 Thank you, David. We're now going to transition to providing with a physician perspective on these issues. And I want to introduce my colleague and the moderator for this session, Dr. Maisha Draves. She's the medical director for Pharmacy in Northern California for the Permanente Medical Group. And she basically in that capacity sort of oversees a good chunk of the whole process from working with the chair of the P&T Committee on formulary and pharmacy policy, working with drug information services on shortages and recalls, and providing oversight on pharmaceutical research and pharmaceutical utilization management, so full spectrum. Dr. Draves, welcome, and I'll let you introduce the panelists. Thank you for having us here today as physicians. You heard from David Mitchell and his perspective as patients. And I think as physicians we share the exact same perspective in many ways. I want to bring up our panelists, then I'll speak for a moment, then our panelists will have a chance for discussion and then Q&A. So I'm honored today to bring, to be here today with Dr. Samir Alsaray and Dr. Eliza Choi. First, Dr. Samir Alsaray is a practicing physician, board certified in internal medicine. He has been with the Permanente Medical Group since 1993. He's an associate executive director in charge of pharmacy, adult and family medicine, and the opioid initiatives. He is also serving as secretary and the chair of the governance committee of the Mid-Atlantic Permanente Medical Group. He has a former volunteer faculty for the Stanford University School of Medicine. And he is a fellow of the American College of Physicians, the largest specialty organization in our country. Please welcome Dr. Samir Alsaray. We're also honored to have Dr. Eliza Choi. She is a practicing physician and board certified in internal medicine and infectious disease. She has clinical interests in health disparities and cultural competent care for Asian Pacific Islander and minority populations. She is on faculty at the Harvard Medical School. She's a fellow also of the American College of Physicians. She is also the governor-elect for the Massachusetts chapter of the ACP. She will be the first woman and the first Asian-American female elected to the position of governor in the history of the Massachusetts ACP chapter. Please welcome Eliza Choi. So before our panelists begin, I've been asked to say a couple of words. So physicians also deal with the issue of high drug prices. Our patients come into our office. They ask for help with their health. We listen as physicians. We listen. We touch. We diagnose. And then we develop a treatment plan. All too often, our patients then turn the conversation to the next question. How will I afford these medications? As physicians, we sit and we grapple with our patients and struggle through this conversation. It's a difficult one. And it often stands in the way of what the both of us are there to do, partnering to take the best care of them. One in four patients have difficulty affording their medications according to the Kaiser Family Foundation health poll in 2015. That's not just a statistic. We live this every day in our clinics. It is reality. When I was 12, we'll talk about asthma as a disease where we should be able to treat it pretty easily. When I was 12, a schoolmate died from asthma. There was a steroid inhaler available to treat her. When I was 16, a neighborhood friend died of asthma from an asthma attack. But there was a treatment available, the steroid inhaler. It's been available since 1976. And 42 years later, it's still out of reach for many of our patients. 30 years later, I sit in the doctor's office with my patients and still have to have the same conversation. How can I afford my steroid inhaler? I watch mothers and fathers and the looks on their faces as they grapple with affording this medication for their children. I watch patients decide to skip using their medication and live on the verge of stability of this disease versus their next asthma attack. So why 42 years later is a basic drug that's the same still out of reach for our patients? Every couple of years, the drug companies repackage it into new devices that don't offer new value and care, but they do maintain high prices. They protect profits over patient care. We also, in 2018, are still faced with generics putting in applications to the FDA who cannot gain approval for their medication. So 42 years later, the same drug is still, oftentimes, hard to afford for our patients. So we're here today to stand with our patients, with leaders, with policymakers, on the issue of addressing high drug prices. So we'll hear today from two outstanding panelists who are mission-driven to take care of their patients and address the issue of high drug prices. First, we'll hear from Dr. Samir Alsare. Thank you. I believe that the drug pricing system in this country is simply broken. I think there's something really wrong when the average price of a specialty drug exceeds the median US household income. I mean, that is just absolutely wrong. These drugs are continuing to rise. And you might think, well, it's these specialty drugs that are expensive. Take a look at the generic drugs. Those costs are going up astronomically. And if you looked between 2013 and 2014, the top 200 generic drugs went up by almost 200%. And these are simple medications, like Maisha mentioned, for people to take care of their asthma, antibiotics for acne, or lung infections, et cetera. So these are things that simply should not be going up. And David and several of the other speakers have talked about what pharma keeps saying. We really spend a lot of our money on research. And you heard that most of the money, 50% of the research money today, comes from places like the National Institutes of Health. Our state governments, for us in