Podcasts about pbms

If you'd like your question answered on next month's episode, call/text 469-213-6381 and leave us a voicemail/text.Each month on Last Month In Healthcare, producer Nathaniel joins me to discuss the previous month's podcasts, headlines, and listener-submitted questions.This month, we're doing something a little different to close out 2025. Instead of just looking back at December, we are ranking the biggest healthcare stories of the entire year on a Tier List, from "Not Impactful" to "Super Impactful." We cover everything from the FTC suing the Big 3 PBMs and the J&J fiduciary lawsuit dismissal to the "bloodbath" of 2026 renewals and the explosion of GLP-1 usage.Plus, we debut a new "Explain Like I'm 5" segment where I break down complex concepts like Reference-Based Pricing, Captives, and Stop-Loss using simple analogies involving candy shops and dirt bikes. Finally, we answer a listener question about building confidence as a young professional in the industry.Chapters:0:00 - Intro: Last Year in Healthcare0:51 - Tier List19:05 - Explaining Insurance To A 5-year-old24:24 - Ask Spencer Anything

If you'd like your question answered on next month's episode, call/text 469-213-6381 and leave us a voicemail/text.Each month on Last Month In Healthcare, producer Nathaniel joins me to discuss the previous month's podcasts, headlines, and listener-submitted questions.This month, we're doing something a little different to close out 2025. Instead of just looking back at December, we are ranking the biggest healthcare stories of the entire year on a Tier List, from "Not Impactful" to "Super Impactful." We cover everything from the FTC suing the Big 3 PBMs and the J&J fiduciary lawsuit dismissal to the "bloodbath" of 2026 renewals and the explosion of GLP-1 usage.Plus, we debut a new "Explain Like I'm 5" segment where I break down complex concepts like Reference-Based Pricing, Captives, and Stop-Loss using simple analogies involving candy shops and dirt bikes. Finally, we answer a listener question about building confidence as a young professional in the industry.Chapters:0:00 - Intro: Last Year in Healthcare0:51 - Tier List19:05 - Explaining Insurance To A 5-year-old24:24 - Ask Spencer Anything

Send us a textIn this eye-opening episode, we dive into one of America's biggest policy failures: the pricing of prescription medications like GLP-1s. While many focus on the legalization and rescheduling of cannabis, there's a far more insidious, legal, and mainstream drug policy draining your paycheck and costing countless lives. We break down the economics, the hidden players like PBMs, and the stark differences in drug pricing between the US and other countries. Learn how we can fix this broken system and why it matters for your wallet and your health.

Up first, Inspirogene-by-McKesson with Joe DePinto   InspiroGene" is a dedicated business unit launched by McKesson in October 2024, focused solely on supporting the commercialization of cell and gene therapies (CGTs). It leverages McKesson's expertise in supply chain, logistics, and specialty pharmacy to help manufacturers, payers, and providers navigate the complex CGT landscape. https://www.mckesson.com/business-solutions/our-businesses/inspirogene-by-mckesson/ Our featured interview: Sponsored by MatchRX The TrumpRx Playbook for Independent Pharmacies CEO of MatchRx Johny Kello co-hosts with Todd Eury featuring our guest speaker, Dae Lee, Pharm.D., Esq., CPBS. Dae is a pharmacist-attorney and a Shareholder in the FDA & Biotechnology practice at Buchanan Ingersoll & Rooney. What makes Dae especially valuable for this conversation is that he's not just reading policy from 30,000 feet — he represents pharmacies every day in high-stakes fights with PBMs, from audits and reimbursement disputes to network suspensions and terminations. So, when we talk about TrumpRx — how it works, what it could break, and what independents should do next — Dae can translate the legal and contracting reality into real-world consequences behind the counter. Connect with MatchRX: MatchRX.com Special Message from Greg Reybold with APCI, update of the "Pharmacists Fight Back Act" Connect with Greg: https://www.apcinet.com/ Next, we talk with Dr. Jessica Daley PharmD Fractional Supply Chain and Operations Executive, with Pharma Logistics, we dicuss drug shortages and strategies for 2026. Connect with Jessica: https://www.linkedin.com/in/jessicaldaley/ Last interview, a suprise message from International Pharmacy 50 Pharmacist & Author Katrina Azer, announcing her new book  https://www.katrinaazer.com/#books   The TrumpRx Playbook for Independent Pharmacies - with MatchRX | TWIRx 

In this special 2025 U.S. Policy Highlights edition of the Vital Health Podcast, we look back at our most important discussions on the Inflation Reduction Act (IRA) and its ripple effects across drug development, Medicare, and patient access. Over the past year, the biopharma industry and the broader healthcare system have undergone a period of rapid change as new rules surrounding drug pricing reshape how therapies are developed, financed, and delivered. In a landscape where policies are still being interpreted and adjusted, and where the long-term impact on innovation and access is far from certain, this episode serves as a year-end guide to what has changed and how to think about the road ahead. Throughout 2025, we paired our research with a series of podcast episodes where host Duane Schulthess sat down with industry leaders. In this highlights episode, we revisit several of those conversations: Douglas Holtz-Eakin: “Indications are going to be deeply affected by the IRA” Steve Usdin: Tariffs, Price Controls, & Inflation Reduction Act (IRA) VT’s Grumpies Talk IRA with Virginia Acha Key Topics: Pill Penalty: How the shorter negotiation window for small molecule medicines relative to biologics is changing the calculus for pursuing oral therapies in areas such as cardiovascular disease, neurodegeneration, and other chronic conditions. Part D Redesign: Why moving more liability to plans is driving new premium and coverage tradeoffs, influencing which products stay on formularies, and raising questions about access in rural and underserved areas. Early Stage Investment: What our data suggest about the pullback in trial starts and funding for projects most exposed to IRA mechanics, and how that is influencing company formation, licensing strategies, and pipeline mix. PBMs, Vertical Integration, & Biosimilars: How consolidated intermediaries and payer-owned biosimilar strategies interact with IRA price setting, rebate flows, and the outlook for generic and biosimilar competition. Patient Advocacy & Real World Impact: What older adults, cancer patients, and rare disease communities are already experiencing as coverage rules change, cost-sharing is redesigned, and uncertainty grows around long-term treatment availability. Policy Paths Forward: Ideas from our guests for adjusting timelines, refining negotiation rules, and protecting incentives for follow-on and orphan indications while still improving affordability for patients. Opinions expressed are those of the speakers.See omnystudio.com/listener for privacy information.

Few patients take a paper prescription down to the local pharmacy any more. The modern era of prescribing is shockingly complex and getting more so, according to Dr. Colin Banas, Chief Medical Officer, and Drew Hunsinger, Head of Growth, at DrFirst.Banas says that the goal at DrFirst, a 25-year-old company, has always been to provide an end-to-end medication journey: for patients, providers, payers, and pharmacies. Hunsinger points out that the prescribing workflow involves payers, PBMs, and even drug companies.Plus, they share how many of the EHR companies they work with are happy to offload all these medication management complexities to DrFirst so that as EHR product managers, they can focus on other EHR innovations. Not to mention EHR vendors can benefit from the innovations that DrFirst continues to implement since their major focus is medication management.Learn more about DrFirst: https://drfirst.com/Healthcare IT Community: https://www.healthcareittoday.com/

Coming to you from the #NCPA2025 expo floor, host John Beckner and co-host Ed Cohen talk with Brian Connelly, president and CEO of TheracosBio, about Brenzavvy (bexagliflozin), an FDA-approved oral SGLT2 inhibitor for adults with Type 2 diabetes. They discuss how the company's model bypasses PBMs to offer pharmacists and patients a fair, transparent price.

Send us a textSchedule an Rx AssessmentWhat happens when GLP-1 compounding, TrumpRx, and PBM audits all collide in your pharmacy?In this episode of the Bottom Line Pharmacy Podcast, hosts Austin Murray and Bonnie Bond, CPA, are joined by healthcare attorney Dae Lee of Buchanan Ingersoll to unpack the fast-moving legal and regulatory landscape around GLP-1s, PBMs, and audits—and what independent owners need to be doing right now to protect their businesses.We cover: - The vertical integration behind the “big three” PBMs and their rebate aggregators- Why PBM audit triggers and the realities of today's audit tactics- A practical roadmap for responding to an audit- What “recredentialing season” really means- TrumpRx And more!More About Our Guest:Dae Y. Lee, Pharm.D., Esq., CPBS focuses on representing pharmacies in their dealings against Pharmacy Benefit Managers (PBMs). With extensive experience in the intricacies of PBM audits, investigations, network enrollment, network suspension, network terminations, reimbursement disputes, and DEA as well as other governmental investigations, Dae has become a trusted advisor to a broad cross-section of pharmacies and pharmacy providers, including community retail pharmacies, chain pharmacies, compounding pharmacies, specialty pharmacies, mail order pharmacies, home infusion providers, and dispensing physician practices.. His practice also extends to assisting other stakeholders in the pharmacy industry such as wholesalers, manufacturers, and other healthcare providers. In addition to his PBM-focused work, Dae represents entities in pharmacy-related transactions and assists clients with corporate formation, due diligence, licensing, change-of-ownership requirements and credentialing, providing comprehensive legal support throughout the transaction process. Dae is a Certified Pharmacy Benefits Specialist™ (CPBS™). Offered through TransparentRx and accredited by the University of Kentucky School of Pharmacy, the CPBS program is designed to cover complex topics of pharmacy benefit management in order to provide a foundational knowledge required for higher-level evaluation of PBM business operations, fundamentals of PBM pricing, plan design, cost-containment strategies, PBM contracts, PBM procurement, Specialty Pharmacy benefits management, and overall PBM performance with emphasis on cost effectiveness.Stay connected with Dae and Buchanan, Ingersoll, & Rand: Dae Lee LinkedInBuchanan, Ingersoll, & Rand WebsiteBuchanan, Ingersoll, & Rand LinkedInBuchanan, Ingersoll, & Rand TwitterBuchanan, Ingersoll, & Rand FacebookStay connected with us on social media:FacebookTwitterLinkedInMore on this topic:Podcast: The Startup Compounding Pharmacy PlaybookPodcast: The Trusted Pharmacist: Advocacy and Building a Resilient PharmacyPodcast: From Counter to Capitol

In this episode, Jakob Emerson, Associate News Director at Becker's Healthcare, breaks down the latest debates over ACA premium tax credits, explores a potential Humana and Mark Cuban partnership, and highlights the policy and market forces reshaping the payer environment heading into the new year.

In this episode of Main Street Matters, Elaine Parker and Alfredo Ortiz sit down with former Congressman Dr. Tom Price to break down the growing healthcare crisis facing small businesses. They discuss skyrocketing health insurance premiums, the promise of association health plans, the powerful role of pharmacy benefit managers (PBMs), and why Congress must shift its focus from political gamesmanship to real solutions. Dr. Price shares his insider perspective on how market-driven healthcare reforms can lower costs, expand access, and give small business owners the relief they need.See omnystudio.com/listener for privacy information.

