcome to significantly reduce Unnecessary Health care spending. Finally we need to do things to increase competition for Prescription Drugs by facilitating and identifying the drugs with little or no competition and with the anticompetitive practices. So thanks to the hill and i will turn back over to get things started. [applause] so lets dive right in with a conversation vs two democratic members of congress the congressmen and of texas is the House Energy Committee end of the Ranking Member on oversight and investigation and with a halt they held national correspondent. 84 being here this morning. We will chat about transparency. And what role does Congress Play in transparency . So with that Commerce Committee of patent exclusivity and availability with Medicare Part the and basically we have restrictions so we think what we should be doing is having indepth investigations to figure out why all of a sudden they seem to be pervasive ever wear and to enjoy the of colleagues on either side of the aisle. It is in just us simple issue Prescription Drugs are going up but is a complex system growing more complex and also more opaque by the day. And Congress Needs to take an active role. Itll let us call hearings because were democrats but and to work with cms more so we dont create any more problem but also with the drug prices to get things that stick out like sore thumbs like a venture capitalist to raise the price astronomically not one dime of that goes into research but wed want to drive up investment because that is to rediscover the new cures. Since they are the main sponsors you want to continue that with that intensity with fda funding. We are using insulin as a case study to try to figure out how is it, insulin, which obviously every type one diabetic and many type two diabetics reliant, how is it that is suddenly spiked up in price. So we have been systematically talking to people from Interest Groups we just mentioned. Of course it is always someone elses fault. So, what we are trying to do is get a full picture to convict the chairman and i respective subcommittee to have a series of investigations and hearings but its not so clear exactly weighted at this point. I think jean would agree. I think thats a good example. When you see some of the Market Forces and i think we can agree on a bipartisan basis that we dont see that kind of jump in price just because someone can go by the patent. That doesnt help the system. It just raises the price for the consumers. Says congress now appears to be moving toward a bipartisan fix of the Affordable Care, or at least some part of bipartisan negotiation, what role would you like to see pharmaceutical pricing plate and some kind of next version of the file. I would hope that somewhere we would go to. Theres been a push in the senate for bipartisanship, did a one minute yesterday morning on the floor saying that we dont have a democrat or republican solution and we need to sit down across the island have an american solution for healthcare. And that would be allencompassing. Obviously access is important from where we come from. I want folks to go to some of the greats facilities that they had to have some type of vehicle weather through the employer and the exchange or medicaid and again we should not have allowed states not to take the whole medicaid. That was not in our bill, that was in a senate bill. In our district 46000 of the constituents would get medicaid. 90 , typically in texas 98 10 is really good deal. To survive many more people. So, maybe you have some information, we do not have about bipartisan negotiation on Affordable Care act. I will say that is jean mentioned, i worked with fred upton, the chairman for three years to develop 21st century cures. Jean and i both believe that the best at legislation is Bipartisan Legislation. We have been trying to convince our colic in the house to work on a bipartisan way on healthcare reform. We realize that the Affordable Care act, while it is provided opportunities for millions of americans, and needs improvement. I identify ten areas where i think we could research it on a bipartisan way. One was Prescription Drug pricing. So far, despite her many of approaches, we have not seen any appetite on that part of the republicans on the house to work in a bipartisan way. I think its unfortunate. I think all of these solutions will have to be bipartisan. We can do it. Twentyfirst century cures in the house is overwhelmingly bipartisan. All of us worked like diana works on diabetes with tom reed, john and i work on the next generation of antibiotics and with the legislation going to the senate were trying to see how we could jumpstart that medical research into that new antibiotic resistant illnesses. The chairman and i worked on trauma care. So, we can do it. We just need to look at it we did a great on cures, but now with whats happened in the senate, and i would hope that we would do that bipartisan on how we will provide healthcare to americans. Some proposed requiring pharmaceutical companies to explain their drug pricing models, says something that would help the market . I think transparency is important. Although we also know anyone who has a patent, they may not want to share some of it so they can have a knockoff, but i think transparency and drug pricing so people will know. Even physicians will know that if they have a an array of drugs for an illness they would know this is the cost of it. The goal should be that you need to prescribe the most effective for your patient. I think transparency would help both on the end result of her employers, unions have plans. A couple of things we need to investigate and pursuit of this transparency is that we need to investigate the current exclusivity rules and if they are appropriate. As jean said, we want to encourage development of new therapies and new drugs. Some of those take years to develop and many hundreds of millions of dollars to develop. So we need to recognize that on the one hand. On the other hand we need to see if there are adequate generic drugs being developed that will give price competition. And we need to have the transparency to see if the pricing is in line with what these drugs cost to both research and to produce. Finding a legislative solution to the is not easy. You cant just take your magic want it all goes back to investigation and hearings before we call me crazy, thats where would benefit we all support and support patients with those therapies for the insulin and then we have some new a very targeted excellent influence. Those are not going to do any good if the formula doesnt offer those and parents of diabetic children have to decide whether theyre going to decide hundreds of thousands of dollars a month because the insurance wont cover that. The white house is working on an executive order to deal drug prices. What would you like to see them too . What you think they will do . You know, they dont call us first. I would like to see leadership out of the white house. But again, you can jump from we just need to know what to do to accomplish the goals. Its not going to done be done in one session of congress. It the cures took three years. And to have buyin from everybody. So weve seen generics being cut or even new drugs to market, where do you see the balance between them to increase access and protecting patients in the long room . I think we need to look at this as part of it. It takes such a long period of time to get from the lab table to the other side. Cures gave the fta to half a billion dollars, but also to streamline and to prioritize some of the pharmaceuticals and needs to be on a fast track. Ill give an example. Fda can do it. When we had the a bowl a scare three years ago the u. S. Citizen doctors are being treated and i asked one of the doctors, i said, what would happen if that dr. Who is aware have the if there is something in there, if you could ill try that. And i was told that it took the fda 24 hours to get permission to administer that. The sad part is they dont know what that pharmaceutical help with the treatment or survival, there needs to be more tests. The fda can move away want to make sure that they take on some of the more terrible illnesses. Diabetes is one of on the cost so much. Also we have the breakthrough therapies bill that we passed some years ago. That has been extremely successful. In helping Companies Get their piece on a fast track at the fda for approval. It is targeted at their piece for diseases we dont have treatments for. I think encouragement of generics is important because i does give to competition. As i said earlier we have two issues, one is that its really easy to develop a generic for aspirin, its a lot harder with some of the