California, or the University of California, puts in a lot of money. And so essentially, it is the taxpayers who are paying for the research. And so for doing that, we actually get rewarded. We get higher prices in the United States. And as you can see on the right side of the slide, you see a drug called Humira. And this is a drug that's being used for rheumatoid arthritis. And as you can see, the price for that drug varies almost 500% for us here in the United States. You see that in South Africa, it's $552. And in the United States, and this slide is old, the price is over $3,000 today. And as some of you might have looked in the news, Humira was about to get some competition from a biosimilar that had been developed by Amgen and by a company in Korea. And what did they end up doing? They actually ended up signing a deal with them to keep that biosimilar off the market for another five years so that they can continue to thank the American public for funding their drug and giving them research dollars and charging us more money than the rest of the world. So I think that's simply unconscionable. And David also mentioned that nine out of the 10 drug companies today spend more money on sales and marketing, putting commercials on TV, right? You cannot watch any program without seeing at least five drug commercials, detailing our physicians and spending more money on sales, marketing and reaching out to our patients and doctors instead of really working on research and development. So here's what we're here to talk about today is really our patients. So high drug prices are really affecting the decisions that our patients make today. And I'm reflecting back to one of my patients who had heart failure and she was not actually getting better. And I thought, well, is this drug not working that we're giving her? Finally, when I had a conversation with her, she was not able to afford the copay for a heart failure drug. So it turned out that she was actually taking this medication every other day. And so that's a choice that she was making because she could not afford that drug which is not good quality care for her. And if you think about it, she could have gotten admitted to the hospital. She could have ended up in the emergency room. And this would have not only resulted in bad outcomes for her, but also continues to increase the costs for healthcare to our nation. The other example I heard recently from one of my colleagues in infectious disease, and I know Dr. Troy is an infectious disease colleague, is a couple of their patients who wanted to be able to get on PrEP. And as you know, Kaiser Permanente actually has done the study in Northern California to show that taking PrEP prevents HIV infection. As of today, we don't have a single patient who has converted when they have taken PrEP. Yet our patients have to now decide, can I afford this medication which will prevent me from getting HIV infection, or do I just take that risk? And that's simply because they cannot afford that medication. So like Maisha mentioned today, not only do I have to think about what the patient's diagnosis is and how I'm gonna treat it, I really have to think and decide, is this patient actually going to buy this medication? Once they leave my office or they leave the hospital or the emergency room, I really have to have a conversation and say, are you gonna be able to get this medication? We talk about drug adherence and sometimes we think it's because patients don't wanna take the medicine, but often it turns out they can't simply afford it. So I think this is an issue that not only patients have to deal with, I think physicians are dealing with it every single day, but I think society has to take a look at this as well. As the cost of pharmaceuticals goes up, it takes a bigger and bigger chunk out of our healthcare dollars. If you take a look at what happened to the Cleveland Clinic a couple years ago, they mentioned that their operating margin dropped by almost 70-some percent and they attributed a large chunk of that to the higher cost of pharmaceuticals. And I think if you looked at their financials, they were actually paying more for pharmaceuticals than for the medical care or their doctors or the hospital care. So simply these high costs of pharmaceuticals are simply outstripping the rest of the, what's happening in our healthcare industry. So I think Kaiser Permanente has been part of the campaign for sustainable drug pricing and here's a potential solution for you to think about and it actually has three components. Pharma talks about innovation, but let's talk about transparency, competition and value. So what does that mean? If you go on the website today, I practice at our hospital at Santa Clara in California, you can go on and see all of the statistics for this hospital. What kind of care do we give our patients when they have pneumonia? Do we do the right things for them when they come with a heart attack and we giving them the right kinds of drugs? And I'm happy to say you'll see that happening 98, 100% of the time. So this kind of data is up there today all of the time. Our physicians take care of people with diabetes, hypertension, this is reported to HEDIS and NCQ and again you can go on almost any public website and you can find out what kind of care physicians are giving to patients in a particular area or system. Unfortunately for pharma, we don't see any of that and you've heard from David about the prices that they come up with. Look at the cost for our hepatitis C drugs. If you recall, Gilead said they spent a lot of money on research and development. Actually turns out they bought a company for $9 billion and in the first three quarters of the drug being out, they actually made $11 billion. So so much for research and development. They found a good company to buy. I guess they