This episode of The Dish on Health IT features Denny Brennan, Executive Director of the Massachusetts Health Data Consortium (MHDC), in conversation with host Tony Schueth, CEO of Point-of-Care Partners (POCP), and co-host Ross Martin, MD, Senior Consultant with POCP. Together, they examine how MHDC is translating national interoperability policy into practical, statewide action, specifically around the CMS-0057 rule.After brief introductions, the conversation quickly turns to MHDC's long history and why it matters. Founded in 1978, before the internet, MHDC guided Massachusetts through nearly every major health IT transition: HIPAA, Meaningful Use, ICD-10, and now interoperability and automation. Denny explains that this continuity has created something rare in healthcare: sustained trust across payers, providers, vendors, regulators, and associations. That trust, he notes, is what allows competitors to work through shared infrastructure problems that no single organization could solve on its own.From there, the discussion turns to why the MHDC community chose to coordinate and support members in their CMS-0057 compliance journey, versus just letting each member organization go it alone. Denny emphasizes that while healthcare is regulated federally, it functions locally. Each state has its own mix of insurers, hospital systems, rules, and market pressures. In Massachusetts, where long-standing relationships already exist, MHDC saw an opportunity to move faster, test real workflows, and generate lessons that could inform efforts far beyond the state.The discussion then moved to how work to improve prior authorization became such a high-priority focus. Denny describes how the process has grown into one of the most disruptive administrative burdens for clinicians. Rules vary by plan, criteria change frequently, and the information providers need is often hard to access in real time. The result is defensive behavior. Offices routinely submit prior authorizations “just in case,” often by fax or phone, simply to avoid denials and treatment delays. That inefficiency, he explains, ripples outward by slowing patient care, driving up providers' overhead, and requiring health plans to spend more time and resources processing and reviewing the required PA alongside the unneeded submissions.The financial impact quickly becomes apparent. Denny points to evidence showing that administrative costs consume a massive share of U.S. healthcare spending, with prior authorization playing a meaningful role. If automation is implemented through a neutral, nonprofit infrastructure, MHDC believes there is a much greater chance that savings will flow back into premiums and public program costs rather than being swallowed by inefficiency.Ross adds an important dose of realism. Prior authorization friction, he notes, is not always accidental. In some cases, operational complexity functions as a utilization control mechanism. That creates a built-in tension between access, cost containment, and patient experience, and helps explain why national reform has moved slowly despite widespread frustration.At that point, the conversation shifts from why this is broken to how MHDC is trying to fix it. Denny walks through MHDC's operating model: convene the full ecosystem early and often. In a recent deep-dive session, roughly 60 representatives from health plans, providers, and the state participated in a working session focused on what an automated prior authorization workflow could realistically look like. MHDC brought a draft framework to the table. The community pressure tested it and surfaced workflow conflicts, operational blind spots, and policy misalignments that no single organization could see on its own.That collaborative process, Denny explains, is the real engine behind adoption. When stakeholders help build the solution themselves, implementation becomes a shared commitment rather than a compliance exercise. It also reduces resistance later because decisions are not delivered top-down. They are constructed collectively.The discussion then turns to FHIR adoption and why, while real, progress has taken time. Denny traces the turning point back to the 21st Century Cures Act, which reframed patient access to health data as a legal right and categorized data blocking as a regulatory violation. That policy shift, combined with the growing maturity of API-based interoperability, created the conditions for real-time data exchange to finally move from theory to practice.Ross provides a historical perspective from the standards side. Earlier generations of health data standards were conceptually elegant but extremely difficult to implement consistently. FHIR changed that equation by aligning healthcare data exchange with the same API-driven architecture that supports the modern web. He points to accelerating real-world adoption, particularly from large EHR platforms, as evidence that FHIR has entered a phase of broad, practical deployment.Although pharmacy prior authorization falls outside the formal scope of CMS 0057, Denny makes clear that MHDC could not ignore it. For many physicians, especially in oncology, dermatology, and primary care, PA for prescriptions is far more frequent and far more disruptive than PAs for medical services. If MHDC solved only one side of the problem, much of the daily burden for clinicians would remain unchanged.Pharmacy prior authorization, however, introduces a new level of complexity. PBMs, pharmacists, prescribing systems, payers, and patients are all involved, often across fragmented workflows. Denny explains that the challenge looks less like a pure technology gap and more like an orchestration problem. It is about getting the right information to the right party at the right moment across multiple handoffs.Ross shares insights from the pharmacy PA research work conducted with MHDC and POCP. One of the most striking findings was the massive year-end renewal surge that hits providers every benefit cycle as authorizations tied to prior coverage suddenly expire. He also reflects on a recent national electronic prior authorization roundtable, where deep stakeholder discussion ultimately led most participants to conclude that today's technology alone still is not sufficient to fully solve pharmacy PA. The tools are improving, but the problem remains deeply multi-layered.As the episode winds down, the tone shifts toward practical calls to action.Denny challenges the industry to separate where competition belongs from where collaboration is essential. Contract negotiations may be adversarial by nature, he notes, but interoperability initiatives cannot succeed under the same mindset. Real progress depends on bringing collaboratively minded people into the room. These are people willing to solve shared infrastructure problems even when their organizations compete elsewhere.Ross builds on that message with a longer-term challenge: sustained participation in standards development. Organizations cannot sit back and hope others shape the future on their behalf. Active involvement in national standards organizations is critical. This is not for immediate quarterly returns, but to influence the systems everyone will be required to use in the years ahead.The episode closes with a clear takeaway. MHDC did not wait for perfect conditions. It moved when the pieces were good enough, tested real workflows with real stakeholders, adjusted in the open, and began sharing lessons nationally. In an industry often slowed by fragmentation and risk aversion, this conversation offers a grounded look at what forward motion actually looks like when collaboration, policy, and technology finally align.You can find this and other episodes of The Dish on Health IT wherever you get your podcasts, including Spotify and Healthcare Now Radio. If you found this conversation valuable, share it with a colleague and be sure to subscribe so you never miss an episode. Have an idea for a topic you would like us to cover in future episodes? Fill out the form and tell us about it. Until next time, Health IT is a dish best served hot. 

Send us a textHealth insurance in the United States is incredibly complex, filled with deductibles, co-pays, co-insurance, narrow networks and more. Why is our system such a maze? Is it the unintended product of decades of patchwork policies, or is the complexity intentional?In this episode of CareTalk, hosts David E. Williams and John Driscoll break down the real reasons health insurance is so hard to navigate, exploring the structural fragmentation of the system, the role of intermediaries like PBMs and brokers, the impact of convoluted billing practices, and what meaningful simplification would actually look like.

If you'd like your question answered on next month's episode, call/text 469-213-6381 and leave us a voicemail/text.Each month on Last Month In Healthcare, producer Nathaniel joins me to discuss the previous month's podcasts, headlines, and listener-submitted questions. This month, we're joined by Chris Hamilton! We talk about the J&J lawsuit being dismissed, Eli Lilly switching PBMs, AI in healthcare, and much more. We also play a Christmas game called Home Alone: The Wet Bandit's Bills, where Chris and I try to guess the average hospital price for the injuries incurred by the bandits from the Home Alone films.Chapters: 0:00 - Intro0:42 - J&J Lawsuit Dismissed9:20 - Eli Lily Switches PBMs11:17 - New FDA Rules On Biosimilars16:36 - AI Adoption In The Healthcare Industry25:21 - Survey On At-Home Medical Devices29:57 - Home Alone: The Wet Bandit's Bills42:32 - Ask Spencer AnythingSources: https://www.healthcaredive.com/news/fda-biosimilars-guidance-speed-development-comparative-efficacy-studies/804191/https://www.beckerspayer.com/legal/judge-dismisses-lawsuit-accusing-jj-of-mismanaging-employee-drug-benefits/?origin=PayerE&utm_source=PayerE&utm_medium=email&utm_content=newsletterhttps://www.healthcare-brew.com/stories/2025/11/25/eli-lilly-switches-big-3-pbm-alternative-transparent-rivalhttps://www.fiercehealthcare.com/health-tech/amid-shutdown-health-it-vendors-say-hospitals-are-cutting-back-spendinghttps://www.techtarget.com/virtualhealthcare/news/366633680/Survey-At-home-monitoring-devices-popular-affordablehttps://pubmed.ncbi.nlm.nih.gov/41265449/https://www.emarketer.com/content/ai-spending-healthcare-outpaces-overall-us-economy-

If you'd like your question answered on next month's episode, call/text 469-213-6381 and leave us a voicemail/text.Each month on Last Month In Healthcare, producer Nathaniel joins me to discuss the previous month's podcasts, headlines, and listener-submitted questions. This month, we're joined by Chris Hamilton! We talk about the J&J lawsuit being dismissed, Eli Lilly switching PBMs, AI in healthcare, and much more. We also play a Christmas game called Home Alone: The Wet Bandit's Bills, where Chris and I try to guess the average hospital price for the injuries incurred by the bandits from the Home Alone films.Chapters: 0:00 - Intro0:42 - J&J Lawsuit Dismissed9:20 - Eli Lily Switches PBMs11:17 - New FDA Rules On Biosimilars16:36 - AI Adoption In The Healthcare Industry25:21 - Survey On At-Home Medical Devices29:57 - Home Alone: The Wet Bandit's Bills42:32 - Ask Spencer AnythingSources: https://www.healthcaredive.com/news/fda-biosimilars-guidance-speed-development-comparative-efficacy-studies/804191/https://www.beckerspayer.com/legal/judge-dismisses-lawsuit-accusing-jj-of-mismanaging-employee-drug-benefits/?origin=PayerE&utm_source=PayerE&utm_medium=email&utm_content=newsletterhttps://www.healthcare-brew.com/stories/2025/11/25/eli-lilly-switches-big-3-pbm-alternative-transparent-rivalhttps://www.fiercehealthcare.com/health-tech/amid-shutdown-health-it-vendors-say-hospitals-are-cutting-back-spendinghttps://www.techtarget.com/virtualhealthcare/news/366633680/Survey-At-home-monitoring-devices-popular-affordablehttps://pubmed.ncbi.nlm.nih.gov/41265449/https://www.emarketer.com/content/ai-spending-healthcare-outpaces-overall-us-economy-

