6. PBM Perspective: An Interview with Industry Veteran Mesfin Tegenu

In this episode, we interview Brian Reid, the founder of Reid Strategic and the creator and editor of our favorite industry newsletter, the Cost Curve. Brian shares his journey to create the Cost Curve and how he navigates the onslaught of information to identify the most important issues of the day. We also get his take on what he calls the highest & importance-to-attention &; healthcare stories, highlighting critical topics that are undercovered related to their significance. We also get the opportunity to understand his perspectives on the threats to innovation, the risks to patient affordability programs, and what all of us should be doing to be better healthcare consumers.

• Brian Reid- Reid Strategic
• Cost Curve Newsletter
• Martin Shkreli & Daraprim
• BioPharma Dive: Biotech and Pharma Industry News
• GLP-1s
• Net Price– “a drug’s net price equals the actual revenues that a manufacturer earns from a drug after rebates, discounts, and other reductions” Source: Drug Channels 
• Armamentarium
• Pharmacy Benefit Managers (PBMs)
• Mark Cuban Pharmacy
• Psuedo-Generic Medication
• CVS Cordavis
• Quallent
• Nuvalia
• Biosimilars
• Lilly Direct
• Novo

• 340B Drug Pricing Program

• Copay maximizers
• AFPs

Questions or comments?
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In this episode, we explore the complex and often debated concept of value in prescription drugs. They discuss how different stakeholders—payers, manufacturers, providers, regulators, and patients—define value, and how methodologies like health technology assessments (HTA) and cost-effectiveness analyses shape drug pricing and access. With insights from leading experts, the conversation examines the controversies surrounding value-based pricing, including the role of real-world evidence, quality-adjusted life years (QALYs), and innovation incentives. Can we strike a balance between affordability, innovation, and patient access? And what does the future hold for value-based drug pricing in the U.S.? Tune in for a deep dive into one of the most critical issues in healthcare today.

• Daniel Ollendorf, Chief Scientific Officer and Director of HTA Methods and Engagement

• Lou Garrison, Professor Emeritus at University of Washington CHOICE

• Institute for Clinical and Economic Review (ICER)
• FDA
• GLP-1 Drugs
• Medicare
• Biosimilars
• Generics Versus Biosimilars
• PBMs (Pharmacy Benefit Managers)

• 340B Drug Pricing Program

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In this episode, we interview Sarah Emond, MPP, President and CEO of the Institute for Clinical and Economic Review (ICER). Sarah joined ICER over 15 years ago as Chief Operating Officer and was appointed to lead the organization following the retirement of Dr. Steven Pearson. Sarah outlines her vision for ICER and the priorities for strengthening the framework and collaboration to achieve their mission of evaluating the comparative effectiveness of new medicines. Sarah also discusses ICER’s efforts to expand patient engagement and the evaluation of payers to ensure fair access to medicine.

• Sarah Emond, MPP, President and CEO, Institute for Clinical Economic Review (ICER)

• Dr. Steven Pearson, Founder, President, Institute for Clinical and Economic Review (ICER)

• Barriers to Fair Access Report 

• Gross-to-Net Bubble

• Pharmacy Benefit Managers (PBMs)

• Humira biosimilars

• Institute for Clinical and Economic Review (ICER)

• 340B Drug Pricing Program

Questions or comments?
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In this episode, we sit down with Stacie Dusetzina, Ph.D., a leading health economist from Vanderbilt University Medical Center to discuss the critical healthcare and policy trends shaping 2025. From shifts in federal leadership to the evolving impact of the Inflation Reduction Act, our guest provides expert insights on what to expect in drug pricing, health insurance, and patient access in the coming year. We explore how the public and private sectors are addressing affordability challenges and highlight innovative approaches to improve access to essential medications. With a focus on the future, this conversation offers a thoughtful outlook on the policies and market dynamics set to redefine healthcare in 2025.