must have researched that pretty well. So that's what we're talking about when we talk about transparency. We definitely want pharma to make money. They come out with life-saving things as David mentioned is multiple myeloma is treated by drugs like this. The hepatitis C drugs are in the high 90% curable rate. The prep that I talked about is something our patients want but really $1,000 a pill or some of the ridiculous prices they're coming up with are simply not sustainable. The second area I wanna highlight is competition. How many of you have a flat screen TV here? Raise your hands, I see one over here, right? Do you remember a decade ago? How much were they? They were like $10,000 and they came to $5,000 and today you could just go to Best Buy or log on and you can get one for a few hundred dollars. So competition has brought the prices of these televisions down. Okay, take a look at multiple sclerosis. About 10 years ago the first drug for MS came out and it was like six or $7,000. Today we have 15 drugs. Do we think the prices of these drugs went down? They actually went up and they're all $60,000 today. So what pharma does is really shadow price. There really is no true competition. You can look at it for almost every single drug class. Whenever something new comes and there's 10 or 15 new drugs now, you would expect the price of these drugs to go down for our patients, but we absolutely do not see that. And then the final one I wanna touch on is really value. So the drugs that I mentioned for hepatitis C or PrEP or many of these other drugs simply are life-saving and let our patients do better. But pharma often has some really good tricks. Do you remember that purple pill that came out a few years ago for heartburn, right? So originally they came out with something called omenoprazole or Prilosec and that was the drug that they were pushing a lot. And when the patent on Prilosec went out, they actually created a reverse molecule, a mirror image of the same molecule, made it purple. Maybe people like purple pills better and then increase the price. And you see that all the time. Often there are drugs that are taken twice a day and now you get a formulation that's once a day. Now it's patented and now the price is even higher and now my patient can't afford it. So that is not providing good value to our patients. So I think what we wanna really do is bring pharma to the table. I think they are an important player in our healthcare. We wanna find out how they're coming up with these drug prices. When there's definite competition, why aren't the prices going down and then actually having drugs that will create value for my patients. So that ended over to you. Good morning. Good morning everyone. I wanted to start off by thanking the forums, organizers for the invitation to speak. It's really a thrill to be here speaking with fellow colleagues who all feel similarly that we really have to address this blossoming overwhelming problem of high drug prices. My spin will reiterate a bit that has already been addressed by Dr. Graves and Dr. Oswari and hopefully also leave all of you with a sense that we as physicians, particularly for the physicians in the room do have ways to give voice to some of the issues and to advocate on behalf of not just the healthcare providers and physicians, but also our patients. So let me start by just letting you know who I represent and what our organization does. There are a number of different physician organizations, but I'm specifically here on behalf of the American College of Physicians. And as Dr. Graves alluded to, we are currently the largest physician specialty organization, not just in the country at this point, but in the world given our international reach. Importantly, we represent physicians who take care of adult patients, internists and internal medicine sub-specialists. And what I'm really proud to be a member of ACP, particularly about is that we have a very, very strong advocacy component to what we do. We really work on focusing our care in the most compassionate and evidenced based way possible, but we really also focus our efforts, particularly our legislative priorities and our advocacy on how we can make care for patients accessible. And just to reiterate the mission that we are fostering excellence and professionalism and advocacy is right there in black and white in our vision. So before launching into the next series of slides, I think stories are sometimes the most powerful ways to give a sense of what the problem is. And Dr. Graves and Dr. Osari had very powerful stories. I will reiterate some of those. I've had patients who are end stage emphysema patients. Emphysema is a chronic lung disease where as the disease progresses, it becomes increasingly more difficult for patients to breathe without the assistance of medication and a big risk factor is smoking for that, but not only risk factor. I just the other day had an end stage emphysema patient who could not afford his inhaler. And this is somebody who is constantly on the verge of ending up in the hospital because of his end stage emphysema. He and his pulmonologist and I partnered together to take care of him. And he was put on an inhaler that was really one of those combination inhalers with multiple different inhalers in one inhaler. And that has many reasons for that, particularly for patient adherence to be able to actually take all of the inhaler medications without needing to juggle multiple ones. And when he went to the pharmacy was told it was going to cost him $600 for this inhaler. And the interesting thing is it was really not different than having his three inhalers that he was previously prescribed. Now we may be able to overcome that through prior authorization and all sorts of paperwork, but I give you that illustration to emphasize points made