I was out drinking martinis with Cora Opsahl, director of 32BJ Health Fund, and Cora said, "Look, most plan sponsors' biggest expense is health system spend, hospital spend." I know this is an unexpected start to an episode about pharmaceutical pricing and value featuring Sarah Emond, CEO of ICER (Institute for Clinical and Economic Review). But yeah, 50% of most plan sponsors' spend these days goes to health systems. Fifty percent! One half! For a full transcript of this episode, click here. If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe. So, if a patient who is adherent to a drug and that drug keeps that patient out of the hospital, why do I want to make a patient have excessive skin in the game to get that drug, which everybody knows at this point this "skin in the game" can cause said patient to not be adherent in many cases, cost being a very big reason patients give for not taking medications as prescribed. So then we have this not adherent patient who winds up in the hospital, via the ER often enough. The core issue here that surfaced, bottom line—and I'm not sure if this was in spite of the martinis or as a result of them—but while hospital spend is the largest health expense, high-value drugs that prevent hospitalization often face patient cost sharing and access restrictions, which leads to poor patient adherence and ultimately higher system cost potentially. So then Cora and I spent the next half hour debating when the statement is empirically true and when it's not. And you know what it all boils down to? What's the value of the drug? Do we even know what that means to start? But if it's determined that the drug is relatively high value, then the plan desperately should want to do everything possible to keep that patient on that medication, and cost sharing is a huge barrier to adherence. Today, as I said, I'm speaking with Sarah Emond, CEO over at ICER, and we get into all of this in the conversation that follows. In fact, most of the conversation that follows explores the tensions that exist in the current way that we sell and buy pharmaceutical products. I'm just gonna sum up these tensions in a list here at the top of this show. There's six of them that Sarah Emond and I discussed today by my counting, and each of these we explore in some depth. So, here's the list. Tension 1: The value of any given drug (in other words, what is the fair price for that drug considering the health gains that it delivers) versus the total cost to the plan for the total population taking that drug. GLP-1s have entered the chat. GLP-1s (by ICER's analysis, at least) are super high-value drugs that also can bankrupt plans due to the number of folks who may benefit from taking the drug. Definitely a tense tension to kick off our list here. Tension 2: The list or net price of a drug versus patient access and affordability. Again, this can be tense in an area of much misalignment. You can have a great well-priced drug with huge patient affordability and access challenges because drug net price and coinsurance amounts often have nothing to do with each other. Tension 3: Lifetime value of a drug versus a 3-, 2.5-year, whatever time horizon that many plan sponsor actuaries use in their value assessment. We discussed this today, but there's a Summer Short (SUMS7) on actuarial value horizons with Keith Passwater and JR Clark if you wanna dig in on this further. Tension 4: The tension between the societal value of a drug or even the patient's perceived value of a drug versus what an employer plan sponsor might perceive as the value. What is the formula used to determine value? What's in and what's out? So, that's a bigger conversation just beyond the time horizon for what's included in this calculation. Tension 5: Exacerbating the what's included in the value contemplation beyond just what you include in there is the tension between what is hypothetically of value and what is possible to measure. If you have pharma datasets and medical datasets separate in silos, who knows how many hospital readmissions were prevented by whatever drug? And how much presenteeism or absenteeism exists. I mean, it is an outlier, again, if anyone even knows the net price they paid for a drug, just to level set context here. Tension 6: Lowering financial barriers for patients to take drugs that are of value versus status quo goals and incentives. Like, for example, PBMs (pharmacy benefit managers) are often told that their goal is to reduce drug spend. Okay … so, how do I do that? Oh, reduce access either by prior auths or delay tactics or really high coinsurance, which is gonna reduce adherence by design. And it's someone else's problem—if I'm just thinking like a status quo PBM—if medical spend goes up, right? So, that's our last and not insignificant tension. And look, who comes out the loser in all of these tensions when they get tense? Patients. Not pricing based on value and not buying and setting up cost sharing based on value punishes patients and also plan sponsors or any other ultimate purchaser in the long term, given that the plan is but a population of patients if you start thinking about it in that context. Here is Sarah's advice in a nutshell: Pharma, sell. Pick your price based on something other than market power. And some pharma companies are actually dipping their toe into these waters and doing it. But then PBMs and plan sponsors have to hold up their end of the bargain here and buy drugs based on their value, not just the size of their rebates or some other discounting promise. And then we gotta continue the through line through to member affordability and access. High-value drugs should get preferred. So, right, do a high-value formulary. Listen to the show with Nina Lathia, RPh, MSc, PhD (EP426) on high-value formularies and then listen (after you're done with that one) to episode 435 with Dan Mendelson entitled "Optimized Pharmacy Benefits Are Required if You Want to Do or Buy Value-Based Care." Also, as I said, GLP-1s come up in this conversation, so … yeah, buckle up. One last thing, besides my normal thank you to Aventria Health Group for sponsoring this episode, I am so pleased to thank Payerset for donating to help Relentless Health Value stay on the air. Payerset is a price transparency company with a mission to create fair and equitable healthcare for everyone. Love that. Payerset empowers healthcare organizations, employers, and patients with the most complete set of healthcare price transparency data. They benchmark every negotiated rate and claim and delivering the actionable insights needed for smarter contract negotiations and a more transparent healthcare system. As I have said several times today, my conversation is with Sarah Emond, CEO of ICER. Also mentioned in this episode are Institute for Clinical and Economic Review (ICER); Cora Opsahl; 32 BJ Health Fund; Keith Passwater; JR Clark; Nina Lathia, RPh, MSc, PhD; Dan Mendelson; Aventria Health Group; Payerset; Antonio Ciaccia; Elizabeth Mitchell; Purchaser Business Group on Health (PBGH); Shane Cerone; Sam Flanders, MD; Mark Cuban; Morgan Health; and Tom Nash. For a list of healthcare industry acronyms and terms that may be unfamiliar to you, click here. You can learn more at ICER.org and follow Sarah on LinkedIn.   Sarah K. Emond, MPP, is president and chief executive officer of the Institute for Clinical and Economic Review (ICER), a leading nonprofit health policy research organization, with 25 years of experience in the business and policy of healthcare. She joined ICER in 2009 as its first chief operating officer and third employee and has worked to grow the organization's approach, scope, and impact over the years. Prior to joining ICER, Sarah spent time as a communications consultant, with six years in the corporate communications and investor relations department at a commercial-stage biopharmaceutical company and several years with a healthcare communications firm. Sarah began her healthcare career in clinical research at Beth Israel Deaconess Medical Center in Boston. A graduate of the Heller School for Social Policy and Management at Brandeis University, Sarah holds a Master of Public Policy degree with a concentration in health policy. Sarah also received a bachelor's degree in biological sciences from Smith College. Sarah speaks frequently at national conferences on the topics of prescription drug pricing policy, comparative effectiveness research, and value-based healthcare.   08:18 Why list prices are a lie. 10:59 How does the rebate model sometimes get in the way of paying for value? 12:50 Bonus clip with Sarah Emond. 13:14 EP491 with Elizabeth Mitchell. 13:20 EP490 and EP492 with Shane Cerone and Sam Flanders, MD. 14:37 The tension that is created between affordability and adherence. 15:03 When cost sharing makes sense in pharmaceutical drug pricing. 17:26 INBW42 with Stacey on moral hazard. 18:53 How GLP-1s are "wildly cost effective." 21:32 Why the sticker shock on cost-effective drugs is a failure in the system for paying for value. 22:38 ICER's report on GLP-1s. 26:59 EP385 with Dan Mendelson. 28:57 How employers and payers can have a value assessment approach and a health insurance system that allows access to cost-effective drugs. 29:48 How cost-effective prices are calculated. 31:55 One of the core value underpinnings for value assessment of drugs. 34:54 Why manufacturers and pharmacy benefit managers should work together more by referencing something like an ICER report. 36:55 EP426 with Nina Lathia, RPh, MSc, PhD. 38:21 "We can make different choices."   You can learn more at ICER.org and follow Sarah on LinkedIn.   @sarahkemond discusses #pharmaceutical #drugpricing on our #healthcarepodcast. #healthcare #podcast #financialhealth #patientoutcomes #primarycare #digitalhealth #healthcareleadership #healthcaretransformation #healthcareinnovation   Recent past interviews: Click a guest's name for their latest RHV episode! Stacey Richter (INBW43), Olivia Ross (Take Two: EP240), John Quinn, Dr Sam Flanders and Shane Cerone (EP492), Elizabeth Mitchell (EP491), Shane Cerone and Dr Sam Flanders (Part 1), Dan Greenleaf (Part 2), Dan Greenleaf (Part 1), Mark Cuban and Cora Opsahl

Investor and healthcare disruptor Mark Cuban joins The Other 80 to talk about his online pharmacy, Cost Plus Drugs, that is bringing affordable drugs with transparent markups to American households. Mark lays out his basic formula for taking overhead and complexity out of the US healthcare system by disaggregating huge vertical businesses and disintermediating middlemen.In this episode, Mark Cuban pitches:That direct contracting with hospitals is his next healthcare disruptionWhy he thinks medical schools should be freeHow financial audits are a first step to lowering healthcare pricesWhy price transparency is contagiousMark thinks the best way to make change is from outside the system:“What makes [Cost Plus Drugs] radical is when we started, everybody presumed and expected that we would work within the system. That we would partner with the big three wholesalers that control 98% of the sale of drugs - that we would partner with the big three PBMs that control 85% of prescriptions. And, we did the exact opposite because we knew they were the problem.”Relevant LinksThe Cost Plus Drugs mission statementRead and watch Mark Cuban testimony for the Senate Special Committee on Aging More on Mark's hospital negotiation strategyAbout Our GuestMark Cuban is an investor who lives for his family, his "Shark Tank" companies and the Dallas Mavericks. He is the owner of the 2011 World Champion Dallas Mavericks and bestselling author of "How to Win at the Sport of Business," and was an entrepreneur from the early age of 12 when he sold garbage bags door to door. Today, Cuban is the highly successful entrepreneur and investor with an ever-growing portfolio of businesses.A lifelong entrepreneur and investor, Cuban has started and built multiple industry-changing organizations including Costplusdrugs.com, which sells medications at industry low pricing with total cost transparency, which he founded with Dr. Alex Oshmansky. Named a winner of the GQ Men of the Year in 2006 and included in The New York Times Magazine's Year in Ideas, Cuban is recognized as being among the most influential people in both the cable and sports industries. He may be best known for his purchase of the Dallas Mavericks on Jan. 4, 2000. Under his leadership, the team's home games have become a total entertainment experience.Prior to his purchase of the Mavericks, Cuban co-founded the first commercial streaming company AudioNet, which became Broadcast.com, the leading provider of multimedia and streaming on the Internet. Broadcast.com was sold to Yahoo! Inc. in July 2000. MicroSolutions, a leading national systems integrator, was co-founded by Cuban and partner Martin Woodall in 1983, and later sold to CompuServe.In 2001, Cuban founded AXS TV (www.axs.tv) and sister network, HDNet Movies, the very first all high-definition TV network. He also co-owns the Landmark Theater chain, Magnolia Pictures, Magnolia Home Video and 2929 Productions along with partner Todd Wagner. With the release of the movie "Bubble" in 2005, Magnolia and Landmark Theaters pioneered the release of the movie's "day and date," meaning the

Pharmacy benefits shouldn't feel like a black box. We sit down with Susan Thomas, Chief Commercial Officer at Lucy Rx, to unpack why drug costs keep rising and what it takes to build a benefit that serves patients and plans—not middlemen. Susan started as an oncology nurse and moved into PBM leadership, and that dual lens shows up in everything we cover: from the real-world stress of waiting days for an oral chemo to the hidden economics of rebate chains and vertically integrated networks.We dig into the two biggest levers for change. First, formulary autonomy: instead of being locked to a single, opaque GPO, a marketplace approach lets employers compare multiple rebate contracts, see drug-level net cost, and choose the best path for categories like Humira biosimilars or GLP-1s. That shift enables utilization management that protects value without opening the floodgates. Second, network independence: when PBMs own specialty and mail, steering is inevitable. By contracting with integrated health systems for specialty and modern mail partners for home delivery, plans can speed therapy, reduce waste from 30-day auto-ships, and improve member experience at a lower overall cost.We also talk fiduciary duty, policy momentum, and technology. Employers need verifiable net-cost math—not averages—to defend decisions in a post–J&J lawsuit world. Washington's scrutiny is rising, and incumbents are signaling changes, but structural misalignments remain. On the tech front, AI-driven reporting and specialty navigation are already here, while precision medicine and pharmacogenomics promise to target high-cost drugs to the patients who will benefit most. The question is whether the industry will embrace smaller, smarter populations when volume shrinks and outcomes improve.If you care about cutting pharmacy spend without compromising care, this conversation is a practical roadmap: ask for drug-level net cost, insist on formulary choice across GPOs, require independent specialty and mail, and set utilization criteria that put patients first. Subscribe, share this episode with a colleague who manages pharmacy benefits, and leave a review with the one PBM metric you wish you'd had sooner.This episode is sponsored by Benepower, the platform of choice for a modern benefits experience. Benepower is an AI-powered benefits platform offering access to top products and services, enabling consultants and employers to create customized plans, optimize usage, and measure effectiveness. www.benepower.com

The level of interest in Episode 84 of Astonishing Healthcare made this one an easy choice to lift it to "best of" status. We'll be back with fresh new episodes in early December, and then we'll close out the year with two more Best of '25s. For those of you who didn't check this one out, Josh Golden, SVP of Strategy, and RFP Content Manager, Nic Bolitho, joined host Justin Venneri in the studio for a discussion about trends they're seeing in the market and how to run a better request for proposal (RFP) process to select a pharmacy benefit management (PBM) partner. Long story short, the "old way" of running a PBM RFP is broken, but, as Josh describes, there are some "tectonic shifts" happening as plan sponsors demand to see more options (i.e., transparent PBMs) and benefits brokers and consultants upgrade the questions and scoring used to force accountability and drive meaningful results for plans and plan members.HighlightsUnit-cost-based spreadsheet comparisons and marketing fluff are "out;" evaluating drug mix and how the PBM manages the plan (the 'M' in PBM) or makes money off of the plan are "in."Plan sponsors and benefits consultants must demand flexibility - the PBM contract should not be a "house of cards." For example, agreements should provide the freedom to add new vendors or carve out services without collapsing your financial arrangement.Legacy tech platforms are a barrier to innovation; ask potential partners if their technology can handle customizations and integrations with agility to avoid being told, "We just can't do that."Precise questions about member experience are a must; RFPs should move beyond open-ended questions that invite marketing fluff. Use specific, binary questions to obtain an accurate measure of the member experience and the effectiveness of clinical programs (e.g., NPS, turnaround times for prior authorizations, etc.).Related ContentReplay: PBM Procurement Decoded: Insights from a Pharmacist and an Actuary Why Savings Don't Materialize: The Truth About Pharmacy Benefit Procurement eBook AH034 - Customer Care in Healthcare: Setting a Higher Bar, with Will TafoyaAH035 - Pharmacy Benefits 101: Clinical Programs, with Bonnie Hui-Callahan, PharmD5 ways to improve PBM procurement (EBN) For more information about Capital Rx and this episode, please visit Judi Health - Insights.

On this episode of the podcast, Missouri Congressman Eric Burlison discussed his proposal for a new healthcare account, the MAHA account, which would function like a supercharged Health Savings Account (HSA), allowing individuals to save up to $25,000 tax-free annually for health insurance and wellness expenses.He emphasized the need for a new solution to address healthcare affordability issues, criticizing Obamacare's preserve incentives. The Missouri Republican also highlighted the role of pharmacy benefit managers (PBMs) in driving up pharmaceutical costs and advocated for giving patients direct choice. He believes MAHA accounts could be implemented by March 2026, potentially reducing healthcare costs and increasing consumer options.See Privacy Policy at https://art19.com/privacy and California Privacy Notice at https://art19.com/privacy#do-not-sell-my-info.