biologic their piece that we have to develop equivalent generic solutions. Secondly, some of the expensive treatments are being developed for diseases that affect a small population, and so it is economically not feasible to develop a generic. We need to figure out how to incentivize competition in those areas. On the one hand, already we are incentivizing the development of any treatment for these diseases and we have to figure out how we can do the same so we can have competition. I have one more question, congressman you mention exclusivity. What do you do about the lifespan of a patent and how long one company can put a stranglehold on a drug . This is a lengthy and complex conversation that we had when we did 21st century cures. But we need to do is find that sweet spot where you again patent exclusivity for some time that incentivizes and encourages people to develop the therapies. On the other hand, you want to make sure its not so long that people get a monopoly over the drug and then they have no incentive to keep the price low. Study after study have shown that where theres a generic alternative that brings the price down. So we continue to work and rework. Theres a number of provisions along right now. We had a small one in 21st century cures but theres continuing dialogue and pressure around that and theres no Silver Bullet. As members of congress we have two levels to increase funding, and we need both public funding for nih and private sector funding froms pharmaceuticals. Exclusivity is one of those that federal money going in to nih and you have to be careful because both are sensitive. Also a lot of members have real concern about the use of exclusivity. If you want those breakthrough drugs thats the only leverage that we have, come up with the money or longer patents. Lets go to questions for the audience. We have a question in front. Thank you. I think its very important to reduce costs on a Prescription Drug, i want to mention there is another important way that you should consider a very good effort to rule on this subject, one is the hospitalization and Health Provider and er and whoever send somebody to the hospital to see the doctors when they are unnecessary to do so, not only are they allowed to use those prescriptions are the increasing or for medical costs, so if you can take that effort where its very important. You are right, of course if we repeal the Affordable Care act that would exacerbate the problem. It would throw us back to the situation where people who did not have insurance felt like they had to go to the hospital for treatment. When people who dont need that treatment come to the hospital that increases costs. One thing we have been seen in the diabetes row is people who cannot afford to get the insulin because the prices have gone up so much theyre going to the hospital, they go into diabetic shock, go to the hospital so they can get the insulin. Seems like a very poor way to treat diabetes to me. Affected support way to treat anything. I should not be in the emergency room with my sinus infection. Thats why if you have a huge number of uninsured folks thats where they can ago. Theres no other option. Hello. Im with inside Health Policy. Now send in your comments about the need for hearings and investigation before legislating, are there any solutions to drug pricing that you see republicans able to get behind. If Congressional Republicans cannot get behind truck pricing is it up to the Administrative Branch to be pursuing fixes to the problem . I think there will be some Congressional Republicans here in a little while. I suggest you ask them that. I will say one thing that jean and i both fought for is the ability of hhs to negotiate Prescription Drug prices under Medicare Part t. We saw that will pass out lawn 2005, 2006, and i think it would help bring transparency, number two it was sent waves throughout the system if you let the secretary negotiate Prescription Drug prices. You have to have two groups to sit down and work, and we have a paradigm for, whether it be 21st century cures or other things we worked across party lines. Thats where we need to get started on healthcare in general. But also items like truck pricing. I will take one more shot, what about an agency like the virginia . The eight virginia by so many Prescription Drugs, what role can they play in forcing the industrys hand, and should they . The virginia negotiates for pharmaceuticals. Thats one agency that can do it. Ive a district in houston was refineries and chemical plants and my unions represented negotiate for those certain pharmaceuticals. So negotiation would be Something Like diane said that is one way we can do is to like the virginia does. When the Prescription Drug plan passed in 2003 that was not part of it. That was part of the problem. Thank you both so much for being here. Thank you. [applause] i would now like to call scott, the new commissioner of the fda. Doctors indicated the fda could play a role in tackling the price of Prescription Drugs by encouraging competition. We look forward to hearing from him. Welcome. I thank you for being here. Congrats on the new job. Have you found all the light switches yet . This is my first time of the new facility. Its a lot different. I a matches first time in the big chair. What role do you see the fda playing in the pharmaceutical market . We have a marketbased system for drugs in the u. S. We do that to make sure were giving proper awards to innovative entrepreneurs. In order for a marketbased system to work in my view we need to have true competition. If theres places of the market right now where were not seen the competition that congress intended and did architecture for drug pricing thats will focus on. There places where we could affect the competition the market with both generic drugs and new drugs. We see places on the truck side where there are market failures because people are either taken advantage of regulations and ways unintended or our regulations are not working to create the type of competition that congress intended. For example theres places with respect fda regulations receive certain drugs have monopolies largely because we dont have a good framework for seeing those. Those are complex drugs there either complex and that they cant be measured in the blood easily where they asked locally on tissues and demonstrating through the approval process they dont apply or dont work well. I think were focused on places where we see competition that should be happening in the market not happen because theres failures in the system. How do you fix that factor of people taking advantage of the regulation is written . To have to write new regulations to plug those loopholes . I said i dont want to be in the business a plane whack a mole with companies. But we want clear rules that people can take advantage of. When i look in the market and i look at places where there are rules where things are being gains for branded drugs, its a disparate set of factors. We need to address them one at a time. For example, we see situations where Companies Risk management plans to ensure the safe use of drugs to deny Companies Access to do the bio equipment studies even though the Generic Companies are willing to pay fair market value. Companies are using tactics to prevent them from getting access. Thats not what congress intended when we created those regulations for a specific purpose to ensure that drugs could be used safely. There are things we can do to address that. Another thing you want is a Risk Management plan in place around the use of certain drugs and then a drug comes into that market you wanted to have the same Risk Management to be using the same system to decrease the burden of providers. Sometimes those negotiations enter into the same system because a company owns a system and they have to come to some kind of compromise. Sometimes negotiations become protracted. So thats a situation where thats been used and we need to talk about it for going to cut off those. Thats another thing we can look at policy changes to create more competition sooner. Theres that a number of areas where we see it happening also on the commercial side. Probably the biggest impediment is that in contract the company has they have exclusionary language and some of those that prevent the intermediate readers for selling. The makes it hard for them and that doesnt seem to make sense. The Generic Company wants to enter the market and do studies and is willing to pay fair market value they should be of the purchase it like anyone else. There shouldnt be provisions to prevent them from getting access to. So i think we could do something with working with our partners as well. You wrote out the drug action