by our moderator and my co-panelists in that a lot of the cost has really nothing to do with innovating and advancing the field and advancing new and novel medications and has perhaps everything to do with gaming the system to try to figure out how you can repackage the old into something that can then be sold as something new at an exorbitant cost. In my patient's case, the challenging problem is he's the kind of patient that might just not bother. He's a pretty tough patient to really engage and all it takes is one obstacle like an inhaler that he's been prescribed causing $600 for him to then disengage. I've also had patients as have many of my colleagues who are diabetics and diabetes really needs management chronically and needs treatment chronically, otherwise the end stage complications of that condition can lead to even more severe comorbidities. Insulin is life-saving for many and this is not a new drug and there's new formulations of it but it's fairly old in terms of how long it's been around. There are patients now who are coming to me and to some of my colleagues and saying I have to pay a couple hundred dollars for my insulin and I can't afford it. And the problem there is many patients won't realize that they have a choice to first contact their doctor. So we've also had patients come back and say, well I went to the pharmacy and tried to pick up my insulin it was a couple hundred dollars so what I did was I only started to take it once a day instead of twice a day. And that was to try to stretch out how much time they can use this medication. And then another example is a medication similarly. It's not novel, it's been around for decades. One of my patients has a liver and gallbladder condition that requires a medication called ursodial and he came up to me several months back and told me that when he went to the pharmacy he was told he would need to pay $1,200 for this medication and he was so baffled he didn't know what to do and finally did contact our office and we worked together with his liver specialist to try to figure out how to, through rebates and prior authorizations and so forth get it to a more manageable level. Now the scenarios I gave thus far all have relatively happier outcomes but there are situations where there isn't any choice. There aren't any alternatives, there aren't rebates, prior authorizations and what really I think is compelling about all of us gathering here today is these are potentially our stories as well. As physicians we are also patients so this particularly for us hits home I think when we face it one on one in the office visit. I'll share with you one last vignette and then move on to more formal topics that I address in my slides. Many of you may have been aware of the notoriety surrounding Martin Shkreli, so called pharma bad boy. He had some unfortunate turn of events in his life but more importantly he was the head of the pharmaceutical company that acquired a medication called Daraprim or Pyramethamine and this is one of the most egregious examples that I've read in recent memory. This is a medication that he himself acknowledges costs very little to make, perhaps barely $1 to actually produce this medication per pill and on the market it cost $13 but when he acquired it and his pharmaceutical company acquired it about two and a half years ago they in very quick order jacked up the price so that it was $750 per pill. That is about a 5,000% increase and he himself also acknowledged that there was really no justification for that, perhaps a justification that well we'll take some of that profit and turn it into research and development for a newer version or a different drug. We still are waiting for that and that's since 2015 perhaps even less likely to happen now given his unfortunate turn of events in his life. Might be hard to do R&D in jail but in any event he's also been very blunt about saying part of that jack up in price was due to he really wanted to make profits. So that's where we really need the transparency, the competition that Dr. Ansari alluded to and we really need to all come to the table and understand that this is not about stemming innovation. We need new innovation, we need new drugs but we really also need to do right by our patients. So what can we do about it? Part of what we do in ACP, we really are physicians who advocate for patients and ACP nationally has identified high drug prices, escalating drug prices as one of our top priorities. We have an annual Capitol Hill Day, an advocacy day where we all gather all of the different chapters across the country and spend two days on the hill learning about priority issues and then going and advocating on behalf of our health priorities to legislators and virtually every single year high drug prices comes to the top of the list as one of the issues we advocate on behalf of. And in fact, the Annals of Internal Medicine which is our companion journal published a position paper in July 2016 stemming the escalating cost of prescription drugs position paper of the ACP. I've given you the reference and you're welcome to reach out to me afterwards if you want the copy of it. It's a wonderfully written comprehensive evaluation of the current issue and I urge you to take a look at it, I think it addresses this issue in a very thoughtful way and addresses many of the topics that have already been raised by former previous speakers and will likely be touched on later in the day, issues of how drug companies can product top evergreen, do me too drugs and all of that and how that is really affecting the escalating cost of drug prices. And let me share with you several bills that national ACP currently is advocating on behalf of that touch upon in various capacities the issue of drug prices, high drug prices. David Mitchell spoke a bit about creates, give you