In this episode of Tech Trends by PrimeRx, we continue our deep dive into the evolving world of pharmacy technology. Building on the momentum from our previous discussion—where we explored the shifting landscape of pharmacy tech innovation—we now turn our focus to one of the most urgent challenges facing independent and community pharmacies: making sense of inventory and purchase data. Dr. Matthew Song joins us to break down why automation is no longer optional and how data intelligence is transforming pharmacy operations. With rising costs, shrinking margins, and increasing administrative demands, the ability to automate and optimize data workflows is becoming a competitive advantage. Dr. Song sets the stage by examining how automated systems offer unprecedented visibility into a pharmacy's financial and clinical activity. Today's modern PMS platforms, including PrimeRx, go far beyond dispensing—they automatically collect, analyze, and interpret operational data. Throughout the episode, we'll uncover how automation identifies top payers, high-impact drugs, key prescribers, patient adherence trends, and more. These insights help pharmacy leaders make informed decisions around purchasing, contracting, staffing, and patient care. Listeners will also gain actionable takeaways tied directly to real-time metrics, including dashboards that connect inventory fluctuations to financial performance. Dr. Song explains how automation eliminates manual entry errors, accelerates purchasing decisions, and helps pharmacies avoid costly stockouts or overstocking. From surfacing seasonal medication trends to pinpointing high-volume PBMs or top-referring providers, this episode demonstrates the power of transforming raw data into strategic intelligence. Stay tuned through the end as we tease what's next on the horizon—AI-driven predictive inventory management and the next evolution in pharmacy automation.

Dr. Robert Popovian is a pharmacist, and economist with a deep background in research and public policy. In this episode we have a nuanced discussion on policy impacting pharmacy including PBMs, President Trumps Most Favored Nation Executive Order, Rebates, and insurance premiums.    Links to resources referenced in discussion: • Pioneer Institute, 340B tool: https://pioneerinstitute.org/340babuse/ • Pioneer Institute, IRA tool: https://pioneerinstitute.org/the-inflation-reduction-act-ira-overview/ • Editorial regarding TrumpRX: https://www.linkedin.com/pulse/promise-trumprx-robert-popovian-vskne/?trackingId=dtiG1P%2B%2BSDq6adLfFeEbeg%3D%3D • Pioneer Institute, IRA report: https://pioneerinstitute.org/wp-content/uploads/Prescription-Drug-Price-Controls-06252025.pdf  • GHLF tool, Impact of Accumulators and Maximizers on Premiums: https://cutt.ly/Rr9Di7Vf • Conquest Advisors website: https://conquestadvisors.godaddysites.com/

In this episode of Disruption/Interruption, host KJ interviews Mark Mincy, Chief Commercial Officer at US RX Care, about the hidden complexities and conflicts of interest in the pharmacy benefits industry. Mark shares how his company is disrupting the status quo by demanding transparency, eliminating conflicts, and helping employers reclaim millions in savings. The conversation uncovers the tangled web of PBMs, rebates, and the urgent need for legislative and technological change. Key Takeaways: The PBM System is Riddled with Conflicts of Interest [2:34]Mark explains how pharmacy benefit managers (PBMs) and consultants often act in their own financial interest, not the employer’s or patient’s, leading to inflated drug costs. Rebates and Purchasing Contributions Inflate Drug Prices [8:59]The system of rebates and retrospective payments to PBMs can account for up to 80% of a drug’s cost, forcing manufacturers to raise prices and employers to pay more. Transparency and Fiduciary Duty are Essential for Reform [21:37]Mark’s company, US RX Care, operates with complete transparency, passes back all rebates, and offers per-member-per-month guarantees to eliminate guesswork and conflicts. Employers and Consumers Can Take Action [33:34]Mark recommends joining healthcare purchaser coalitions, hiring ERISA attorneys, and demanding non-conflicted consultants to protect interests and drive industry change. Quote of the Show [31:27]:"Everything's intertwined. You want to move and do the right thing. These employers are between a rock and a hard place, so I do think some legislative action needs to occur." – Mark Mincy Join our Anti-PR newsletter where we’re keeping a watchful and clever eye on PR trends, PR fails, and interesting news in tech so you don't have to. You're welcome. Want PR that actually matters? Get 30 minutes of expert advice in a fast-paced, zero-nonsense session from Karla Jo Helms, a veteran Crisis PR and Anti-PR Strategist who knows how to tell your story in the best possible light and get the exposure you need to disrupt your industry. Click here to book your call: https://info.jotopr.com/free-anti-pr-eval Ways to connect with Mark Mincy: LinkedIn: http://www.linkedin.com/in/mark-mincy-a185497 Company Website: https://us-rxcare.com How to get more Disruption/Interruption: Amazon Music - https://music.amazon.com/podcasts/eccda84d-4d5b-4c52-ba54-7fd8af3cbe87/disruption-interruption Apple Podcast - https://podcasts.apple.com/us/podcast/disruption-interruption/id1581985755 Spotify - https://open.spotify.com/show/6yGSwcSp8J354awJkCmJlDSee omnystudio.com/listener for privacy information.

In this eye-opening episode of The ASHHRA Podcast, hosts Bo Brabo and Luke Carignan welcome Kinjal Patel and Brady Heiner from RxBenefits to demystify the complex world of pharmacy benefit management (PBMs). As costs skyrocket, driven by specialty drugs accounting for 50% of spend from just 2% of prescriptions, HR leaders face fiduciary risks, hidden contract clauses, and potential class-action lawsuits. Kinjal and Brady reveal how transparent PBMs differ from traditional models, why "transparency" claims often fall short, and how RxBenefits operates as a client-aligned Pharmacy Benefits Optimizer with 3 million members' negotiating power.Discover actionable strategies for hospitals and health systems to leverage in-house pharmacies, avoid rebate pitfalls, and conduct essential market checks and audits. The duo emphasizes the critical fine print in PBM contracts (e.g., CVS, Express Scripts, OptumRx) that can erode savings if overlooked. RxBenefits offers free, comprehensive contract analyses to uncover hidden opportunities and protect your organization.Key takeaways for healthcare HR professionals:Understand true PBM transparency vs. marketing hype… demand bias-free alignment.Specialty drugs dominate costs; optimize high-dollar prescriptions for massive savings.Hospital pharmacies are goldmines; structure contracts to maximize rebates and utilization.Fiduciary duty demands expertise; avoid legal risks with proactive audits.Don't DIY pharmacy benefits; partner with consultants for smarter plan design and pricing.A must-listen for HR managing escalating drug spend and compliance. Take control… request your free RxBenefits analysis today!From Our Sponsors...Optimize Pharmacy Benefits with RxBenefitsElevate your employee benefits while managing costs. Did you know hospital employees fill 25% more prescriptions annually than other industries? Ensure cost-effective, high-quality pharmacy plans by leveraging your hospital's own pharmacies. Discover smarter strategies with RxBenefits.Learn More here - https://rxbene.fit/3ZaurZNStreamline HR Compliance with oneBADGEhealthcareSimplify screening, credentialing, and compliance for healthcare HR. oneBADGEhealthcare from ISB Global offers a tailored solution to keep your workforce compliant and efficient. Built for healthcare leaders, it's your all-in-one compliance tool.Get Started here - https://isbglobalservices.com/onebadgeunitedstates/ashhra/ Support the show

TWIRx in the WORKS!!!  Welcome back to This Week in Pharmacy (TWIRx) — your weekly deep dive into the most important pharmacy news, innovations, and conversations shaping healthcare. In this episode, host Todd Eury brings you stories that move from data to impact, exploring how pharmacists are driving change through knowledge, leadership, and advocacy.

HOUR 1 What's fueling the surge of cancer across America's Midwest—and why won't the media name the most controversial suspect? In this gripping episode of Rush to Reason, John Rush, Dr. Kelly Victory, and Steve House expose alarming cancer trends and ask: are toxins to blame—or something far more recent and widespread? Dr. Kelly reveals evidence linking “turbo cancers” to spike proteins found inside tumors, while John and Steve question why the medical community stays silent. When proof threatens power, who decides what the public gets to know? Meanwhile, a buried $600 billion Big Pharma lawsuit reveals how PBMs have quietly controlled drug prices for decades. Could new technology finally break this monopoly—or has corruption gone too deep? Don't miss this explosive conversation that connects hidden lawsuits, rising cancers, and the fight to uncover the truth. HOUR 2 What happens when unlicensed, illegal truck drivers hit the road—and who's really responsible when things go wrong? Why did Denver come so close, yet fall short, in its bid to host the 2030 Gay Games—and what does that say about the city's political and cultural identity? Then, former President Trump makes a shocking move: ordering the Pentagon to prepare for nuclear weapons testing for the first time since 1992. What's behind that decision, and what message is it sending to the world? And finally—what would you do if you won $2 billion? One California man is using his winnings to buy up properties lost in the L.A. fires. Is it rebuilding or opportunism? HOUR 3 What drives a New Yorker who despises billionaires to throw his support behind socialist candidate Zorhan Mamdani for mayor? Is this a glimpse into the future of urban politics—or a warning sign for the rest of the country? Meanwhile, the CEO of Walmart takes on George Stephanopoulos over the real cost of Thanksgiving dinner this year—so who's telling the truth about inflation? And in a bizarre twist, how did an AI system mistake a bag of Doritos for a gun? What does that say about the technology shaping our everyday lives? Then—California's SEIU union is pushing a new ballot measure: a 5% wealth tax on billionaires, retroactive to 2025. Could this start an exodus—or a revolution? Plus, emergency funds for SNAP and a local race that hits close to home—Steve Altschuler is back in the running for Longmont City Council.

HOUR 1 What's fueling the surge of cancer across America's Midwest—and why won't the media name the most controversial suspect? In this gripping episode of Rush to Reason, John Rush, Dr. Kelly Victory, and Steve House expose alarming cancer trends and ask: are toxins to blame—or something far more recent and widespread? Dr. Kelly reveals evidence linking “turbo cancers” to spike proteins found inside tumors, while John and Steve question why the medical community stays silent. When proof threatens power, who decides what the public gets to know? Meanwhile, a buried $600 billion Big Pharma lawsuit reveals how PBMs have quietly controlled drug prices for decades. Could new technology finally break this monopoly—or has corruption gone too deep? Don't miss this explosive conversation that connects hidden lawsuits, rising cancers, and the fight to uncover the truth. HOUR 2 What happens when unlicensed, illegal truck drivers hit the road—and who's really responsible when things go wrong? Why did Denver come so close, yet fall short, in its bid to host the 2030 Gay Games—and what does that say about the city's political and cultural identity? Then, former President Trump makes a shocking move: ordering the Pentagon to prepare for nuclear weapons testing for the first time since 1992. What's behind that decision, and what message is it sending to the world? And finally—what would you do if you won $2 billion? One California man is using his winnings to buy up properties lost in the L.A. fires. Is it rebuilding or opportunism? HOUR 3 What drives a New Yorker who despises billionaires to throw his support behind socialist candidate Zorhan Mamdani for mayor? Is this a glimpse into the future of urban politics—or a warning sign for the rest of the country? Meanwhile, the CEO of Walmart takes on George Stephanopoulos over the real cost of Thanksgiving dinner this year—so who's telling the truth about inflation? And in a bizarre twist, how did an AI system mistake a bag of Doritos for a gun? What does that say about the technology shaping our everyday lives? Then—California's SEIU union is pushing a new ballot measure: a 5% wealth tax on billionaires, retroactive to 2025. Could this start an exodus—or a revolution? Plus, emergency funds for SNAP and a local race that hits close to home—Steve Altschuler is back in the running for Longmont City Council.