plan. Weve laid out certain elements so far to try to address when talking about. Were looking at places where we see a Branded Company gaining rules and looking at issues around the complex drugs. Were looking at issues around ordinary review process in everyday drug process. Historically the drugs have gone through four cycles of review before they reach approval. An average of 48 months. Weve committed to proving the drugs and eight or ten months depending on the application. That will allow drugs to come to the market sooner. It will also and a regulatory arbitrage where speculators can come in and buy off generic drug. Jack up the price a lot and they need to make sure they can take advantage of the system. So what were doing is prioritize and publishing a list of where theres no competition for branded drugs, only one drug on the market if its gone generic. Will prioritize so theres lack of competitors will commit to reviewing the generic drugs quickly trying to get review timestamp of they come into the market and try to raise the price out of proportion to any notion of a value that will kick going to market very quickly, not for years but hopefully six or eight months. You want have that long opportunity that you had historically. Thats created that situation. You seem less of that activity now but you do see some of it. Thereve been commentators who felt its abusive. Theres an important principle at stake and that should come onto the market much sooner. Talk about the office of generic drugs. You have advised some of their procedures and how do you want them see operating in the future. Will thanks to the user fee related to generic drugs that will hopefully pass soon. I remember a time at fta that office was historically funded through budget authority. Whenever there are budget cuts across the agency they would not get caught so you not seen increases over the time. I was there. I think its a much better shape now. s excellent management where we announce this week changes in the procedure for how they will review applications. Will put in place a map which is guiding viewers and making in creating a template to make it consistent in how drugs get review. Were also looking at manufactures and trying to help Generic Drug Companies learn about common problems and applications. The problem on the generic drug side and on the new drug side as well as the applications go through cycles. When they come and they dont come in where they can be approved on the first cycle. We made an effort the last time to try to reduce multiple cycle reviews. We are able to do that and will do the same on the generic drug side. Will focus activity on the review function. So when applications come in they can be reviewed and approved on the first cycle. Thats a goal. What kind of backlogs does fta face . I dont think its a choice between more regulation or more safety. I think that we could have a situation where we have smart regulation that allows us to have a more efficient process get drugs to market more quickly eventually but also make sure we are improving Patient Safety and improving what we know about the risks and benefits associated with drugs. Thats another part of what we are doing. We have an innovation plan that we have been announcing to try to look at places where across the agency especially on the new drug side we can have a better framework for looking at safety risk benefits, better framework for looking particularly at new areas of technology to evaluate against current standards and current rules and make sure we have in place the right policies approve drugs more efficiently against more one of the guidance as we went into his looking at their certain drugs that target certain molecular disease and cancer that might appear different organ systems but driven by the same molecular signature so if a drug targets the underlying molecular driver of the cancer you have to prove efficacy and every tumor type two per fruit prove that it works or changes prove that works against tumors in this particular molecular driver based on targeting the molecular driver in each organ which is going to obviously make the review process more efficient. You can do what we call including patients who have different types of tumors patients with liver tumors in patients with a tumor in the lung and get overall approval. You can treat more quickly that way rather than studying organs individually predestined example where we are looking at modern science and the way drugs are being developed today in looking at how we look at standards and more efficient way that will be less costly and drugs get to market more quickly. Remember that new drugs, something i learned in my life as a venture capitalist obviously a lot of considerations are made and how drugs are priced so i dont know the issues that go into that but certainly the cost of capital to do a notch by meryl endeavor bear some relationship how you estimate approximate. The sense that we can affect the capitol capital we can ultimately impact how drugs need to be priced at eventually out pricing the market. It isnt just the direct cost of developing a product but is the cost of uncertainty in the biggest driver if you look at models of how these decisions are made the biggest driver is often time and its certainly not the direct cost for the direct costs can be understood. They can be financed through uncertainty and risk is hard to finance. Entrepreneurs tend to overestimate it. I want to go back the fda has targeted this niche market of older drugs with high costs. Where does the priority . Well older drugs with a highpriced the complex drugs you are talking about this is a high priority because this is a whole class of drugs that should be subject to competition under the rules the congress establishes only because the complexity of trying to demonstrate sameness for those drugs that go through the typical process. These complex drugs and these are things like metered dose inhalers or an oral drug that you swallow or a drug thats hard to measure in the blood secant do the traditional i o availability to measure the availability of the drug in the blood. These drugs are basically drugs that are being sold as branded drugs the branded drug prices but for our ability to put them through the generic approval process so to me thats a failure of regulation. We have to come up with a rated tory standards to allow the drugs to go through process and congress clearly intended that. The reality is the more drugs are moving into the complex realm things like extended release formulation different kinds of complex from elation that it allow drugs that benefit patients that make them part of the copy. The traditional approval process works by basically you have the old credit 30something years ago. There were chemicals. They come in and approve that when you swallow there till the generic pill. It gets into the blood at the same amount of time and stays in the blood are the same duration of time. That works well in a world where drugs were chemicals and they got into the blood systemically and they got the target organ and they worked but when a drug is acting locally on tissue topical drug or an eyedropper or an inhaled drug it can be easily measured in the blood because of the complex formulation we not complex mixture. The old process doesnt work so well so the question is do we need a new statutory language to create a new pathway for these drugs . Perhaps but i think there are things the fda can do so we have committed to put out guidance and two years in advance of the earliest possible generic entry date for any complex drug Going Forward so hopefully we will eliminate this problem Going Forward by putting out the standards for how the complex improves sameness. We have committed to go back and look at the complex drugs currently on the market but not subject to generic competition and try to put in place clear standards for those drugs as well through this isnt a trivial amount of spending creates an billion dollars it should be subject to competition but isnt because the rules or lack of rules and as a policymaker thats where want to focus brit awards locus on the area where congress clearly anticipated there would be vigorous competition but for one reason or another usually because of policy failure because of a market distortion we are not seen the competition that was intended. I have one more for Scott Gottlieb and i want to open up for your questions as well. Is it the other das ruler should it be the fdas role to increase transparency in the pharmaceutical market . That sort of a broad question. I think we are creating transparency in the pharmaceutical market. We oftentimes when Generic Companies come to us and can