Prescription drug corporation. Jon, thank you for coming over from des moines. Jon rosmann thahas for the opportunity. Craig vansandt as i said, our topic t tay is the ethics of drug pricing. There has been no shortage of news this fall about price increases with prescription drugs. If you read the news, you see that prices, or at least it seems to be, that prices are going up very rapdly. Ben, id like to start off f e questions with you as a phd student. Is the popular press giving us an accurate picture . Are prices going up this rapidly . Ben urick you know, i would say it depends on the medications you look at. If we talk about brand name pharmaceuticals, the answer is yes. Certainly things like sovaldi, made by gilead pharmaceutut als, for hepatitis c, coming out at 86,000 is an incredible price to pay for a know, im sure many of the viewers have heard about daraprim that was purchased by Turing Pharmaceuticals who then increased the price 5000 . Now, those are extreme cases but i think it does show something a little bit larger about the state of brand name pharmaceuticals. If we talk about the cost of medications in society as a share of total healthcare spending, pharmaceutic als have doubled since the early 90s. We went from about 5 of all healthcare spending in the early 90s being spent on pharmaceuticals to about 10 today. A lot of that increase is increased prices of very expensive brand name products. If we talk about Generic Products, which are actually about 8590 of all products dispensed in the United States, those products have generally stayed about even or even a little bit down, but even within that category, there are some generic drugs that have had extremely high price increases as well. Definitely within brand name drugs, big price increases. Generic ugs, most of them not, but a few of them you also see well. Craig vansandt okay. The other question that i would like any of you to address is the question of drug prices in the us versus in foreign countries. It is my understanding that we pay significantly more here than in other countries. Is that true . Dr. Ghosh that is true. 5080 more we pay here okay, and why is that . Dr. Ghosh you know, i dont know. I think its a multifactotoal. I ththk the. Anytime talk about the drugug pricing, the Pharmaceutical Company will say what they say, that it takes time, effort, cost, and money to produce a drug and so on and so forth. I think the story is more than that. Im going to give you an example. The scientists, the molecular curing chronic myelogenous leukemia with a targeted drug thats called imatinib or gleevec. It was marketed in 2001, and i remember, i was in the clinical trial, 28,000. We thought thats too pricey. We have heart and we supported the concept that they have to recover the cost. Today, same drug, more people are using it. In a chronic use, is more business. If you take an antibiotic, you take for fourteen days, but if you take antibiotic year after year, year after year, its a different profit. Were selling this drug to 98,000, so please, i want to hear what research has been done more for a drug that was discovered in 2001. Then, you know, we feel that competition, if you have e similar drugs, the price would five similar drugs. The price of the other drug has gone up to 130,000. We are creating g lot of new drugs, a lot of new drugs, a lot of good treatment but we are pricing out the patients care. Let me tell you the published study shows that the outcome of chronic myelogenous leukemia in United States is poorer than in european country. We have created a structural for noncomplianc e. People are not taking their drugs because they nnot afford to take the drugs. If you have a 100,000 drug and we have insurance. Thats a vague word. Most of the drug is coming as an oral. We need a prescription benefit. Many patient do not have prescription benefit and when they have, they have 20 copay. If you have a your copay is 20,000 and average income in United States is 52,000. So how a person can come up with 20,000 . Theyre not taking it. You know, Breast Cancer, we cure Breast Cancer by giving drug to block the receptor, tamoxifen or aromatase inhibitor. Patients are not taking it, so all the cientific that we are doing, we are not able to deliver that because of the structure of pricing. You know, the. I have some number, valeant increased the price of sodium nitroprusside. On next day of the the drug by 625 . Isuprel, the drug they , the next day it went up by 820 . Penicillin, a drug that was used read in my medical school, went up by 2949 in a day. Cra vansandt if i might interrupt you there, i gather that youre very concerned about this for your patients sake. Ill ask you to talk sosoe about what your ceceer does in a mimite. Jon, id like to get you in here as well. I wonder if you could tell us a little bit about what idpc does and your interest in drug pricing. Jon rosmann yeah, absolutely. The whole mission of our organization is quite simple. Its simply to connect lowincome, uninsured or underinsured patients with access to free and lowcost medications. Much of what were talking about today is simply the issue that were trying to address. Were a safety net provider. We work to try and provide access to affordable or free medications. We have essence recycling medications, taking previously dispensed medications, having those medicationinspect by a pharmacist and then we provide them to pharmacies or to clinics to dispense to patients at no cost. Were very familiar with the issue and its a main reas why theres such a dire need for our programs, but unfortunately we