a little summary here and I'm not gonna read the entire slide but primarily I wanna emphasize that this is really trying to address some of the abuses that pharmaceutical companies can utilize to try to inhibit the ability of generic versions of their medications to go to the FDA for approval. Right now as Mr. Mitchell had alluded to there's a fair bit of support, albeit not much legislative movement at this time and I'm fairly certain that this will be something that ACP will continue to tackle on a national level. National ACP also supports this particular bill with the Fair Pricing Act and somewhat frustratingly as you can see at the very bottom current action is none. This is a bill that is really asking for pharmaceutical companies to disclose any planned drug price increases including R&D costs and will really help with the transparency aspect that we've discussed but hard to say if we're gonna get much more traction on this particularly in the current government atmosphere. Another bill that we also support is the Medicare Party Negotiation Act and similarly this has not particularly moved anywhere and we're hoping that we can join forces with other organizations perhaps to really get some forward traction on this. This is authorizing CMMS to negotiate directly with pharma regarding prices that are covered under the Medicare prescription drug benefit and then the last bill I wanna share with you if that national ACP supports is the Drug Price Transparency and Communications Act. It's a Senate bill currently and it requires disclosure of the wholesale acquisition cost in the direct to consumer advertising. So shifting gears in my final series of comments I'm gonna talk about really the importance that I find has been so compelling about my involvement so deeply in ACP. We really can do things nationally as I've outlined but importantly at the chapter level, state level and for many of us that feels even more empowering because federal government has many parts to it and sometimes it's hard to feel like you can gain some traction but often at the state level you really can see some movement and we as a chapter, a Massachusetts chapter have identified drug price escalating drug prices as one of our top priorities within our chapters Health and Public Policy Committee. Here's a pictorial representation of the issue where it stands in our state. Total prescription drug pricing over $8 billion. 300% rise of pharmacy costs and is really larger than the second largest expense which is actually outpatient services and a 20% increase, a 20% of generic drugs that have undergone price increases over 100%. So the scope is quite broad in terms of the problem. And I'll share with you one bill that we've particularly championed and then give some acknowledgments and maybe some words of empowerment. We are currently as a chapter supporting a state senate bill that is sponsored by one of our state senators and act to promote transparency and prevent drug price gouging of pharmaceutical drug prices. And I'll share with you just a summary of it. It's really a very hard hitting drug price transparency bill and it really involves engaging pharmaceutical drug manufacturers to disclose all of their costs whether it be R&D or manufacturing costs or advertising and marketing costs. And also monitors the rise of their drugs so that if it exceeds a certain threshold it will trigger some regulatory action. And perhaps because it's so hard hitting it has stalled out, albeit some portions of this bill is now making its way into a larger omnibus healthcare cost containment bill that is likely to get through both houses of our state legislature. For many of us that's still not satisfactory enough because the real elements of drug price transparency has perhaps due to some strong lobbying by drug manufacturers has really been watered down a fair bit. In any case, we are still actively pursuing that particular Massachusetts state senate bill 652 and we are not giving up. And so as we all gather today think about this enormous problem. I want to leave you with a sense that we each can do something. I am not particularly someone that would have expected myself to be sitting here today at a health policy forum talking to all of you, many of whom are experts in this field about drug price transparency and health policy. Never having taken a political science class and never having done a health policy class ever this is a very surreal position to be in. But I guess I put myself out there as a perfect example of how you follow the issues and find ways to make sure that your voice can actually come to the table. And what I'll share is for those particularly physicians in the room, our voices are critical whenever I've gone and I've gone now for the past six or seven years to Capitol Hill on behalf of National ACP and also for the past three years to our state legislators when we go there and speak to our elected officials and policymakers as physicians share our stories about our patients, even our own personal stories as patients, it really leaves a mark and that cuts through all of the statistics and all of the policy papers that is incredibly powerful. So I actually find despite the complexity of this issue this is a really empowering opportunity for all of us and our voices particularly as physicians who advocate for patients is so critical to this. We're not paid lobbyists, we're not here to promote anything other than optimal patient care. So with that I want to acknowledge some crucial people who helped with this particular presentation. I wanna acknowledge Hilary Daniel who has far more knowledge than I do in all of these matters but has been instrumental in helping me think through these issues. She's a senior analyst in health policy and health policy and regulatory affairs in the DC office of ACP