get access to the drugs they need to do their ia cloven studies we send a letter to Branded Company saying theres a reason why you cant sell us their rounds. We say the rams that you have in place we ever viewed the Generic Companies bialek lebanon to study plan and we have determined they will adequately comply. They are going to maintain custody of the drug and appropriate fashion critic and sell it to them. Those letters go to branded companies. We have sent 150 of them. We are looking to make them public and i think we can so that will provide public transparency in situations where we believe because we are sending a letter that there might be an impediment to the Generic Company getting access to the doses that they need for the bioequivalent site. That kind of transparency could be useful in the market to help effect some of this behavior. All right, lets open it up to questions. Anybody got any . The microphone is coming right to you. Hi im julie and i worked for prime therapeutics and where theres competition we can drive down cost and there has been a lot of great prioritization of breakthrough therapies. Think one of the challenges in the market more generally that we have to sometimes theres less of a priority for drugs. You get the competition on the branded side and have several drugs competing in a particular branded class producer in the effort to take a look at getting that third or fourth branded drug or a particular action or condition . Thank you. We oftentimes will give designation to multiple drugs within a class so there will be multiple drugs are that are prioritized in something that congress is looking at as well trying to give designation to other drugs within a category. Not just the first drug but also the second drug within the market. I think its not necessarily a situation where a di fda is hearing rigorous review timelines at the agency and i dont give prioritization of applications that might be a therapeutically available products and. The challenge is more for commercial challenge which has some things are more reluctant to be in the second, third or fourth drug in a category and i think thats more commercially driven than regulatory issues and to your point theres less competition within some of these categories and also its important to have variety. Even though a drug is molecularly similar to another product and targeting the same condition sometimes patients do have a tip rancho response. Its always important to have therapeutic variety and categories and we are seeing less that unfortunately. All right, do you have another question . The microphone is getting there, dont worry. There we go. Hi i was wondering if you could walk through why fda hasnt publicized those letters previously. What issues there are bear. Previously the fda hasnt been able to share for sample when a Brand Company in the Generic Company cant reach a shared ground. Im wondering if there are particular legal issues that you are possibly running into when trying to share these letters it varied them public and information for example like the name of the Branded Company with that information be made public . With these letters in particular and talking about these letters are being sent to Brand Company so we are making the Brand Company aware that the generic applicant is trying to copy their drug but not making the public aware. There is confidential information has been shared with the third party. We are looking at the issue of whether or not there is confidential information and how we would redact that. I think theres more that we can make public at a lot of these come down to questions of how much resource you are willing to spend redacting commercial confidential information in the question of your point how much of legal risk is a policy objective . If we have a strong public rationale we cant do anything just because we certainly dont do things as a public shaming vehicle. The campy doing it just to inject ourselves into commercials and disagreements. Redo them when we have public rationale and that they have a Strong Health rationale taking on the burden of using resources to redact things associated with these activities we have to look long and hard at doing that and thats what we are doing. One more question. We havent heard from anybody in the back. We have got one right back here. Hi im from amgen and i was thinking of larger pharmaceutical companies are spending hundreds of millions of dollars to put a new drug on the market and then generic drugs come in more quickly are these two Good Companies going to see a return on investment in this this going to impede new drug innovation the future . Remember im not looking to appropriate intellectual property. What im looking to do is make sure we have competition in the market when intellectual property has lapsed other product or the Company Comes to market with their intellectual property may make a decision to develop products based on how much ip they have to protect their product whether or not they have used patents to protect it past a certain point in time and make economic decisions subject to the kind of protections they have. What im looking to do is make sure when that period has expired competition that congress fully intended for there to be under waxman comes to marketing people are using our own rules in particular as ways to extend monopolies. Thats whats happening in some cases. People are taking advantage of rules were created for another purpose as a way to extend franchises and monopolies passed the point of the patent expiration and having the unfortunate effect of certain situations people are getting the Competition Congress intended for them to have. Its an enormous Capital Investment and too much relative to what the expected ability of those investments given what the patent life is on products that go to market. The average patent license is something for congress to contemplate but not something for us to contemplate. Our job is to make sure the product can be subject to generic competition once the special property that protects protects drugs has left and once we legally approved the generic product. Scott gottlieb thank you so much for being here. Thanks for having me. [applause] b our last headliner bill cassidy is a member of the Senate Health education labor and Pension Committee one of the few positions in the senate and an influential voice on health care issues. Please welcome senator cassidy. s senator cassidy and thank you for being your senator could we really appreciate it. The last 40 to 72 hours has been. Intense up on capitol hill. What are the next steps for addressing the aca . [laughter] i came away very encouraged last night. The president very much wants a replace with repeal and he has said that over and over but he wants something done. Its clear that they are willing to do more to achieve something. That said something that senator collins and i have proposed and senator graham and i a subset which is that you give the talking point if you will the power back to the patient, the power back to the state. She then chose the money typically has the power so if you return it to the state into the patient, the dollars that she has the power, the patient has the power so how come i block grant . He we take all these dollars that the federal government spends restraints on how you spend and senate back to the state with guidelines. It on health care for sample with some provisions such as for example you can use a Health Savings account to pay for premiums which would allow the state to. Fund a Health Savings account or someone purchasing insurance of their choice. That would give away to give up power back to the patient of the state increasing Competition Among Insurance Companies and get the federal government out of micromanaging someones insurance. We think its a good approach and we are getting some traction on that. On the cost of Prescription Drugs what role does congress have to play in increasing transparency over drug prices . You are making a great case that the lack of transparency is contributing to the rise. For example pointofsale rebates the pbm negotiates a sharp discounts come Insurance Company gets it but when a patient is inherited dockable she does not get the discount so she is paying three times more for the drug than the contractual price. If she knew when that pointofsale was she would get that discount and maybe the congress would have to mandate that those patients get pointofsale rebates. The degree to which hes paying more outofpocket more rapidly pushes her into the catastrophic forest of Medicare Part d so not only is she paying more than the contractual price but the taxpayer is paying so in our part d benefit