dont have the solution. Were just trying to fill the gaps best we can. Craig vansandt coming back to what you were talking about, it sounds like were paying significantly more for drugs in this country and the medical outcomes arent any better or may even be worse. Is that accurate, ben . Ben urick yeah. Article that came out in the wall street journal on december 1st that looked at how much we spend in the United States drugs like a in your practice, compared the prices here in the us to prices in england and in norway. What they found is that t r 37 out of these 40 drugs, we spend more than norway does. For 39 out of these 40 drugs, we spend more than england dodo. These are the exext same medicines that theyre getting in england, that theyre getting in norway, but were paying a lot more here in the United States. Just one specific example from this, rituximab, very common used in cancer thehepy, costs 3500 a dose here in the United States, norway 1500. Thats a 2000 difference for a very common drug. You do see that we spend a lot more in the United States on brand name medicines. You cant really say that we spend a lot more in the United States on Generic Medicines. We have great laws for Generic Medicines that allow for solid competetion within the generic market that does bring down prices and actually, you know, economics work as you would expect them to, where you bring more competitors d then prices for t tse products fall. As you were talking about with brand name pharmaceutical, the economics, kind of that basic idea of a firm coming in and lowering a price doesnt workrkif you see gleevec, for example, whenever you have a competitor entering the market at a little bit higher price, the manufacturer for gleevec understands that they can raise the price gleevec a little bit because theres a new sort of price thahathe market will bear. Whenever you see. Often times when you see new brand name pharmaceutic als come in, they come in at a little bit higher price. Rising tide raises all ships and you see this increase in price over time. Craig vansandt my understanding, and again, i dont want to go too far down this rabbit hole, but my understandin g is e en some of the drugs s at are going off of their patent, which then you would normally think would allow generic drs to be produced, the drugs do what they can to keep other manufacturer s from producing generics. Am right on that . Ben urick yes. This gets into fda law and we dont have the time this morning to. Craig vansandt none of us are lawyers. Ben ick right, cluding me. Youre e ght. These are called pay fordelay settlements. Its something that. If you look it up online, you can see what a payfordelay settlement is. What happens is, the first generic entry into the market ofofntimes has six x nths of exclusivity, if its the first generic drug that comes into the market. They can forgo that six month exclusivity in exchange for some sort of large payment from a brand name pharmaceutical manufacturer. The fda has determined that. There were a couple of lawsuits that were surrounding this. What weve kind of found out now is that its not necessarily strictly illegal for brand Name Companies to offer settlements to Generic Companies to delay their product pretty high level of still technically allowed. Theres an idea that sinceceoure going six additional months without any sort of generic competition that you do end up increasing prices for anybody who would purchase that druand that is tr to a large extent. These payfordelel settlements, they have some impact but i would say that thats not anything that makes a big, big, big impact on the amount of money that we spend in pharmaceuticaca in the United States. Craig vansandt conceptually, the law needs to be changed because when a pharmaceutic al company manufactures a drug, there is a life of the patent. It is a routine thing to delay, push back, the Generic Products by lawsuits, and that takes four, five years so t`at needs to be prevented. Also, the company goes to the courts and appeals for an extension of law needs to be defined up front, that this is the duration of the time you have the patent. You cannot come back and extend that and you cannot push back the Generic Products. There is a for the Generic Product manufacturer because they know that they might not be able the law needs to be changed. I think the only way it will be changed is that if we have a patients advocacy. Ill tell you that we have an experience in the United States. We have done it with the aids movement. You know, the aids movement. They changed the law, the way the business was done, the pharmaceutic al company agreed on that, they produced 35 drugs in 10, 15 years and they kept the price down to 18,000, and the life has been prolonged. I think we have an example when the patients get involved in it, the Community Gets involved in it, things do change. Craig vansandt to put that in perspective, this ght, the late 1980s, early 1990s, am i in the right time frame . Dr. Ghosh 1980s, right. Craig vanaandt not that any of us are political experts, but my take is that the chance of getting government to make the kinds of changes youre talking about with the aids issue is much less today than it was 20 years ago. Dr. Ghosh i think we need to go back to history. These were young men who shut down the fda for a day, closed the wall street for 2 days. They were young, they were dared, they advocated. They were their own advocate. The government is not going to change unless we make it change. There is a movement that is going on from our part, thats at one million signatures