HOUR 1 What's fueling the surge of cancer across America's Midwest—and why won't the media name the most controversial suspect? In this gripping episode of Rush to Reason, John Rush, Dr. Kelly Victory, and Steve House expose alarming cancer trends and ask: are toxins to blame—or something far more recent and widespread? Dr. Kelly reveals evidence linking “turbo cancers” to spike proteins found inside tumors, while John and Steve question why the medical community stays silent. When proof threatens power, who decides what the public gets to know? Meanwhile, a buried $600 billion Big Pharma lawsuit reveals how PBMs have quietly controlled drug prices for decades. Could new technology finally break this monopoly—or has corruption gone too deep? Don't miss this explosive conversation that connects hidden lawsuits, rising cancers, and the fight to uncover the truth. HOUR 2 What happens when unlicensed, illegal truck drivers hit the road—and who's really responsible when things go wrong? Why did Denver come so close, yet fall short, in its bid to host the 2030 Gay Games—and what does that say about the city's political and cultural identity? Then, former President Trump makes a shocking move: ordering the Pentagon to prepare for nuclear weapons testing for the first time since 1992. What's behind that decision, and what message is it sending to the world? And finally—what would you do if you won $2 billion? One California man is using his winnings to buy up properties lost in the L.A. fires. Is it rebuilding or opportunism? HOUR 3 What drives a New Yorker who despises billionaires to throw his support behind socialist candidate Zorhan Mamdani for mayor? Is this a glimpse into the future of urban politics—or a warning sign for the rest of the country? Meanwhile, the CEO of Walmart takes on George Stephanopoulos over the real cost of Thanksgiving dinner this year—so who's telling the truth about inflation? And in a bizarre twist, how did an AI system mistake a bag of Doritos for a gun? What does that say about the technology shaping our everyday lives? Then—California's SEIU union is pushing a new ballot measure: a 5% wealth tax on billionaires, retroactive to 2025. Could this start an exodus—or a revolution? Plus, emergency funds for SNAP and a local race that hits close to home—Steve Altschuler is back in the running for Longmont City Council.

This is Derek Miller, Speaking on Business. RealRx was founded in 2020 as a joint venture between University of Utah Health Plans and Cooperative Benefits Group. They provide efficient, high-quality pharmacy solutions focused on delivering value to members. President, Jeffrey Dunn, joins us with more. Jeffrey Dunn: We all know that high drug costs can be a burden for Utah businesses and families. What you may not realize is that traditional pharmacy benefit managers, or PBMs, often profit when prices stay high. They make money through rebates, spread pricing, and fees that are all tied to the cost of the drug and the number of prescriptions. At RealRx, we knew there had to be a better way. Founded in Salt Lake City by local pharmacists and healthcare leaders each with more than 20 years of experience, the RealRx solution is transparent, 100 percent pass-through drug pricing. As an employer, you pay the exact amount paid to the pharmacy, less any applicable member cost - with no markup and no games - ever. Our model cuts prescription costs by 20 to 30 percent, while giving members a better experience. RealRx is proud to be part of this community, and we're committed to making prescription drugs more affordable. Derek Miller: By enhancing access to affordable, high-quality pharmacy care, REALRx continues to strengthen Utah communities. Their member-focused approach lowers costs, supports local health initiatives, and promotes better outcomes. Learn more at realRXsites.com. I'm Derek Miller, with the Salt Lake Chamber, Speaking on Business. Originally aired: 10/23/25

Brandon Weber, Co-founder & CEO of Nava Benefits, joined us on The Modern People Leader.We talked about why benefits have become the second-largest company expense — and how HR can “moneyball” their healthcare spend, cut down on benefits-related admin work, and deliver better employee outcomes through the emerging “alt marketplace.”---- Nava Links:

Health care data strategist Lee Ann McWhorter discusses her article "Why health care reform must start with ending monopolies." Lee Ann explains how monopolistic control by entities like GPOs, PBMs, EHR vendors, and MMIS platforms drives up costs, suppresses innovation, and undermines patient safety. She highlights how opaque contracts and data silos leave hospitals flying blind, why favoritism often trumps performance, and how COVID-19 revealed the dangers of centralized sourcing models. Lee Ann emphasizes that hospitals have the power to break this cycle by rejecting monopolistic contracts and investing in transparent, independent, and sustainable solutions. Listeners will learn why cost is not the true crisis—control is—and how restoring competition can protect patients and rebuild trust in the system. Our presenting sponsor is Microsoft Dragon Copilot. Microsoft Dragon Copilot, your AI assistant for clinical workflow, is transforming how clinicians work. Now you can streamline and customize documentation, surface information right at the point of care, and automate tasks with just a click. Part of Microsoft Cloud for Healthcare, Dragon Copilot offers an extensible AI workspace and a single, integrated platform to help unlock new levels of efficiency. Plus, it's backed by a proven track record and decades of clinical expertise, and it's built on a foundation of trust. It's time to ease your administrative burdens and stay focused on what matters most with Dragon Copilot, your AI assistant for clinical workflow. VISIT SPONSOR → https://aka.ms/kevinmd SUBSCRIBE TO THE PODCAST → https://www.kevinmd.com/podcast RECOMMENDED BY KEVINMD → https://www.kevinmd.com/recommended

Donovan Ryckis is the award-winning founder and CEO of Ethos Benefits, leading the charge in fiduciary-driven healthcare strategies for employers. A former Securities Advisor, he shifted from investment advising after uncovering inefficiencies in employer healthcare plans—achieving 40% savings for a client without reducing benefits. Alongside his wife and business partner, Chelsea, Donovan applies a fiduciary financial process to help organizations cut costs and improve outcomes.Brenda Kruse, CFO of Axiom Healthcare Services, brings over 26 years of financial leadership in healthcare and senior living. A licensed CPA, she excels in strategic planning, compliance, and cost management, driving both financial strength and quality care across her organization.In this episode, Eric, Donovan, and Brenda discuss:How employers can apply a fiduciary mindset to healthcare plans under ERISA.The importance of data transparency in managing plan costs and pharmacy benefit managers (PBMs).Aligning advisor compensation with employer and employee interests.Real-world examples of reducing costs while improving employee benefits.Key Takeaways:Many employers don't realize their healthcare plans carry ERISA fiduciary liability just like retirement plans. Creating a formal benefits committee ensures decisions are documented, consistent, and defensible.Data ownership and transparency are critical. Without detailed claims and pharmacy data, employers can't pinpoint where costs are being driven or negotiate effectively.Pharmacy Benefit Managers (PBMs) are often overlooked sources of cost savings. Changing PBMs can reduce plan expenses by up to 50–70% with minimal disruption to employees.Aligning broker and consultant incentives with the employer's goals prevents conflicts of interest and ensures decisions are made in the plan participants' best interests.“If we don't have data, we don't know where our costs are being spent… 60% of our costs were in pharmacy, and yet our previous broker really wasn't even trying to change our pharmacy plan at all.”— Brenda Kruse“Even disclosing fees is only since the CAA of 2021, even still today, companies are doing it very poorly… They say it's part of their entire book of business, so they can't calculate it per client—that's certainly a bad starting point.” — Donovan RyckisConnect with Donovan Ryckis & Brenda Kruse:Website: https://ethosbenefits.com/ & https://www.axmservices.com/LinkedIn: https://www.linkedin.com/in/donovanryckis/ / https://www.linkedin.com/in/brenda-kruse-1a90592b/Connect with Eric Dyson: Website: https://90northllc.com/Phone: 940-248-4800Email: contact@90northllc.com LinkedIn: https://www.linkedin.com/in/401kguy/ Important clarification from the podcast show dialogue: "If an ERISA plan exceeds 100 participants with an account balance but remains under 120 in perpetuity, then the plan would not require an audit for each subsequent year that it remains under 120 participants with a balance. Please verify current rules and check with your plan record-keeper, advisor, or CPA to ensure compliance with this requirement." The information and content of this podcast are general in nature and are provided solely for educational and informational purposes. It is believed to be accurate and reliable as of the posting date, but may be subject to change.It is not intended to provide a specific recommendation for any type of product or service discussed in this presentation or to provide any warranties, investment advice, financial advice, tax, plan design, or legal advice (unless otherwise specifically indicated). Please consult your own independent advisor as to any investment, tax, or legal statements made.The specific facts and circumstances of all qualified plans can vary, and the information contained in this podcast may or may not apply to your individual circumstances or to your plan or client plan-specific circumstances.

Florida's Octagon Doctor joins Nephilim Death Squad to pull the curtain back on modern medicine: how direct primary care actually works, why urgent care is mostly a money trap, what PBMs do to drug prices, the reality of AI “doctors,” and how to find a physician who knows you—not just your chart. We also hit COVID after-effects (phantom smells, dulled taste), moving from Puerto Rico → Iowa → Florida, and what it's like working cage-side for UFC/BKFC while running a patient-first clinic. If you're tired, burned out, or stuck paying a second mortgage for “healthcare,” this one's for you. Follow Dr. YaredWebsite: OctagonDoctor.com. Octagon DoctorInstagram: [@octagondoctor] Instagram+1X (Twitter): [@dryared] X (formerly Twitter)+1YouTube: Octagon Doctor channel. YouTubeFacebook (Page): Octagon Doctor. FacebookFacebook (Profile): Yared Vazquez. FacebookLinkedIn: /in/doctoryaredNEPHILIM DEATH SQUADPatreon (early access + Telegram): https://www.patreon.com/NephilimDeathSquadWebsite & Merch: https://nephilimdeathsquad.comSupport Joe Gilberti: GiveSendGoListen/Watch:Spreaker: https://www.spreaker.com/podcast/nephilim-death-squad--6389018YouTube: https://www.youtube.com/@NephilimDeathSquadRumble: https://rumble.com/user/NephilimDeathSquadX: https://twitter.com/NephilimDSquadInstagram: https://instagram.com/nephilimdeathsquadContact: chroniclesnds@gmail.comX Community – Nephilim Watch: https://twitter.com/i/communities/1725510634966560797TopLobsta:X: https://twitter.com/TopLobstaInstagram: https://instagram.com/TopLobstaMerch: https://TopLobsta.comRaven:X: https://twitter.com/DavidLCorboInstagram: https://instagram.com/ravenofndsSponsors:Rife Tech – https://realsrifetechnology.com/ (Code: NEPHILIM for 10% off)Purge Store – https://purgestore.com/ (Code: NEPHILIM for 10% off)Credits:Intro Animation: @jslashr on XMusic: End of Days by Vinnie PazBecome a supporter of this podcast: https://www.spreaker.com/podcast/nephilim-death-squad--6389018/support.☠️ Nephilim Death Squad — New episodes 5x/week.Join our Patreon for early access, bonus shows & the private Telegram hive.Subscribe on YouTube & Rumble, follow @NephilimDSquad on X/Instagram, grab merch at toplobsta.com. Questions/bookings: chroniclesnds@gmail.com — Stay dangerous.

The host has been a community pharmacy advocate for 22 years. Always looking for ways to help community pharmacies be more profitable. The guest is an experienced Pharmacist with a demonstrated history of working in the pharmaceutical industry. Skilled in Diabetes, Pharmacy Practice, Community Pharmacy, and Clinical Pharmacology.

In this special RxBenefits-sponsored episode of The ASHHRA Podcast, hosts Bo Brabo and Luke Carignan explore the dynamic pharmacy benefits landscape with experts Sarah Hearn and Wes Hill (Director of Compliance & Legal Operations). Amid the busiest legislative season yet—over 1,500 bills—they discuss PBM reforms, ERISA challenges, compounding alternatives for GLP-1 drugs like Ozempic, 340B pricing, and emerging lawsuits. Gain insights on transparency, cost savings, and compliance for healthcare HR pros navigating employee benefits.Key takeaways for healthcare HR leaders:Legislative Surge: 1,500+ state bills target PBMs, carriers, and more; expect increased reporting burdens but better data for informed decisions.ERISA Erosion Risks: States challenge federal uniformity—multi-state plans face conflicting laws; monitor for compliance headaches.Positive Reforms: New mandates empower plan sponsors with PBM data; leverage 340B and coupons to cut costs (e.g., Wegovy from $1,000 to $100/month).Compounding & Innovation: Affordable GLP-1 alternatives via telehealth, but ensure safety and avoid controlled substance pitfalls.Lawsuits to Watch: Oklahoma ERISA win; Arkansas PBM permit ban challenges interstate commerce—outcomes could reshape operations.Action Steps: Demand vendor transparency; align with ERISA; educate teams on benefits to prevent misuse and optimize savings.Essential listening for HR managing rising pharmacy costs and regulations. Spark curiosity—reach out to RxBenefits for guidance!From Our Sponsors...Optimize Pharmacy Benefits with RxBenefitsElevate your employee benefits while managing costs. Did you know hospital employees fill 25% more prescriptions annually than other industries? Ensure cost-effective, high-quality pharmacy plans by leveraging your hospital's own pharmacies. Discover smarter strategies with RxBenefits.Learn More here - https://rxbene.fit/3ZaurZNStreamline HR Compliance with oneBADGEhealthcareSimplify screening, credentialing, and compliance for healthcare HR. oneBADGEhealthcare from ISB Global offers a tailored solution to keep your workforce compliant and efficient. Built for healthcare leaders, it's your all-in-one compliance tool.Get Started here - https://isbglobalservices.com/onebadgeunitedstates/ashhra/ Support the show

Send us a textWhat does leadership look like when control disappears? We sit down with Jeff Moss—Bronze Star Army aviator, bestselling author of My Leading Edge, Pfizer veteran, and Inc. 5000 franchise owner—to trace a life built on moral courage, mentorship, and service that lasts. From piloting AH-1 Cobras in Desert Storm to refusing to field unsafe aircraft under pressure, Jeff explains how clear standards and documented truth protect people and missions. Then we pivot from the flight line to the family room: his daughter Mallory's intractable epilepsy, two brain surgeries, and the night a hospital chaplain asked the question that reframed Jeff's faith. If you've ever wondered how to carry purpose through a season that feels like autorotation, this story will meet you where you are.We also get practical about the civilian runway—19 years inside big pharma, what most people miss about drug access, and why pharmacy benefit managers (PBMs) complicate care with needless switches. Jeff opens the books on small business realities: lawfare, soaring insurance premiums, and the discipline it takes to build a values‑driven moving and junk removal company that still invests in people. Along the way, we talk tech and trust (autopilot doesn't replace a pilot, it demands one), media skepticism, and what it means to judge less by first impressions and more by character.Threading through it all is a simple flight plan: pre‑flight your life with mentors and values, commit on takeoff, build systems for normal flight, stay calm in autorotation, and debrief for legacy. If you care about leadership, faith, veteran transition, small business, healthcare access, or just becoming the kind of person others can trust when the air gets thin, this conversation belongs in your queue. Subscribe, share with a friend who needs a lift, and leave a review to help others find the show. What part of Jeff's story challenged you most?