Stacie Dusetzina, Ph.D., Vanderbilt University

Vanderbilt University Medical Center

A primer on copay accumulators, copay maximizers, and alternative funding programs

CMS
FDA

IRA

Medicare Part D

Pharmacy Benefit Managers (PBMs)

Medicaid

CMMI’s Medicaid group negotiation 

COVID-19

Statins

PCSK9 inhibitors

Imatinib

340B Drug Pricing Program

Questions or comments?
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In our second of three episodes in conjunction with members of ACCESS Forum, we engage with leading experts to uncover the multifaceted challenges of access and affordability in cell and gene therapies. Our conversation investigates how these treatments’ innovative yet complex landscape leads to challenging regulatory pathways, pricing models, and reimbursement strategies. We examine the high costs associated with these therapies, the implications for healthcare systems, and the delicate balance between innovation, patient needs, and sustainable funding. Tune in as we explore the current barriers and opportunities in the evolving world of cell and gene therapy and what this means for the future of patient access and affordability.

In this episode, we sit down with leading Market Access experts and members of ACCESS Forum to compare and contrast the drug pricing and access systems worldwide and the US. Our discussion delves into the distinct approaches taken by government vs. private markets, examining how regulatory environments, pricing controls, and reimbursement processes impact patient access to innovative therapies. We explore the challenges each approach faces, from cost pressures to affordability and access, and how they balance the interests of patients, governments, and pharmaceutical companies. Join us for a deep dive into how the global healthcare landscape is evolving and what lessons can be learned.

Nikos Maniadakis, Ph.D., Professor, Health Management & Policy, University of West Attica
Kimberly Baldwin, Senior Vice President, Value & Access, Ipsen Biopharmaceuticals
Fauzea Hussain, Vice President, Public Policy, McKesson
CMS (Centers for Medicare & Medicaid Services)
European Medicines Agency
Health technology assessments (HTAs)
IRA (Inflation Reduction Act)
Medicaid
Medicare
National Institute of Clinical Excellence (NICE)
NCCN guidelines
P&T committee (Pharmacy and Therapeutics Committee)
PAP (Patient Assistance Program)
Part B (Medicare)
Part D (Medicare)
Pharmacy Benefit Managers (PBMs)
Quality-Adjusted Life Years
Tricare
Veterans Administration
Medical terminology referenced in this episode:

• Cell and gene therapies (CGT)
• Insulin
• Orphan drugs

Questions or comments?
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In this episode, we explore the evolving role of healthcare and patient advocates and how this profession has become an essential part of the healthcare system. We begin by defining what a healthcare advocate is and tracing the development of the profession over the years. Key milestones are discussed, such as establishing codes of ethics, training, and certification processes. We also share real-world examples of how advocates help patients navigate the complexities of healthcare, making a measurable impact on patient outcomes. The discussion covers the scale of advocacy in the U.S., examining the roles of professional advocates compared to family members and volunteers. We also address how advocates are helping patients overcome barriers to accessing and affording medicines. Finally, we look to the future of advocacy, discussing potential healthcare reforms, the impact of technology, and practical advice for patients seeking an advocate in today’s challenging healthcare environment.

Rachel Westlake, Managing Director, Coalition of Health Care Advocacy Organizations
Danielle Marshall, Executive Director, Patient Advocate Certification Board
Fred Larbi, Chief Operations Officer, HealthWell Foundation
CHCAO
Patient Advocate Cerification Board
Healthwell Foundation
Greater National Advocates
NAHAC
HealthAdvocateX
Umbra
Solace 

Questions or comments?
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In this episode, we explore the evolution and future of the Pharmacy Benefit Management (PBM) industry with insights from two seasoned pharma managed care executives. We discuss the early role of PBMs, their acquisition by pharmaceutical companies, and subsequent industry consolidation. We examine how vertical integration of the PBMs transformed their business model, including the restricted formularies that gave rise to rebates. We also address evolving PBM-manufacturer relationships, the effects of public scrutiny, and predictions for key trends. Join us for a comprehensive look at the past, present, and future of PBMs, focusing on the changes needed to better serve patients.

Steve Stefano, Managing Director, ReprizioRx 

Steve.Stefano@repriziorx.com

Bill Leonard, Managing Director, ReprizioRX

wjl@repriziorx.com

ReprizioRX

PBMs

IPA model HMO

Medco

Metro Containment Services

Medicare Catastrophic Coverage Act of 1988

Merck

SmithKline Beecham

Eli Lilly

340B

NDC blocks

Group Purchasing Organizations (GPOs) 

Medicare

United Healthcare

FTC

CostPlusDrugs

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