to the to be addressed. In a discussion with. We are rationing the care. We are depriving the care in the back door. Change. That was the difference is the aids advocate is a patient warrior on the street. We have cancer r dvocacy group. Unfortunatel y, most of them are funded by the pharmaceutic al companies. Craig vansandt jon, does your Organization Get involved in Patient Advocacy . Jon rosmann yeah, absolutely. We provide most of our services directly to pharmacies or medical providers, but on a daily basis, we receive a number of calls from patients that are dealing with the struggles of accessing medications. I think its important to note that the safety net patient, at least in iowa, has changed historically weve thought of the safety net patient as an individual that is lowincome, uninsured. Iowa has been fortunate to take part in medicaid expansion, so we have an additional 99,000 persons that are now covered. People 138 up to 200 of the federal Poverty Level where, technically, many of these patients are insured but, for example, that insured patient could have insurance through a bronze level plan. That bronze level plan will require an individual, for example, 200 of federal Poverty Level, that would be 28,000 approximately, that person would have a 6300 deductible before any medication assistance or medical coverage is provided. I think its insured patients in this state, the services are still required from the underinsured patients and something needs to be done to address that as well. Craig vansandt okay. As we were talking before the show, you indicated that the organization that you represent is somewhat unique in the United States. Jon rosmann our organization is another good example of how iowa has been somewhat of an innovator on the issue. Our organization was established through a partnership were initiated by senator harkin and then governor vilsack. Our mission is simply to provide access to free and lowcost medications. We do that through a variety of funding mechanisms, many of which are contracting with the department of public health, or the these programs. Were fortunate enough that we have legislative leaders that have valued access to medications in our state. We have now developed the largest drug donation repository in the country. Our state serves as a model for how medication or medication waste, existing medications within the heaeahcare system, particularly longterm care, how those medications can be recovered, inspected, and repurposed for patients that cannot afford their medications. Craig vansandt thank you for bringing a bit of good news to this show. Dr. Ghosh just one question i have. Jon rosmann yes. Dr. Ghosh thanks for doing this. The question i have. Say somebody needs some medicine like gleevec, we talked about, in cancer care. Thats a day after day, month after month. Do you think that your organization can fulfill that need . Jon rosmann that is a great question. 95 of our settings, so coming from nursing homes. Many of those medications are going to be maintenance medications, hypertension, diabetes, but one of our areas of focus is to try and bring more specialty medications into the starting an initiative to provide outreach to the Oncology Centers and the Cancer Centers to bring those medications in. Its certainly. Its not an ideal situation because anytime youre working with donated items, you have no way of controlling your inventory. For some patients, we can fill gaps in access and for a family where an individual may have passed away, we can provide a meaningful way for that family to provide a positive outcome for a patient. Dr. Ghosh right. I think thats a great effort, but that does not answer the biggest problem that we are great inroad in the cancer care. The melanoma, the. All the new immunotherap y checkpoint fantastic outcome. For example, in melanoma, the 2 drugs together is going to cost 159,000 a year. If you have to treat all the melanoma, to provide the best care that we have defined, it is going to cost 281 billion dollars per year. Right there is the issue. In 2014, the world was spending 100 billion dollar on the cancer drugs. Those kind of differences we need to solve, and we need to solve by discussing, discussing openly, honestly, because i dont think any drug is a good drug if the patient cannot take it. Thats not a drug to me. Craig vansandt i appreciate now. Weve seen, just from our discussion, that there is a crying need for these drugs. Weve seen that there is a very strong profit motive from the companies producing them. How do we meet in the middle . I think part of my question that i want to get at there is. Is healthcare a right that citizens have or is it a privilege that people should pay for . Ben . Ben urick i, you know,. Healthcare is not a constitutional right in the United States. Thats what the courts have said so far. The only people in the United States who have a right to receive healthcare are prisoners, because its considered they are not given healthcare. Do i think that healthcare should be a right . That is how i tend to think, but that is something that i dont think would actually happen in the current political climate, right . What were left with is solutions that really if we want to talk about reducing cost of medications for society, involve more intervention from the federal government. Those are the solutions to providing reasonable access to healthcare that. Other industrialized nations have come up with but we in the us have been very resistant to this. One thing that is kind of a lowhanging fruit is allowing medicare to negotiate for