and for some of the state-based information that I shared with you, we have as a chapter worked very closely with General Counsel Audra Riding in our senator's office and then I will share my contact information here and finally leave you with this picture. I'm really in full advocacy mode. Our state chapter went to the state house on Wednesday and advocated on behalf of numerous issues and this is a picture from all of us after our triumphant advocacy meetings. So thank you so much and look forward to speaking with any of you who have questions and learning from all of you for the rest of the day. Right. So thank you Dr. Alsari and Dr. Choi. I'd like to open up to the audience for questions as you make your way to the microphone. I'll open with a first question. Besides the opportunity through the ACP as physicians to advocate on behalf of our patients and to address the issue of high drug prices, perhaps Dr. Alsari, you can also comment. What are other ways physicians can be involved in addressing the high drug prices? You know, I think we can engage our patients directly. I mean, often, and I bet you most of the physicians in this room get this, right? People come with their little print out from Google or the advertisement that they've seen on TV and that, you know, often you could just cave in and write for whatever it is that they're advertising but actually having a conversation with our patients to say, well, what is it that we're trying to take care of? What are you actually bringing? What are the options? And if this was me or my family member, this is the kind of medicine that I would give them and really educating our patients to work with us is definitely one of the approaches that we can take. I think even without the umbrella of a supporting organization, we really ought to reach out to our elected officials and that's where I would emphasize perhaps the local. Sometimes government starts locally, change starts locally. What was very empowering for us when our chapter advocacy day just a couple days ago, these were people that we put in office and 2018 is an election year for us. So it's really powerful to reach out, get to know the elected official and really make sure that they're aware that we feel this is a priority. And then I would say other ways to get involved. There have been a number of different organizations from our keynote speaker, Mr. Mitchell, as well as some of the people who've come up to the microphone for questions. Sounds like there are some really wonderful organizations here that will help be an opportunity for us to get our voices heard about these issues. Thank you. We have a question in the microphone. Please introduce yourself. Sure, hi. Hi, I'm Steve Pearson with ICER which is in Massachusetts. So we'll talk more later. I just have to say, even though I don't practice right now as a clinician, I'm just so impressed, thrilled and grateful for the power of your voices as clinicians to be involved in this. I think you recognize the power of witnessing what happens for patients and how clinicians can really represent that voice in an advocacy way. So I just can't tell you how powerful that is and how much I and I'm sure many others appreciate your leadership. One of the things that as clinicians, I was gonna ask you how you think of the clinician response to some of the potential solutions that have been discussed. One of the trickier ones is if the problem here is the individual patient who can't afford the drug, why don't we pass legislation that caps all out-of-pocket payments for prescription drugs at $10 a month or $20 a month? There's been some talk that that's the, as you will, you could take the energy around drug pricing concerns and its impact on individual patients and you could channel that into capping out-of-pocket payments without doing too much else to the system. Now lots of people in this room would have the obvious, what's the next shoe to drop when that would happen. But as clinicians, how do you respond to the natural instinct to want to protect the individual from those massive out-of-pocket payments? Let's have Dr. Choi and then Dr. Alsari. Yeah, first, definitely look forward to speaking with you afterwards, the fellow traveler from the Commonwealth. I will answer this question not on behalf of ACP. This will only be my own personal opinion. I've thought about that solution a lot and I would love to see further conversation about why can't we do that. Now I recognize there's a lot of moving parts to try to come up with that type of a solution and there may be a fair bit of spillover effect in doing so, but I think this is the enormity of this problem and the pervasiveness of out-of-control drug pricing. For me personally, my own opinion is that I think at this point we shouldn't be turning away any possible proposed solutions. They should be on the table for discussion. I think the challenge is going to be if there's enough opposition to that type of a solution, whether it would be on the table, but I personally would like to see different ideas addressed as a possible solution. You know as a physician you wanna do the right thing for your patient and make sure that they have access to everything that's appropriate and evidence-based and it really makes great sense if they didn't have to pay a whole lot and they could actually get their treatments, but somebody's gonna have to pay for it somewhere, right? So who's that gonna be? Is that our federal government, our state governments? What are they going to balance if the pharmaceutical costs keep going up? No fire, no for leasemen, no highways. I'm not sure where that, you know, I think it still comes back to these crazy costs of pharmaceuticals. I'm happy to, you know, support my patients, take care of them, relieve the burden on them, but society has to take a