In the 2025 Payer Oncology Trend Report, we analyze how health plans and PBMs are navigating the shifting landscape of branded cancer drug management. To deepen our findings, we spoke with industry experts Michael Kolodziej, MD, and Ira Klein, Vice President, Medical Affairs & Payer Relations at Tempus, who shared their perspectives on the data, key trends, and what these insights mean for manufacturers moving forward.

After I posted the final part of my 3-part series on GLP-1s and kidney function, I got a question from reader Liza:“I appreciate how you always talk about how the authors get money from the drug company, I think it's important to know. As I read this newsletter [GLP-1 and Kidney Function Part 3] I was wondering if it is possible to calculate how much the drug company themself would make?”This is an interesting question. I think it's tough to figure out because (at least here in the US) discount cards and insurance companies and PBMs and discount pharmacies et al. mean that people (even people in the same family!) can pay vastly different amounts for the same drugs.I do think it's possible to at least come up with an estimate of the highest possible amount of gross profit. Get full access to Weight and Healthcare at weightandhealthcare.substack.com/subscribe

Brigham Buhler is a healthcare entrepreneur transforming America's broken system. As founder of Ways2Well, owner of Revive Rx Pharmacy, and an investor in psychedelic research, he champions a model of care that prioritizes patients over profits through preventative medicine, transparency, and innovation. His work is guided by a few core convictions: -Former insider's perspective: With deep experience navigating the corrupt systems of pharmacy benefit managers (PBMs), insurance companies, and the FDA, Brigham knows firsthand how the system is stacked against patients. -Uncompromising advocate: He pushes to expose and dismantle the corporate capture of American healthcare. -Bold truth-teller: He believes in revealing the realities of the insurance Ponzi scheme and providing practical ways to bypass outdated systems. -Relentless reformer: He is dedicated to replacing a model that profits off sickness with one centered on health, longevity, and patient empowerment.   Today's Sponsors: Black Rifle Coffee: https://www.blackriflecoffee.com LMNT: https://www.drinklmnt.com/clearedhot        

On this episode of Alloutcoach, host Tim Mikhelashvili, CEO, Amedea Pharma convenes a panel you rarely hear in one room: a policy-minded biohacker and investor (John Hemming, CEO of Cirrostratus, Biohacking Team Leader), a strategy and operations leader who reshapes patient journeys (Bart Zoni, Senior Vice President, Marketing, Woven Health Collective), and an early-stage investor focused on medical technologies (Chris Piedmonte, Managing Director, Neoterra Capital) as well as a senior pharma thought leader in Medical Affairs and Health Economics, Janelle Hardisty. Their catalyst? Fresh takeaways from the 2025 Financial Times US Pharma summit — and an honest look at what's truly accelerating innovation, what's stalling it, and where capital and talent should go next.00:00:00 Cold Open - Episode Highlights: AI accuracy and access00:03:43 Host Intro and Why This Episode00:04:41 Guest Intros00:08:06 State of Innovation - Tailwinds and Headwinds00:12:41 What's Really Accelerating Innovation?00:19:27 Drug Discovery - Reducing the 90% Failure Rate00:22:01 Clinical Trials - Modernize or Stall00:25:11 Access, PBMs, and Direct-to-Patient00:27:03 Longevity and Prevention - Can We Measure It?00:36:52 Data Culture Maturity and Pilot Fatigue00:45:52 Training the Future Workforce00:51:09 Investing - Where Should Capital Flow?00:57:08 Regulatory Reality and Time-to-Access00:59:27 Closing and Invite to Medical Innovation Olympics

GLP-1 therapies are transforming pharmacy benefits, and Express Scripts is leading the way. Harold Carter, PharmD, SVP of Trade Relations, joins host Eric Glazer to discuss how one of the nation's largest PBMs is navigating this disruptive moment in healthcare. Harold shares how Express Scripts is: Capping costs of GLP-1 therapies to expand patient access while keeping plan spending predictable. Redesigning funding models to strike a balance between affordability, predictability, and outcomes. Leveraging digital tools and AI to reduce friction in the member experience and support long-term adherence. Rethinking formularies not just as cost-control tools but as part of a broader population health and behavioral change ecosystem. You'll also hear his forward-looking perspective on how PBMs will evolve over the next three to five years, and the key questions health plans and employers should be asking today to prepare for the future of pharmacy benefits. About Dr. Harold Carter:   Harold Carter, PharmD, is responsible for leading all interactions and contracting with pharmaceutical manufacturers and oversees strategy and management of Express Scripts' drug formularies, data & insights, client underwriting, and product strategy and development. In his nearly 14 years with the organization, Harold has held numerous leadership roles oriented around critical efforts to lower the cost of prescription drugs and ensuring medication access for Express Scripts clients and members. Harold's previous responsibilities include oversight of the organization's medical pharma contracting and drug procurement teams, as well as leading the strategy, development and execution of Express Scripts' wholesale market, value-based solutions and generic strategy, and development of Express Scripts' advanced utilization management solutions.  In addition to his work at Express Scripts, Harold serves on numerous boards including LifeWise Stl Board of Directors, St. Louis University High School Board of Trustees and IVI Board of Directors. Harold earned his doctorate in pharmacy from St. Louis College of Pharmacy.   Partner with Bright Spots Ventures: If you are interested in speaking with the Bright Spots Ventures team to brainstorm how we can help you grow your business via content and relationships, email hkrish@brightspotsventures.com  About Bright Spots Ventures: Bright Spots Ventures is a healthcare strategy and engagement company that creates content, communities, and connections to accelerate innovation. We help healthcare leaders discover what's working, and how to scale it. By bringing together health plan, hospital, and solution leaders, we facilitate the exchange of ideas that lead to measurable impact. Through our podcast, executive councils, private events, and go-to-market strategy work, we surface and amplify the “bright spots” in healthcare, proven innovations others can learn from and replicate. At our core, we exist to create trusted relationships that make real progress possible. Visit our website at www.brightspotsinhealthcare.com.

#IndependentNews #Healthcare #MilitarySEGMENT 1:Feeling anxious and broke? We've got the research-backed habit that lowers anxiety in 7 days (pick ONE and see results).SEGMENT 2: Current eventsWe cut through the BS: the shutdown ISN'T about "illegals getting free healthcare"—that's clickbait. The real fight? ACA subsidies vs. tax cuts while hospital cartels and PBMs bleed you dry. We break down what's actually happening with healthcare costs and why lobbying, not immigrants, is bankrupting families.PLUS: Hegseth's fat generals and the Comey indictment that probably goes nowhere.We're done with team politics. Time to focus on what actually makes America work—new frontiers, real solutions, and getting out of our own way. Drop a comment with which 7-day habit you're trying. Let's go.#OverFiftyStartingOver #O5O #Shutdown #ACASubsidies #Hegseth#Comey #healthcarereform #governmentshutdownSubscribe to O5O on Youtube: https://www.youtube.com/@OverFiftyStartingOver