the same kinds of rebates that are negotiated for in the Medicaid Program. The Medicaid Program drug costs, because they have federallymandated rebates. Medicare, when it was set up, was actually barred from negotiating with drug companies. Craig vansandt right. Ben urick yeah. Some back room dealing with billy tauzin who ended up being the president of pharma afterwards, apologies to pharma if theyre presentation. That can save substantial amount of money for the federal government when it comes to pharmaceutic als and would likely lower to an extent the amount of money that we in the us pay for drugs. At the very least for some medicare patients, i think it could make a big difference for their care. Dr. Ghosh that should be done because most of cancer patient is medicare populations. Theyre not young so we are denying the care to our citizen and it has becoming a care of the privileges. Im going to give you an example. President obama says that we are providing the healthcare and you can pick and choose. I know a patient who has money to get the platinum product, they get the free care. I know patient who was good and tried to get a product that she can afford, bronze. She has copay, she doesnt know how to get the care. She cannot pay for it. That we are providing the care to everyone is wrong. We are privileges. Actually, the person who can pay the bigger premium, his care or her care is getting subsidizes by denying care to the other folks. Jon rosmann were here talking about high drug prices in the United States, and the wall street journal article was talking about a driving factor for high drug costs in the us is all the r d, so how do we balance focusing on drug costs for the United States when the us bears the majority of the r d costs . Shouldnt we be talking about the larger issue of drug costs, including partnerships with other countries if were going to try and come up with a solution to drive down costs in the us . Ben urick right, and i think that, you know, talking about spreading out the r d burden more globally, righgh because everybody benefits from the amount of money that we as us citizens spend on our pharmaceuticals. Also, i would question r d as the sole justification for the amount of money that were spending on these top 10 largest manufacturers spend more on marketing than they do on r d. If you look at the s p 500 list, Pharma Companies have a 17 profit margin. S p average is only 6 . They use r d as a justification for the price that they charge but i really have a hard time buying that. Craig vansandt so now is the time in the program to talk about solutions. What do we do to make drug prices in the us more fair . Dr. Ghosh there. Go ahead. Ben urick no. Dr. Ghosh no, you go ahead. Ben urick one is negotiating through medicare. That would help at least for medicare patients. Marketdriven Solutions Include funding the fga better, or at least allowing them to increase their fees to drug manufacturers so they can move Generic Products through the pipeline a little bit faster and create more competition within its also very important for us to develop an effective biosimilar pathway so that we can get competition for the very expensive biologic products that are causing a lot of the increase in spending. If you look on Hillary Clintons and Bernie Sanders websites, they have full lists of policy options they think are viable for reducing drug costs, some more than others. Bernie want to go up to canada to bring down medicines as part of reimportation. I dont think that would work. Hillary clintons idea is to set a maximum out ofpocket, to set an out ofpocket maximum at 250 per month for everybody in the United States on pharmaceuticals. Craig vansandt right. Ben urick it means you could not spend more than 250 a month out of your own pocket on pharmaceuticals. Its an interesting idea. I dont think it would pass politically. I wonder if that wouldnt actually increase the total amount of money that we spend on pharmaceuticals in the United States because of reduced copayments as a mechanism for controlling drug spending. Craig vansandt okay. Im really sorry that i didnt get you all problem but were about out of time so id like to ask you at this point what do we need to leave our viewers with . What information . Dr. Ghosh . Dr. Ghosh you know, we are talking about the drug pricing but we need to talk as a whole. For example, im an oncologist. Studies have shown that after you cure hodgkins lymphoma, doing repeated ct scan costs 591,000 to save one life. We should not be doing that. I think the national organizations, ncc and other, they need to step in and guide us because thats the way to help the insurance and also pharma, too. I think we have a global responsibilities, you know, like if you have ductal carcinoma in situ, stage 0, from samplings should not be done, but it is resources in other places. The new drugs are going to come, is going to be expensive. Our closet is full so we need to get rid of the old stuff like doing the things that we did before. Craig vansandt great. Thank you. Jon . Jon rosmann i think we need to focus on things that we can have impact on now because some of our solutions could take decades. We can do a better job of recouping costs within our own Healthcare Systems and utilizing models to help recycle or repurpose medications within the system. Craig vansandt right. Thank you all very much for your help. On behalf of the Inter Religious Council of linn county, id like to thank all of you. Id like to thank you for watching. Have a great week. 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