it goes up dramatically. Theres no way g. Report on on that lays out very nicely so that transparency would save money for the patient and the taxpayer. Secondly my state is one of you to do this, there is at least one which puts a gag order on the pharmacist and in some cases the cheaper for the patient to pay outofpocket than it is to go through her benefit. She pays more under her benefit a higher deductible and higher copay. The pharmacist if he tells a patient if you pay cash to get a better price he loses the contract with the pbm. Not all do that for at least one death back in our state louisiana theres a law passed that you cannot have a contract but stops the pharmacist from representing the pace and best interests and thats a good thing. How do conversations about transparency lower drug prices impact funding of Biomedical Research . I dont know of that impacts funding of Biomedical Research. Their folks that would like to socalled march in. Im not sure its got a whole lot of traction. Mr. Gottlieb spoke earlier in response to the question about encouraging investment for we are all hoping their secure for all and that investment make sure alzheimers if theres inadequate or turn up on their investment. Thats a good thing so im afraid to start taking intellectual property it will chill that investment that ultimately will decrease costs for society and improve outcomes for patients. Is Congress Starts to address the aca once again as the senate takes up or at least senator mcconnell has suggested there could be bipartisan discussions going on. Our drug prices a part of that conversation . You know i think thats going to be something a little bit separate. A lot of drug pricing is in Medicare Part d and we are not touching that with the Obamacare Repeal and replace number one. Number two we had a hearing, the joke i went to a hockey game in a fight wrote out. We have a hearing on drug pricing and what broke out with a lot of frustration on the democratic side about the process related to the repeal of the aca. It ends up having a great panel just fabulous witnesses but a missed opportunity to explore that which could be done. Im thinking until we get this repeal and replace behind us it will be difficult to have equal operative formal committee hearing. That said ive spoken with colleagues on the democratic side. Theres a lot of things that we agree on. Can Work Together on most points of agreement setting aside those which we disagree to come to some Common Ground so there are ever so im apart of and im sure others. At the white house is working on an executive order that would address drug prices. What do you want to see out of the president . Obviously Scott Gottlieb is going to implement some of that by the lot of their record Regulatory Regime has i heard dr. Gottlieb say which is allayed the approval of certain drugs. The Supreme Court or think just this past week ruled, made a ruling that would bring generic drugs have an eye logics six month earlier. Thats good thing so theres no one Silver Bullet for a drug pricing or for tried Price Transparency but a lot of things you do on the margin which collectively makes a difference. Wheres the balance between cutting regulations and cutting the time until a drug is approved in protecting the public . When you approach drug pricing you have to set up a metric and this is what we do in my office. We analyze this. We look at it as generic comics use me small molecule Specialty Drug verses brandname and generic and really what you do is different in each segment. Carboni might be a dialogic but there are Specialty Drugs that fall into this category. Lets take a generic which has no competitors in the United States and because the absence of competition they jack up the price. An antibiotic which is 50 or so to someone in buys a lot of this for folks who work overseas. They used to pay 50 cents and now they pay 13 or for a drug which is 50 years old. I know what im told and not what i know and someone may dispute that. Maybe that in this case we should globalize the market. Most likely there is a plant in india which is producing the pharmaceutical and gradient for the drug which is sold in the United States as well as the drug which is sold in the United Kingdom and i can tell you we are to have a memorandum of understanding between the fda and the eu equivalent that says one certified plant in india the other would accept that certifications away already is working relationship. Could we say and believe me i think we should back with this generic small molecule that if there is adequate supply chain integrity for both the drug going to save the eu and the United States that we would allow sale of the drug from here to there. Can imagine walmart driving a lot of certain drug which only has one supplier here, bringing it back and selling it. We would use Market Forces to create competition as opposed to the heavy hand of government regulation. I think thats a way to do it as an example and again you have to have this approach. I will say it once more small specialty brandname generic and once you break it down you come up with Different Solutions for each box. We had dr. Gottlieb appear. Tell us about the trump administrations fda. I think gottlieb is about decrease in the Regulatory Burden and theres a lot they can do either in transparency and or charming processes to improve there have been rules that have been held up. Granted they are complicated rules to get right that once implemented would dramatically shorten introduction of generic generic and thats a good thing. Want to get a generic competitor prices began to plummet so i think gottlieb will bring a lot of energy and a lot of insight to this job. A couple of more than well turn it over to questions from the audience. What role does an agency like an agency like the va which negotiates their own prices in bringing down prices in the market . It certainly is possible and shows what it Drug Companies willing to do to have large market share. If President Trump looked and said va medicaid trump, you name it we buy 80 of this particular drug. Maybe we should negotiate it. And use that position to negotiate whatever price he wished. I can tell you that would save elias in the shortrun but it would quell investment in the long run and President Trump is a business guy that will quickly pick up on that. Can you imagine him doing it . Absolutely. It may encourage our president to go in the direction of strengthening that position even more. Spin it any questions from the audience . Let me say one more thing. One thing im concerned about is the high price of drugs, should be about the patient is a social contract for a very nice rate of return and we need them. They do the research to keep us all healthy. In this room there are people who are alive because advances in pharmaceuticals over the last 30 years. I will give the example. When i was a medical student the most common surgery was cutting out parts of someones stomach because of a bad ulcer disease along came tagamet and now we never do that surgery. This altering drug is now overthecounter. Someone in this room with Crohns Disease and it used to be a common surgery of someones because of Crohns Disease. People with Crohns Disease are most never have surgery. So we need that investment. On the other hand there are some patients denied lifesaving drugs because of the price of drugs and we have Medicaid Programs which typically in medicaid across the nation, Medicaid Programs cannot afford the medicine to treat patients as rapidly as they would wish in order to save those peoples lives. Thats just a reality. By driving down the price variable to afford more of the drug and push out therapy for a lot of people who would not have received it. We have to recognize the prices of drugs that denied treatment so many said to be a success of driving down the price is good for patients and thats something we have to think seriously about on its impact to access further conditions and other payers. Right over here. Carl with the aging institute and i have to take a little history of senator with what you said about the hepatitis curative drugs. You know you mentioned the va is a great example and i think they are down to around 24,000 but for medicaid its around the same price. The rebates, competition and discounts and so we feel this is 20,000 for a cure that will save money down the road and there are a lot of drugs that are lot more expensive. The feel the Medicaid Program should and most of the costs are borne by the federal government. If you feel that way thats wonderful but thats not reality and i dont mean to be rude but if you look across the nation most of the costs are borne by the federal government. On