look at this and figure out how we're gonna make this happen for the whole nation. We have probably time for one other question and if we're waiting for, oh, there we go. Sorry, I'm much shorter than this. Hi, I'm Shafala Luther. I'm a reporter with Kaiser Health News and one thing I've been thinking about this whole time is when you talk to doctors, so many of them say that they can't talk to patients about drug costs, that it's so opaque, they don't understand the price of what they're prescribing and I guess I'm curious is that a problem that you run into, is that sort of a real argument and if it is, how does that get addressed in the solution as well? I think there is some merit to that complaint. It's fairly, I'll share how I view this. When I'm prescribing something for a patient, I'm doing what I think is medically right, trying to base that on the best available evidence that I'm aware of that I have access to and while I think it would be a little bit disingenuous to say cost doesn't factor into it, I try not to let cost affect my medical decision, but I think part of it also is that many of us as frontline doctors, we're not necessarily so aware of which drug, in which class of medications is on-formulary or not on-formulary in a particular patient's insurance plan. Sometimes we're not even sure what their insurance plan is and frankly trying to do a very complex medical visit in 15 minutes, that's a whole other issue whether that's appropriate or not, but that makes that time pressure makes trying to address the cost of a medication even more challenging. I think that for many physicians it's not clear, myself included, I'm not necessarily so aware until I find out, for example, the scenario I alluded to my patient with end stage emphysema who was told he would have to pay $600 for an inhaler. I had no idea, that wasn't necessarily my original, it was not originally prescribed by me and I found out later he never picked it up when he was originally prescribed that, that's how come he didn't take it and then when I tried to prescribe it again, I found out the cost. So it's not so obvious to us. So there has to be, I would broaden the transparency and say that it ought to be much clearer to doctors as well what is the cost. That being said, my own personal opinion is I don't think being unaware of the cost should be a disincentive to get involved to advocate for bringing down the cost of medications. Yeah, I would agree with what Dr. Choi said, you know, whenever I'm taking care of a patient I'm not looking at, well what is this medicine costing? I'm actually looking at what is the right thing to do for this patient. But you're right, I don't know what Lysin, April costs are, you know, any of these drugs costs but I'm happy that I actually work in an integrated delivery system where other colleagues of mine have had a chance to take a look at all of those different classes of blood pressure medications. And if they're pretty similar and have the same efficacy at least they're able to negotiate with the drug company, get the right thing on the formulary. So when I'm ordering that I know that my patient's most likely getting the most cost effective drug. But you're right, most of our colleagues don't know what these things cost. And I don't know how we would practice if we went to order it and then saw the price next to it, what sort of feeling I would have or what kind of feeling my patient would have if I was having that discussion. We definitely have left it out of the conversation in this country but something to think about. We have time for one last question here please. Hi, I'm Fiona Scott Morton. I am a professor at the Yale School of Management. I wanted to just follow up on Steve's comment about capping out of pocket co-pays and your response that that would lead to higher costs for everybody because of course if patients pay less than the insurance premium is going to be higher. I think a missing piece from that optimal policy is dealing with the manufacturer kickback to the patient. So this comes often in the form of a coupon or patient assistance or something that is essentially a kickback to the patient to induce them to purchase a drug for which they're mostly insured. So we give them an extra $100 and they buy a $2,000 medication which goes into the premiums. So insurers I think would like to have those payments eliminated because it would enable them to bargain with the manufacturer more effectively because the patient would no longer be fixed and loyal to that manufacturer but would be elastic. So that's a long preamble but the point just being that to get insurers on board with the idea of capping out of pocket payments I think you need to pair it with saying the state is going to make illegal manufacture payments to patients that run an end run around the PBM or the Kaiser or the insurer. Thanks. Dr. Alsari. I think you make a good point and bring up the issue of drug coupons and if you were trying to sell something you'd probably be giving coupons for things that you really wanted to sell, right? So when it was Prilosec which became Omeprazil and generic you were not going to give a coupon for that but you were going to give a coupon for the purple pill which is now going to be more expensive. And I think in most cases coupons are given for things that perhaps have no added value. The Hep C drugs and PrEP are probably one of the few examples where there's only one single category of drug today and patients do want that assistance but I think you bring it up really well. Drug coupons generally do not help our patients and actually they raise the price 26% that year and then give you a hundred dollar coupon. Well, that doesn't make a lot of sense. Thank you. We, I'd like to invite the audience to thank Dr. Alsari and Dr. Choi for their comments today.