If you are listening to this prior to October 9, 2025, go to the 32BJ Changing the Playbook on Hospital Prices event, where Mark Cuban will be keynoting. Cora Opsahl will also be speaking, and I will be there listening. For a full transcript of this episode, click here. If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe. So, trust, simplicity, and a chicken. Yeah, this is where this whole conversation with Mark Cuban and Cora Opsahl winds up. And it is a barnstormer because you know what some really good advice is for anybody trying to do right by patients and taxpayers and plan sponsors? It will take trust. It will take making the complicated as simple as possible. And also if you could pay with a chicken, like in the good old days, that would be messy—I can say with confidence, having grown up in Pennsylvania Dutch country, where there are many, many chickens—but also being able to pay with a chicken could also indicate that healthcare prices are reasonably chicken proportionate and that the doctor-patient relationship is good enough to break bread (or have chicken). That last part is really important, and Cora Opsahl says this at one point in the episode that follows. It doesn't matter how wonderful the transparency or the financing. If the prices are insane and there's no more reasonably priced options in any given market, then yeah. Shane Cerone says in an upcoming show, he says, “We do not have a broken healthcare market. We do not have a healthcare market. There is no market.” Okay … so, you could call this conversation a continuation of the episode with Ann Kempski (EP444), entitled “Two State Healthcare Laws Often Don't Go as Planned.” But it's not just healthcare laws that often don't go as planned. It's some very foundational constructs that we have built the healthcare sector upon that may also not go as planned. The healthcare sector is like a game of pachinko. You chuck an input into the mix, and it will bounce all around into all the perverse incentives and human beings and the non-market that we have. And who the heck knows what is gonna pop out the other side? It's like game theory at its most unpredictable. So, in healthcare, there are many, many examples of when the solution to a problem arguably creates worse problems than the problems the solution was trying to solve for. But we—Mark Cuban, Cora Opsahl, and I—are gonna shake our fists at two such solutions today: high deductible health plans (or just high deductibles in general) and then self-insured employers trying to solve the complexity of the healthcare industry by hiring consultants and middlemen, middle people, and other vendors to navigate the pachinko parlor (that is, our $4.9 trillion healthcare sector) on their behalf. Now, I am not in any way saying the spirit of these two endeavors—high deductibles and hiring consultants and middlemen—weren't wholehearted. They seem just like many other well-intentioned solutions: very logical on their face. What I am saying is there are many ways in the real world for even the most, again, genuine endeavor to turn into a money grab for those so inclined. While at the same time I'm saying all this, I'm also very much saying that there are some amazing consultants and middle folks such as independent third-party administrators, otherwise known as TPAs, and PBMs (pharmacy benefit managers) who are transparent and hold themselves accountable to the fiduciary responsibilities that their clients are held to in real terms—not just in marketing speak with 40 pages of disclaimers following. There are great folks out there, many of whom listen to this podcast and are part of our tribe on the regular. And to you, I say thank you for being here, because it takes all the knowledge and more from every one of the guests featured in these past 487 Relentless Health Value episodes plus treating every day like a school day to make sure that we all are not getting shanked from behind by some innocent-looking contract term that turns out to be anything but. The conversation that follows starts out talking about high deductibles; naturally segues into how third-party intermediaries can actually exacerbate the issues here; then we get into transparency, financing, clinical organizations taking on risk, and the benefits and challenges of direct contracts; then Mark lays out a vision for the future. Okay … I wanna get to this conversation. If you are a new listener here—and you might be because … yeah, Mark Cuban—let me just inform you that this podcast is largely listened to by those who work in the healthcare industry. So, you are going to encounter acronyms. You will also encounter me referencing earlier episodes because surveys say listeners really appreciate these callbacks to go get additional information about any given topic. You can get what amounts to a personalized Master's of Healthcare Administration curriculum if you follow the episode threads long enough. And that was a direct quote from a listener. About the acronyms: They are holy terrors, and we in the healthcare industry are chock-full of them. See the list of acronyms that come up so that you can follow along at home if this is your first day at our rodeo. Also in the show notes is a transcript of this show, along with links to all of the mentioned episodes. Okay … here's my conversation with Mark Cuban, who is Mark Cuban and also CEO and founder of Mark Cuban Cost Plus Drugs. Also, we have Cora Opsahl, who is health fund director of the 32BJ Health Fund and an expert in many things healthcare. Also mentioned in this episode are Shane Cerone; Ann Kempski; Mark Cuban Cost Plus Drugs; 32BJ Health Fund; Preston Alexander; Stanley Schwartz, MD; Elizabeth Mitchell; Kimberly Carleson; Andreas Mang; Jonathan Baran; Claire Brockbank; Dave Chase; Cristin Dickerson, MD; Green Imaging; Kevin Lyons; and Vivian Ho, PhD.   You can learn more at markcubancompanies.com and costplusdrugs.com and follow Mark on LinkedIn, Bluesky, Threads, and X. You can follow Cora on LinkedIn.   Mark Cuban, a native of Pittsburgh, PA; a graduate of Indiana University; and now a Dallas, TX, resident, has always been an entrepreneur. From selling and trading baseball cards, selling garbage bags and magazines door-to-door, to starting a business buying and selling stamps at age 16, there have been few years in his life when he wasn't starting or running a business. He got a job at one of Dallas's first retail software stores, Your Business Software. He spent nine months doing everything from learning how to code, supporting and installing every type of business software, and of course, making sure the store opened on time. That went well until he made the executive decision to turn over the store opening duties to a peer so he could pick up a check for a sale. He was fired. Mark decided it was time to start on his own. The next day, MicroSolutions was founded. Over the next seven years, MicroSolutions became a national leader in Systems Integration and custom applications for local and wide area networks. Growing to 80 employees, never having a losing month of operations and nearly $36M in annualized sales, in 1990, MicroSolutions was sold to CompuServe. At that point Mark “retired” to investing in public and private companies. His knowledge of the networking industry led to success and brought returns of 80% and more each year. Mark purchased the Dallas Mavericks for $285M. The Mavs would have the second-best record in the NBA during his ownership tenure. Mark sold majority control of the Mavs in 2023 but continues to be actively involved with the team. He first appeared as a “Shark” on ABC's Emmy Award–winning hit business show Shark Tank in 2011 and quickly established himself as one of the most popular and tough Sharks, investing millions of dollars in hundreds of small businesses. He's been nominated nine times for an Emmy for Shark Tank. His last appearance on the program was during season 16 in May 2025. In 2019, Mark co-founded costplusdrugs.com. Its launch on January 19, 2022, with transparent pricing and a limited markup, has fundamentally changed the pricing of medications in the United States. Cora Opsahl is the director of the 32BJ Health Fund, a self-insured Taft-Hartley benefit fund that sets comprehensive design parameters to ensure the 200,000 members and families of SEIU 32BJ have easy and sustained access to affordable, high-quality healthcare. Cora has prioritized a data-driven approach, focusing on reducing trend, solving the affordability challenge on behalf of union members, and, most important, keeping members at the center of every decision. Under her leadership, the 32BJ Health Fund has saved more than $35 million annually—which it has reinvested in new and better benefits, including the first fertility benefit for members—by removing NewYork-Presbyterian hospitals and physicians from its network, transitioning to a new pharmacy vendor and pharmacy group purchasing coalition, and establishing an expanded Centers of Excellence program. In 2024, Cora conducted an innovative medical request for proposal, stipulating that all finalists have a signature-ready contract drafted by the 32BJ Health Fund prior to award. As a result, the Fund negotiated an agreement that brought unprecedented visibility and increased accountability to its benefit. In 2025, the Health Fund is focused on direct-contracting opportunities that allow it to carve out key benefits and ensure quality while managing spend. Cora is regarded as an expert in pharmacy benefit management and was recently appointed to the Board of Governors for the National Alliance for Healthcare Purchaser Coalitions and the Purchaser Advisory Council for the National Quality Forum and Joint Commission. She previously worked at Express Scripts, where she held a variety of roles, ranging from Medicare Part D to operations, strategy, and acquisitions. Cora earned an MBA from Saint Louis University.   06:25 What was the original rationale behind high deductibles? 07:38 How high deductibles are creating a class of functionally uninsured people. 09:29 EP482 with Preston Alexander. 10:20 “We're using health insurance as a proxy for healthcare.” —Mark 12:30 How providers are now in the debt collecting business rather than the healthcare business. 12:55 EP486 with Stan Schwartz, MD. 15:16 “We have a fundamental reasonability problem.” —Cora 16:07 EP425 with Marshall Allen. 18:25 Direct contracting versus self-funded employers. 19:27 EP436 with Elizabeth Mitchell. 19:30 EP480 with Kimberly Carleson. 19:33 EP372 with Cora Opsahl. 23:53 Why the current system doesn't allow the accountability that is needed. 24:39 EP452 with Cora Opsahl. 26:34 How direct contracting gives strength back to independent practices that high deductible plans take away. 27:46 Who pays, what's the price, and where does the power lie? 31:24 EP419 with Andreas Mang. 34:45 How it comes down to power and leverage when controlling healthcare costs. 38:13 EP483 (Part 1 and Part 2) with Jonathan Baran. 38:35 Why putting together a network and just buying healthcare—not discounts—is not as difficult as it seems. 40:10 Why we need to stop talking about disruption and start talking about change. 40:56 EP453 with Claire Brockbank. 41:02 EP484 with Dave Chase. 43:07 EP485 with Cristin Dickerson, MD. 44:32 EP487 (Part 1) with Kevin Lyons. 46:34 EP466 with Vivian Ho, PhD. 47:40 Why it's the incentives that are different between American hospitals and hospitals in a single-payer program. 50:25 The main takeaways from the conversation. 51:08 Why you can't fix the problems in healthcare without transparency.   You can learn more at markcubancompanies.com and costplusdrugs.com and follow Mark on LinkedIn, Bluesky, Threads, and X. You can follow Cora on LinkedIn.   @mcuban of @costplusdrugs and Cora Opsahl discuss trust and simplicity in #healthcare on our #healthcarepodcast. #podcast #financialhealth #patientoutcomes #primarycare #digitalhealth #healthcareleadership #healthcaretransformation #healthcareinnovation   Recent past interviews: Click a guest's name for their latest RHV episode! Kevin Lyons (Part 2), Kevin Lyons (Part 1), Dr Stan Schwartz (EP486), Dr Cristin Dickerson, Elizabeth Mitchell (Take Two: EP436), Dave Chase, Jonathan Baran (Part 2), Jonathan Baran (Part 1), Jonathan Baran (Bonus Episode), Dr Stan Schwartz (Summer Shorts), Preston Alexander

One of the biggest drivers of high drug prices in America is the opaque rebate system between pharmaceutical companies and insurance providers, where savings rarely reach the patient. In this episode, Vinay Patel explains how drug prices are formed, from R&D and manufacturing to complex negotiations involving insurers and pharmacy benefit managers. He breaks down the mechanics of rebates, formulary restrictions, and the consolidation of power among PBMs, showing how these hidden forces raise prices and limit access. He also offers promising alternatives like cost-plus pricing models and calls on employers to take control of their health care contracts to cut costs. Tune in and learn how this broken system works, and what it might take to fix it! Learn more about your ad choices. Visit megaphone.fm/adchoices

In this episode of the Astonishing Healthcare podcast, host Justin Venneri is joined by Josh Golden, SVP of Strategy, and RFP Content Manager, Nic Bolitho, for a timely discussion about trends they're seeing in the market and how to run a better request for proposal (RFP) process to select a pharmacy benefit management (PBM) partner. Long story short, the "old way" of running a PBM RFP is broken, but, as Josh describes, there are some "tectonic shifts" happening as plan sponsors demand to see more options (i.e., transparent PBMs) and benefits brokers and consultants upgrade the questions and scoring used to force accountability and drive meaningful results for plans and plan members.HighlightsUnit-cost-based spreadsheet comparisons and marketing fluff are "out;" evaluating drug mix and how the PBM manages the plan (the 'M' in PBM) or makes money off of the plan are "in."Plan sponsors and benefits consultants must demand flexibility - the PBM contract should not be a "house of cards." For example, agreements should provide the freedom to add new vendors or carve out services without collapsing your financial arrangement.Legacy tech platforms are a barrier to innovation; ask potential partners if their technology can handle customizations and integrations with agility to avoid being told, "We just can't do that."Precise questions about member experience are a must; RFPs should move beyond open-ended questions that invite marketing fluff. Use specific, binary questions to obtain an accurate measure of the member experience and the effectiveness of clinical programs (e.g., NPS, turnaround times for prior authorizations, etc.).Related ContentReplay: PBM Procurement Decoded: Insights from a Pharmacist and an Actuary Why Savings Don't Materialize: The Truth About Pharmacy Benefit Procurement eBook AH034 - Customer Care in Healthcare: Setting a Higher Bar, with Will TafoyaAH035 - Pharmacy Benefits 101: Clinical Programs, with Bonnie Hui-Callahan, PharmD5 ways to improve PBM procurement (EBN) For more information about Capital Rx and this episode, please visit Judi Health - Insights.

Disease-modifying therapies are the cornerstone of MS treatment, but they're not the only piece of the puzzle. Beyond prescription medications, self-care that includes making healthy lifestyle choices can significantly improve your quality of life with MS.  Julie Polisena knows this firsthand. Julie lives with MS, and in a recent blog post, she shared a comprehensive list of the lifestyle changes that have improved her quality of life with MS. Julie joins us today to discuss some of the most impactful changes you can make to start your own journey toward better health and wellness.   We're also diving into the science behind some of the most talked-about diets for MS. We're breaking down the research on the Mediterranean diet, the Keto diet, the Wahls Diet, the Swank Diet, a gluten-free diet, and intermittent fasting, giving you an overview of the studies that have measured their impact on MS. We're discussing the latest developments in the ongoing scrutiny of pharmacy benefit managers (PBMs). There's significant pending legal action and a congressional investigation targeting PBMs, the powerful and secretive middlemen in the prescription drug supply chain. And we'll tell you how they've profited at the expense of millions of people with chronic illnesses, including people living with MS. We'll tell you about a clinical trial that's testing an injectable formulation of Briumvi. You'll hear about a promising new strategy for myelin repair. And we'll remind you about a warning from the FDA and Health Canada about glatiramer acetate (Copaxone). We have a lot to talk about! Are you ready for RealTalk MS??! This Week: A DIY approach to improving your MS journey  :22 A roundup of studies that focused on popular diets for people with MS  1:53 Congress and the FTC have pharmacy benefit managers in their sites  7:32 TG Therapeutics is testing an injectable form of Briumvi   9:32 A research team has developed a novel remyelination strategy  11:03 A warning about glatiramer acetate has been issued  14:08 Julie Polisena discusses lifestyle changes that can make a difference in your quality of life  16:58 Share this episode  33:24 Next week's episode   33:43 SHARE THIS EPISODE OF REALTALK MS Just copy this link & paste it into your text or email: https://realtalkms.com/420 ADD YOUR VOICE TO THE CONVERSATION I've always thought about the RealTalk MS podcast as a conversation. And this is your opportunity to join the conversation by sharing your feedback, questions, and suggestions for topics that we can discuss in future podcast episodes. Please shoot me an email or call the RealTalk MS Listener Hotline and share your thoughts! Email: jon@realtalkms.com Phone: (310) 526-2283 And don't forget to join us in the RealTalk MS Facebook group! LINKS If your podcast app doesn't allow you to click on these links, you'll find them in the show notes in the RealTalk MS app or at www.RealTalkMS.com PARTICIPATE: Take the Shaping Tomorrow Together Survey https://s.alchemer.com/s3/Perspectives-on-MS REGISTER: Attend the virtual Shaping Tomorrow Together meeting with the FDA https://nmss.quorum.us/event/25463 SIGN UP: Become an MS Activist https://nationalmssociety.org/advocacy READ: Small Changes, Big Impact: Managing My MS Through Lifestyle Changes https://mscanada.ca/find-support/blog/small-changes-big-impact-managing-my-ms-through-lifestyle-change STUDY: The Role of Nutrition and Physical Activity in Modulating Disease Progression and Quality of Life in Multiple Sclerosis https://mdpi.com/2072-6643/17/16/2713 STUDY: Transient Gene Melting Governs the Timing of Oligodendrocyte Maturation https://sciencedirect.com/science/article/abs/pii/S009286742500861X REVIEW: Copaxone, Glatopa (Glatiramer Acetate) FDA Drug Safety Communication https://www.fda.gov/safety/medical-product-safety-information/copaxone-glatopa-glatiramer-acetate-drug-safety-communication-fda-adds-boxed-warning-about-rare JOIN: The RealTalk MS Facebook Group https://facebook.com/groups/realtalkms DOWNLOAD: The RealTalk MS App for iOS Devices https://itunes.apple.com/us/app/realtalk-ms/id1436917200 DOWNLOAD: The RealTalk MS App for Android Deviceshttps://play.google.com/store/apps/details?id=tv.wizzard.android.realtalk REVIEW: Give RealTalk MS a rating and review http://www.realtalkms.com/review Follow RealTalk MS on Twitter, @RealTalkMS_jon, and subscribe to our newsletter at our website, RealTalkMS.com. RealTalk MS Episode 420 Guest: Julie Polisena Privacy Policy

Join our co-hosts Todd Eury and Greg Reybold in this exclusive interview with Conor Sheehey, who most recently served as senior health policy advisor to U.S. Senate Finance Committee Chair Mike Crapo (R-ID). In this role, he advised the Committee on a range of health care policy issues, including prescription drug pricing, telehealth, AI, provider coverage and reimbursement, fraud and abuse, medical devices, and Medicare Parts B and D. Sheehey led several bipartisan legislative efforts, including the development of comprehensive PBM reforms and bipartisan proposals on clinician payment reform and drug shortages.