average they pay 57 but if you look at the Disease Burden of those with hep c is disproportionately among those on medicaid this is quite a figure. Hundreds of millions of dollars and most state governments cannot put up that amount of money. We worked on the spreadsheet report in the Washington Post and we put up what is the cost of a liver transplant and the cost of liver cancer the cost of therapy . If we treated everybody they could in the first four years we would save money in the long term. Because he would have fewer transplants but you have to treat them up front and thats a very expensive price tag. That said you still want to reward so two things we looked at one i call the mortgage way of financing and the other would be the prescription way of financing. In a mortgage we are going to treat everybody we can up front in the next four years and pay you off over 30 because we are going to realize the savings to our Medicaid Program so this way we can budget for those savings at the savings will pay for it. The netflix prescription is that you would get us you pay a certain amount to whomever, and then you treat as many as you possibly can. The company would be guaranteed some reasonable okay this is how much we expect to get from you over the normal course of events so we will give it that plus a premium but you can treat as many as you wish. Maybe we dont need to lower the cost but we do need to come up with alternative ways of financing because i can tell you the price tag of some medicines is absolutely limiting. It just totally isnt to say otherwise is not reality. You are wellmeaning but so am i and thats the reality of the situation. We have run out of time. Thanks so much. And thank you, appreciate it. [applause] thank you to senator. Next up we are going to be rethinking pricing. How stakeholders in the health care are finding ways to address health care. Lets welcome onstage the senior director Global Public policy and anticounterfeiting at the liang company. James galvan Senior Vice President of Health Policy at the University Industry committee. Cc connell and present ceo of the alliance of kavinoky health plans. Ellen segal chairperson founder of Cancer Research and chuck davis president and ceo of the Association Works accessible medicine for Health Policy editor kim dixon will be leaving the discussion. Hi thank you very much for coming. We have had a few discussions with touched on some of the challenges we have faced on drug costs. I know dr. Gottlieb talked about some of the things are going on the regulatory side and people in the green room seem to think thats a step in the right direction but there are different opinions on what Else Congress can do. He talks about increasing competition, drug approvals getting rid of some of the regular tory hurdles. What more can be done . Who wants to start . More observations and thank you to you and the hill for having a great morning. I have to remark ive been in d. C. For many many years and i think commissioner gottlieb is really up to a significant start in his role. We have heard some very encouraging things from him with respect to competition. He mentioned this morning what may seem like a small thing to lay people which is getting samples to Generic Companies but its very significant and its been a huge roadblock. If he can have success in areas like that we believe that it really will serve competition and bring down prices. I will just toss out on the table one baby step frankly for congress what should be a bipartisan bill sponsored right now by senators baldwin and mccain on transparency and transparency is not going to solve our drug pricing problems by any means whatsoever but getting some information to the public would sure be a nice start. R d costs are controversial in the health care community. Why do you talk about what you think about that will and the idea of more transparency in r d . Thank you for the opportunity to speak today. What id like to do is take an opportunity to put costume contest and keep the years relative to 2016 retail and physician administered pharmacy spending was roughly 14 . That figure is expected to continue roughly the same percentage the next decade. Medicine spending growth roughly three to 5 and 2016. Brand that price is 3. 5 . Just to put those into context as early to the Overall Health care spent i think its important and what has occurred over the last number of years is Health Savings accounts, and individuals are facing more pressure in terms of their deductibles copays, insurance and outofpocket spending has increased in a significant percentage since 2013 and as congress wrestles with health care the Affordable Care act and drug pricing in drug spending one of the various things to focus on is the outofpocket spending. Senator cassidy spoke to that to some extent. On transparency lilly issued an integrative report earlier this year showing over a fiveyear period the changes lists the net price and our percentage discount which increased to almost 50 . Thats one of the ways we are trying to put more information out in terms of consumers patients stakeholders to understand how we price medicine but as i look at transparency rent legislation particularly in the states were number pieces of legislation last year have been introduced and moving through the legislative process. While their wellintentioned the challenges they dont do anything to address patients outofpocket expenses today. There are some instances anticompetitive provisions that would create some challenges in terms of the Public Disclosure we are working through and dont really speak to the value of medicine. That would be my take on some of the legislation but we want to Work Together in terms of transparency, absolutely. Did you want to jump in . Thank you for inviting me and for doing this. This is a vexing problem because we have the best of all worlds today. We have innovative drugs, targeted signs that in some cases may be curative. On the other hand the system cant sustain it in the patients cant afford if it wont have benefit to the patient. We are challenged by keeping up this pipeline and competition and lifesaving drugs. We also are challenged by the cost. Might inyon speaking of generic and transparency in all these things that are recommended which are important will not be a systemic rome. Its going to take Bipartisan Legislation people working together. Transparency and speaking up generics not enough . What was a bipartisan solution . You have to look at where patients are being treated and for example in my world where we have innovator drugs that are personalized to have to make sure up the diagnostics are working in patients are being treated to a there are many studies that show patients are being treated tonight giving the right drugs. A complex issue because want to keep innovation for patients who dont have access or cant afford the drugs. Paris this defense from the oval industry the drug prices are really not rising and maybe they arent as a whole in the whole ecosystem that we know there are drugs that are saving peoples lives. Those are arising within certain classes and those are the headlines that we see. I dont know hell if you have addressed specifically r d costs and would the industry be willing to give more information on how much it cost to develop a drug . Began speaking to some of transparency legislation when you look at what is introduced and how it progresses through the legislative process the challenge of looking at a byproduct for input costs bases create some of the anticompetitive concern that i mentioned earlier. Cynic if i could add to that of let me join everybody in thinking the hill for facilitating this panel, as johanna seven the ceo and if i would have been their year ago i would have been i didnt switch jobs. Just to add a bit of a context in and one of the reasons we did that in addition to representing generic manufactures and imports of generic competition, it will shock you to hear me associate myself with all of those remarks. That is an exciting and most people know senator cassidy mentioned earlier about biosimilars that have the potential to reap enormous benefits and assist savings against the rise of specialty medicine. The only thing i wanted to upfront say was not all drug prices are going up or generic prices are actually going down. There is deflation in the overall generic marketplace. The media and others will often highlight a single incident of a case that is alleged to have skyrocketing prices. Two examples that have happened over the last two summers each neither one of those products has been traditionally characterizes generic medicine. In fact in my second week i got a phonecall from the media asking if we were moving the manufacture of derek then from armor ship because they wanted appropriate reflections of our commitment i got the word no out before this reporter said how can you defend them and i said im not going to defend them. They are not a member because they are not eligible. Theres a lot of confusion in the marketplace and one of the things we have to do and cc touched upon some of the work that the fda commissioner gottlieb is undertaking right now i would suggest there are a lot of people talking about solutions to the Prescription Drug problem. There are fewer Government Agencies in the executive branch of the legislative branch who are taking meaningful action. He is the exception to the rule because since he has come in he has been activist commissioner and is the potential the transformative. In the marketplace the most important thing is if its good for the patient will help constrain cost and i think no matter who you think is responsible for why we are where we are in the drug place drug pricing debate right now theres a lot of fingerpointing going on. The reality is when more people are coalescing around a key component of the solution is to increase marketbased competition and nowhere the opportunity is by increasing competition from generics. We agree with that provided the pharmacy benefit manager competition is a good thing and a challenge when you look at these big numbers and large groups of people is the individual takes a specific drug and that drug can be very expensive as was pointed out on the panel and some of these drugs are difficult for people to afford. Where i think we ought to Work Together specifically in the ppm industry is to provide the mechanisms to work with our partners in the pharmaceutical companies to a die weight is the drug providing value which is important more so today and to use our systems to drive lowercost alternatives for those that are appropriate and certainly generic products when they are the most costeffective. I really do think it requires effort on the part of pharmaceutical companies certainly patient advocacy. The pharmacy benefit managers that have systems that allow competition that dr. Gottlieb talks about to turn into a low price at implementation. I would like to complement that in the previous comments that the Solutions Lie in collaboration in terms of the supply chain and most important how we can Work Together in partnership to pursue Experimental Solutions and varying places and contractual relationships through partnership with the fda. I think we are in agreement in terms of that. Competition is incredibly important and even in the innovator drugs if they look whats going on we have at least three, four or five approved drugs are probably have 10 or 11 that will be used in combination. They all have to be specific to a biomarker in the patient population. They have to get the right combination that is right for them. Its not static but on the other hand as i said earlier that the copays are high and they dont have the right diagnostics and the right Health Care System thats right for them it wont affect the patient and if they cant afford it its of no value do we have to preserve innovation for Patient Outcomes and figure out how to pay for it. Im so glad you picked up on that in the word value is kind of motherhood and apple pie right now. We all want to value and we deliver value. We are highvalue, im a valuable person and you are all valuable people. Lets get real here. Insulin, valuable, incredibly valuable, right . Think about all the people with diabetes in this country. Cumbersome and degette. By 20151 in three americans will have diabetes. Just think about the implications of that for our society. Our Incredible Team went and pulled the pricing trend for the top seven diabetes products insulin products. What happened between 2010 and 2015 . Acrosstheboard increases in those products range from 93 to 325 . Insulin has not changed. Not one bit. So what is going on there and how are all of these people with diabetes going to afford this . How is our society going to afford this . I agree with that point so much and i think we have a tendency to talk about components in isolation so when you look at the dynamic you just pointed out you would expect the portion that a patient pays to increase as well with the total price that society pays for products. So i think that its very hard to point to a specific piece. Certainly with the members pay is part of it but its hard not to say the price of the product as you pointed out is not an issue. You said there has been a change in the last two years. How do you keep that message going and it sounds like you are all agreeing but what specifically do you see happening or could happen in the next year given the political environment on the help . Nothing is going to happen. I will start by saying employers get 80 of the cost of health care in terms of people that we ensure not just for the people who work for us but also their families and also retirees as well. We are bearing the brunt of these cost increases. I dont think you would find a single employer who would want to see a layoff notice go to good men and women of the fda. We have all at reed. We must fund the fda. At the same time when Congress Says well the next five years there will be one bill and one bill only that talks about drugs and its a musthave piece of legislation with stood out and talk about drug prices later. That is not real talk. We are going to miss the one opportunity we are going to have to have the legislation that we can do meaningful something meaningful on drug prices. Here we are now saying okay will have this hearing and i love hearings. Its testimony for the record and people can ask questions and their witnesses and interesting conversation usually it ends up producing nothing. We are right now going to have to look at what we can do for the Administration Working with our pbm partners who by the way arent the engaging and valuable purchasing agreements getting Drug Companies to have some skin in the game. We love that for the same time we have pbm and Drug Companies trying to do the right thing and it has sent up creating problems in the prices that medicaid which are some problems related to kickbacks things the congress looked at a couple of years ago and said this is complicated, lets find Something Else to do. I know that may be a little bit less kumbaya but we are worried. We are on an unsustainable rate. When i hear things like its not the cost of the drug that matters, its the copay, no its the cost of the drug that matters. Substantially you will have to save wheres that costs going up because obviously the time we have a conversation about drug costs everyone does one of these and some folks say its a supplychain, some middleman and people say its the cost of the drugs they are straight up charging two people were buying them. Im just going to go to the podium. I would like to agree strongly impart and disagree in part. I agree with you on the negotiations. Unfortunately washington is what it is as we all know and dont underestimate some of the forces that dont want to attach to that discussion. At the same time there will be vehicles. There will be vehicles for which the federal government will need to fund money. There is a macropolitical dynamic that a lot of people on both sides of the aisle campaigned on this issue including the president of the United States and when we come to recycle and we all know 2017 is a more realistic year for enacting legislation at 2018 will be. If nothing meaningful is done in this space then i think the folks who ran on it in the media savvy world are going to be reminded about that fact nonstop through the 2018 midterm cycle. When the things things that the focus on his where can we seize the opportunity for alignment specs i would propose there three different areas. This was a simple solution we would have found it but there is certainly the right of. Aspect of it. You heard from a foremost expert this morning and commissioner gottlieb. Their additional things that congress can do short of completely disrupting the market and taking the industry overall to increase competition and there are plenty of high partisan that would allow for that type of competition to pick celebrated and save the federal government money. Imagine that. The third thing we have to do ultimately is make sure the market is working as efficiently as commissioner gottlieb talk about the reality is generics is the last point, generic utilization is up 4 . Generic revenue is down 15 and the reason for that the level of competition in the market for prices but one of the challenges is there as been an incredible amount of