Drug pricing in America is a shell game where patients always lose. Healthcare Bridge host Nathan Kaufman and his guest Richard Helppie pull back the curtain on why Americans pay drastically more for the same medications than patients anywhere else in the world.At the heart of this problem lies a fragmented system where the United States—effectively operating the world's largest health insurance company—somehow lacks the ability to negotiate bulk purchasing deals. While pharmaceutical companies claim high prices fund critical research, the conversation reveals how your money primarily finances the endless parade of drug advertisements dominating television commercial breaks.The journey of a pill from factory to patient passes through multiple profit-extracting entities: manufacturers, wholesalers, and pharmacy benefit managers (PBMs). With three PBMs controlling 80% of drug distribution—all owned by insurance companies—conflicts of interest are baked into the system. Through revealing personal anecdotes, the hosts demonstrate how the same medication can cost $5 with one insurer, $330 with another, yet only $20 through Mark Cuban's pharmacy. Many Americans find it cheaper to purchase medications from Canadian pharmacies despite industry warnings about "dangerous" reimported drugs—even when those medications come from identical manufacturing facilities.Recent policy proposals offer potential paths forward. The Biden administration's efforts to cap Medicare drug expenses met immediate legal challenges from pharmaceutical companies, while Trump's "most favored nation" pricing concept aims to standardize global medication costs. Medicare Part D represents a partial success story by forcing drug companies to negotiate with insurers, maintaining 95% subscriber satisfaction while running 40% below projected costs.Healthcare policy requires informed leadership, but few politicians truly understand the system's complexities. If you or someone you love needs medical care, finding an insider who understands healthcare's nuances isn't just helpful—it could save your life. Subscribe to the Healthcare Bridge for more conversations that bridge gaps in our healthcare system and work toward solutions that benefit patients first.Support the showEngage the conversation on Substack at The Common Bridge!

Right up front here, let me just state loudly that there are some amazing independent TPAs (third-party administrators) out there who have the expertise, the scrappy willfulness, and the deep desire to do right by their clients, their self-insured employer clients. For a full transcript of this episode, click here. If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe. And look, they may be facing some of the same headwinds that plan sponsors themselves face, like anticompetitive contracts, brokers who are up to no good, etc. So, just keep that in mind as you listen. And the main point of all of this if you are a plan sponsor is, find a good TPA partner, which, as Bryce Platt has said about consultants but same rules apply about TPAs here, the difficulty is being informed enough to tell the difference. So, the goal of this show is to help with that, the “be informed enough to tell the difference.” All of this being said, this is technically a Take Two; but we trimmed it down and welcome to a whole new intro. So, call this a refresher and an update about a really, really important topic from last year that is becoming extremely (maybe even more) relevant this year. Really relevant. Consider, for example, the show with Claire Brockbank (EP453) about carrier/TPA RFPs (requests for proposal) and all of the landmines that are really expensive, that are buried in some of these contracts. Then there was the Cynthia Fisher show (EP457) from last year about the millions, maybe billions of dollars in aggregate going missing in medical (ie, TPA or ASO [administrative services only]) spread pricing. We had “The Mystery of the Weekly Claims Wire” show with Justin Leader (EP433), again, revealing money that's being disappeared when the TPA is withdrawing dollars from plan sponsor checking accounts. And then there's the payment integrity episode with Kimberly Carleson (EP480) from a few weeks ago with just another wrinkle on this, namely TPAs or ASOs who insist on auditing themselves and how that turns out for members and plan sponsors. Oh, and last, but certainly not least, is the whistleblower show with Ann Lewandowski (EP476) on how a TPA arm of an EBC (employee benefit consultant) allegedly pocketed $20 million—$20 million of their client's pharma rebates—and used that $20 million to fund their executive bonus pool. What a time to be alive! All of this just highlights the huge stakes for plan sponsors to really understand what their TPA is all about. And when I say high stakes, I mean from both a legal standpoint and also just vast dollars in play here. But this episode with Elizabeth Mitchell is also, I'm gonna say, extremely relevant given just a few ripped from the headlines and news articles such as these. I'm gonna start actually with a post from Kimberly Carleson, and I like the comment by Jeff Evans, who wrote, “How does $8,710 equal $104,266?” Spoiler alert, it doesn't. Lots of missing dollars there. Someone's hands are in the cookie jar. Oh, look, the TPA has entered the chat. In a nutshell, and I'm quoting something Peter Hayes wrote, he wrote, “TPAs have received relatively little public attention. [There's an article in Health Affairs] that describes how TPAs impose hidden fees, benefit from their own form of spread pricing, and otherwise prioritize their own financial interests over those of their plan clients.” Also, here's a totally other issue. Let me quote Luke Prettol highlighting something Jason Shafrin had written about a paper by Jeff Marr, Daniel Polsky, and Mark Meiselbach. Let me slightly rephrase what Luke said. He wrote, “Employers pay, on average, a 4.7% [so almost 5%] price markup when hospitals are in their TPA's [Medicare Advantage] network.” Right? Dr. Eric Bricker talked about this in that episode (EP472) just how TPAs with MA (Medicare Advantage) business negotiate their commercial clients to pay higher rates so that then they can pay lower rates for their own MA members. As Luke wrote, “On its face, this overpayment does not appear to be solely in the interest of participants.” No kidding. Now, let's spin the wheel here. There are barriers for TPAs themselves, even the ones who have a deep desire to do the right thing. As Patrick Moore wrote, “Most TPAs still can't do [many of the things that employers might want because there are] PPO contracts.” So, is it a rock in a hard place situation? I mean, if the TPA has no other options than using a carrier's PPO (preferred provider organization) network with all its attendant contractual issues, then yeah, that is one definite challenge. Along these lines, let me read a post by Rina Tikia, because I think she sums up this really well. “When independent TPAs … push for transparency, they're blocked under the banner of ‘fiduciary risk.' “Meanwhile, the largest carriers and PBMs, with Cayman shell subsidiaries, DOJ kickback probes, [huge] hedge fund ties, [$10 million-plus] lobbying budgets, and antitrust violations continue unchecked. They are not only allowed to operate but celebrated as mainstream options. “Why the double standard? Political donations? Foundation smokescreens? Nonprofit status as a PR shield?” These are excellent questions. And here's another challenge: brokers. Ramesh Kumar Budhani wrote about this one, just how hard it is sometimes to find—for TPA, an independent TPA, trying to do the right thing—to find brokers who prioritize doing the right thing for employers and helping their clients save money. The summary of all of this: There are TPAs and there are ASOs who aren't even trying. They are going to ride the flywheel, the gravy train, and catch all of the dollars flying off of it for as long as they can manage to cling to it with all 10 of their fingers. Then there are TPAs, mostly indies, trying super hard to do the right thing. But how successful they are is going to depend on how boxed in they are by the PPO networks or the carriers that the brokers or even plan sponsors may insist on. Just how courageous they are and just how smart they are and experienced they are about the market and how it actually operates. So, the show that follows is about all of this, including how we can inspire TPAs, which, in the show that follows, subsumes ASOs kind of into it. But in the show that follows, I hope it's inspiring to create an environment so that the market demands TPAs that do all of the things, and we make inertia not a viable business strategy. Elizabeth Mitchell, my guest today, currently serves as the president and CEO of the Purchaser Business Group on Health. Also mentioned in this episode are Purchaser Business Group on Health; Bryce Platt; Claire Brockbank; Cynthia Fisher; Justin Leader; Kimberly Carleson; Ann Lewandowski; Jeff Evans; Peter Hayes; Luke Prettol; Jason Shafrin; Jeff Marr; Daniel Polsky; Mark Meiselbach; Eric Bricker, MD; Tom Nash; Patrick Moore; Rina Tikia; Ramesh Kumar Budhani; Mark Cuban; Harold Miller; Chris Deacon; Moby Parsons, MD; Benjamin Schwartz, MD, MBA; Mishe Health; Rik Renard; and Cora Opsahl. You can learn more at PBGH and by connecting with Elizabeth on LinkedIn.   Elizabeth Mitchell, president and CEO of the Purchaser Business Group on Health (PBGH), advances its strategic focus areas of advanced primary care, functional markets, and purchasing value. She leads PBGH in mobilizing health care purchasers, elevating the role and impact of primary care, and creating functional healthcare markets to support high-quality affordable care, achieving measurable impacts on outcomes and affordability. At PBGH, Elizabeth leverages her extensive experience in working with healthcare purchasers, providers, policymakers, and payers to improve healthcare quality and cost. She previously served as senior vice president for healthcare and community health transformation at Blue Shield of California, during which time she designed Blue Shield's strategy for transforming practice, payment, and community health. Elizabeth served as the president and CEO of the Network for Regional Healthcare Improvement (NRHI), a network of regional quality improvement and measurement organizations. She also served as CEO of Maine's business coalition on health (the Maine Health Management Coalition), worked within an integrated delivery system (MaineHealth), and was elected to the Maine State Legislature, serving as a State Representative. Elizabeth served as vice chairperson of the U.S. Department of Health and Human Services Physician-Focused Payment Model Technical Advisory Committee, board and executive committee member of the National Quality Forum (NQF), member of the National Academy of Medicine's “Vital Signs” Study Committee on core metrics, and a guiding committee member for the Health Care Payment Learning & Action Network. Elizabeth holds a degree in religion from Reed College and studied social policy at the London School of Economics.   08:06 What is the overarching context for health plans in healthcare purchasing? 11:31 Why is it important to reestablish a connection between the people paying for care and people providing care? 13:47 What are the needs of a self-insured employer when managing employee benefits? 19:00 Is it doable for employers to set their own contracts? 21:24 Is transparency presumed? 22:39 Will the new transparency upon us actually expose wasted expense? 24:23 EP408 with Chris Deacon. 25:58 “This is not about individual bad actors. … The systems … that is not aligned.” 27:39 Are there providers who want to work directly with employers? 30:53 Why is it important that incentives need to be aligned? 32:42 EP427 with Rik Renard. 33:51 What's missing from the conversation on changing health plans?   You can learn more at PBGH and by connecting with Elizabeth on LinkedIn.   @lizzymitch2 of @PBGHealth discusses #TPA and #healthplan vs. #jumboemployer inertia on our #healthcarepodcast. #healthcare #podcast #financialhealth #patientoutcomes #primarycare #digitalhealth #healthcareleadership #healthcaretransformation #healthcareinnovation   Recent past interviews: Click a guest's name for their latest RHV episode! Dave Chase, Jonathan Baran (Part 2), Jonathan Baran (Part 1), Jonathan Baran (Bonus Episode), Dr Stan Schwartz (Summer Shorts), Preston Alexander, Dr Tom X Lee (Take Two: EP445), Dr Tom X Lee (Bonus Episode), Dr Benjamin Schwartz, Dr John Lee (Take Two: EP438), Kimberly Carleson, Ann Lewandowski (Summer Shorts)