consolidation within the supply chain. This essentially three wholesalers, three to four large retailers and the pbms who have consolidated as well in the branded area but to expect 10, 12, 13 Generic Company to be competing solely on price with is just something we have to factor in. A lot of people thought you had to get the eighth, ninth or tenth generics to get to moderate price. You can get there now in three to four in the marketplace. When it works and it functions the market is driving a naship naship astor colin mt. Astronomical amount of savings. We have a lot to fix and we also need to make sure we dont disrupt the mechanics that are actually driving that level of sales. Would the talk about drugs you are not talking about a carpeted ticket car from here to case even taken uber or you can walk or bicycle and you are going to get there. When you are talking about medicine and innovative drugs and drugs targeted to specific complication the patient if they get the wrong drug and its cheaper and its going to help and they have to get the treatment that the validated diagnostic in the treatment. We are doing master protocols and rare populations. Some of our if you find these patients 80 or 90 wont get the drug so we have to think about that also because we heard immunotherapy we are dealing with combinations and its going to get very complex. With the patient wants is a drug that will work for them. They want access to it and has to be affordable. How we are going to balance these issues are going to be very challenging. Eventually we are going to have a much smaller population. We have to get the patient the right tree than enough to work for them and quality of life is really important. That go ahead. I just assumed we were going down the line. I agree with my colleagues on the panel. The perspective that i want to make sure the audience leaves with is that the pharmacy benefit managers role is to take competition, to take choosing the right drug and in a perfect situation and implement that for patients. That is how we fit in and its a difficult thing. Perfect information is part of why its so hard to get there. Without the industry in the middle and ill give you a simple example. We are in an Opioid Epidemic and the cdc has come out with guidelines that say doctors should prescribe less than seven days of morphine and they have also said he should have less than 50 morphine equivalent dose average per day and nothing more than that. They understand you take an opioid with the benzodiazepine your risk of overdose which is more lethal to americans than Motor Vehicle accidents, but those things should not be done together. And so what we do is we implement programs that allow the script only to have seven days worth of supply. It allows us to take competition in the generics space and drive more quickly to the generic over more expensive drugs so thats how we fit it into the question. Back to the previous comment about employers and sometimes we forget that lily is not only a pharmaceutical manufacturer but we are an employer as well with tens of thousands of employees, their dependents and retirees who are on a health plan. There are steps in terms of providing the employer contribution of the health plan upfront to help individuals manage their health care expenses. Looking at exempting preventative chronic medicines from a deductible phase and i think those are important to mention as voluntary decisions of an employer that help individuals through what is their Consumer Choice in selecting a health plan and understanding how it progressed through the year. And not have the much more serious. So some of this is being a little smarter and it takes thinking a little more longterm and spending that will save later on i would really like to uc to start to attract back in a much more meaningful way. So right now is in the state of flux. That doesnt apply to every button everyone on the panel so what about this latest repeal bill . Which one . [laughter] so our position in and continues to be coverage for health care that includes Prescription Drug coverage because having access to Generic Medicines moving forward but that said i will tell you that kinney get readings in the overall dynamic . The Prescription Drug costs was such a big discussion that whatever happens or does not happen for repeal in replace the issue will come back on its own. President from brought Senate Republicans with a primary objective was to get them to vote in the repeal effort. One was with high Prescription Drug cost faugh in one was with those user fees paid to get the notice out to the fda employees. I know what that coverage and discussion and great coverage in portable coverage but those that dont have coverage anymore anymore . Id it will take the sensitivity. I would just say with respect to new coverage is thinking back at 2008 or 2009 with the uninsured americans so those individuals of preexisting conditions could like it didnt and the insurance or they went to the emergency room in the of progression of their disease not good for anybody his wallet with employers say and taxpayers and all the rest of us. It is a linchpin piece of the system for girl so managing bad risk pool is 32 the of bright number 32 million . So if theyre off by half so 5,916,000,000 more . That is okay . Who wants to say how many more uninsured is okay . Trying to see what 20 or 30 Million People. They will get the Emergency Rooms so they have to have good insurance. These are just people that need help so what that impact is on families. It is devastating to people. In reaction behalf to read bill whole cbo report but that task to be those ones for the American Health care act. So if you start to repeat read the report beyond the first page they are no longer forced to buy something they dont want so another 5 million are in the states that have not expanded medicaid this far. But it will certainly happen. Three or 4 million currently have coverage for through their employer but the very next paragraph it says probably not an employer to be highly paid individuals. That is the number closer or four or 5 Million People with medicare expansion that is say no. We should be concerned with. And then to make sure they do get coverage. Certainly the Affordable Care act and that consume a lot of the attention there are policies solutions it isnt a Silver Bullet but the shift from that potential of the reimbursement to the real world out comes. And the amendments of the best price and the ability for pharmaceutical manufacturers prior to fda approval and the clarification of that with stakeholders to have value based agreements flourish. They accuse so much this has been fantastic. So to have systems in place right now and with that role so with that population so that if they have insurance the drug is of their formulary and the innovative treatments that were on lot of options. What our Research Shows those that the criteria are denied access. Through a burden on Health Care Providers the impatience. Patients so what we already have been placed if they have a genetic condition then they are denied. The first with a patient that requires a drug that is appropriate and does not getting it i fully agree that should not happen. I think the solutions for the level of the provider so i can tell you some of those things were working on. Electronic communication the with those immediate answers a agenda dialogue. I cannot speak to those members you were referring to. But it is should be o . I could just off for a couple of . Thoughts. But 20 percent of the patients dont even fill those prescriptions because of cost. But those about his or her patients with the information gap so of that integrated system then you get that information sharing which is so important so those conditions are where we have to do something that is the important linkage give him powering pharmacist and that becomes a state issue. But the pharmacist can play a Critical Role to make the connections. What you point out is very important in those Delivery Systems with the things that we can is due today looking at the pharmacys which typically will fill day vacation then process the claim if they do not show up they will reverse the claim which knbc in in the electronic footprint so to go back to the physician so you may want to have a discussion. That is increasingly important that is the definition. Walking up to the counter starting a the therapy. And with that pulling of a recent study that shows that so in those markets where john dart generic is available so to find out if theyll even stay of their therapy. Were out of time. Thanks for coming. [applause] dont forget your surveys for later today. Have a great day. [inaudible conversations]