 This is Capital Conversations, a Longmont public media conversation where we invite during the legislative session our very favorite legislators to come and talk to us about what they're doing to help Colorado and Longmont. Today we have Sonia Hocquez-Lewis from District O, I forgot to ask, 11 or 12? It's 12. It's 12. Our representative, my representative from District 12, and she is by trade a pharmacist and she is running a suite of bills about access to prescription drugs in Colorado that is hopefully going to help us all save money. Yes, we need to. Yeah, so Sonia, why don't you start by giving us a little rundown of what your bills are and then we'll talk about what they do. Absolutely. So I'm in my first term, as you know, Marcia, as a state health rep. We have in my district, 12, our district, we have Louisville, Lafayette, and the eastern part of Longmont. I like to say the best side of Longmont. And as you mentioned, I am a pharmacist by training. So I ran because we really need some folks that know healthcare at the Capitol. So this year, we have a very challenging, I think, agenda ahead of us. The number one issue in Colorado now is healthcare. That issue is a great concern to working families, it's a kitchen table issue for all of us. So the slate of bills that I worked on all for, I'm not running all for as the prime or the main sponsor, but I'm helping because I am the healthcare professional in the house along with a pediatrician and a nurse. And we are doing, the first bill is a transparency bill. So it's trying to get a little bit of data from healthcare companies, from pharmaceutical manufacturers, from vendors that work in healthcare. What are drugs costing us in Colorado? Drug pricing is truly a mystery these days. You can walk into one pharmacy and ask to fill your prescription. And you might get one price at one pharmacy down, and then down the street, you might get a different price. So we're trying to get a landscape of what drugs cost. So the first bill is about doing that. It's requesting data. Why do pharmaceutical manufacturers price drugs the way they do? The second bill, but no, please, did you, I could see you might have a question because there are a number of lines that you can draw to say what is cost. So is it cost to the retail pharmacy, cost to the patient, cost to the, yes, Ellis. Yes. No, it's true. That's what makes drug pricing so complicated. So the first bill is what is it costing payers? And a payer could be the state of Colorado for Medicaid patient, a payer could be an insurance company, a payer could be your employer. So we have, when we look at payers, we're looking at getting data around that. Now the second. It could be me if I'm uninsured. So the cost to the patient, I think is your question, is also a very important question. And in the bill, we are establishing a website that you and I can look up some of the data that we're going to, yes, that we're going to get from this bill. So we want this to be transparent for everyone. So that's the first bill. The second bill is a bill, and this is a little more complicated, but let me give it a good try here to explain it. Right now, when you walk into your pharmacy and you present your prescription, you get it filled, you pay for your prescription and you walk out the door and you have your medication. On the back end, a pharmacy sends that claim, it's converted into an electronic claim. They send it to your insurance company for a lot of patients. If you're a Medicaid patient, they send it to the state. If you're a Medicare patient, they send it to the federal government. So on the back end, the pharmacies get reimbursed by these third-party middlemen, if you will, called pharmacy benefit managers, PBMs. Now, here's what's happening. They are taking money back from the pharmacies 60 or 90 days after the prescription was filled. So the pharmacies have no idea if they are making money or losing money on these prescriptions. And you might say, well, you know, that's tough for the pharmacies, but how does it affect you and I? If you're a Medicare patient, it does affect you, because that counts towards putting you into the donut hole or not, and it messes up the entire calculation. So we've got to fix this. There is a congressional bill to fix it that is cosponsored by Republicans and Democrats. So the problem is it's stuck. It's stuck in the U.S. House. So several states in the country have passed their own bills, and I have authored this one. And we got it through the House chamber with a completely unanimous bipartisan vote. It came out of committee 11 to 0, and it came out of the chamber with just a few negative votes. So this is, I think, what we recognize is that this is hurting small businesses. It's going to put small pharmacies in rural communities out of business. So that one's on the way to the Senate now. Okay. Now, I've got a whole stack of questions about this one. I bet. So first of all, these benefit managers, why do they even exist? What value do they provide? So pharmacy benefit managers were started in the 80s actually by pharmacists because they offer clinical services. They take the, yeah, so if you think about a company like CVS is a large company and they have retail stores, well, they can bundle together all their claims, and then they can actually offer clinical services on the back end. They have health clinics. They do a lot of things. The problem is these fees started only in the last few years, and they're out of control. They're unpredictable. They're not transparent. They happen in different amounts to different pharmacies. We've got to regulate this, and that's what we're doing. We're basically saying no more of these fees unless you do it at the time the prescription is filled. Okay. That's the fair way to do it. What the fees are for is just finding the best drug price or bundling the orders, or what do they actually do to earn these fees? So they started out as performance fees. So if a pharmacy, if you were a diabetic, and a pharmacy is counseling you on how to improve your circulation or improve what we call your A1C, your blood sugar, they were paying pharmacists to do this. The problem is they started grouping pharmacies with these performance goals, and one pharmacy could be at the top of the pile and still have fees taken out, and another pharmacy could be lower, and they might not have fees taken out. There's no transparency. So here's what we got. We had wonderful testimony from multitudes of pharmacies all the way from, we had a pharmacy come in six hours away. He drove six hours into the capital. He's the only pharmacy within 60 miles of his community. He drove in because he was losing over $90,000 a year. So these pharmacies, some have already gone out of business. So we said, you can charge fees. You can, if a pharmacy is performing well, you can give them a little more. You can take it back, but you have to do it when the prescription is filled because the pharmacist needs to be able to see if they're losing money on that prescription. That's the fair way to do business. So this bill actually is, it's a business bill actually. So the pharmacy controls the resale price. They can charge more or less depending on what their expenses are, and these benefit manager fees are an expense to them. They are an expense to them. Now I want to correct one little thing that you said, Marcia. So pharmacies can't charge a big range of price difference because your insurance company has negotiated the rates. Yeah. Well, that's what I thought. That was my, I was surprised to hear you say they could charge more at all. It is a very, very complex subject. It has taken me years about this. I'm a published author in this area. And as the former Medicaid pharmacy director for Colorado Access, it's taken like a lifetime of experience to get to know what is going on. But we think we're on the right track with these four bills. So let me stop and make sure you got the retroactive fee, the banning the, that's the second one. Yeah. So you're banning the retroactive fee. Right. I'm not sure how the money flows in all of this. Yes. A lot of people aren't. If I had had more time, we would have had a picture. Oh, I will bring it the next time. Okay. I have published, published graphs on how the money goes with pharmacy. Oh. I'll bring that. We'll have a little, how about a little drug price 101? That would be wonderful. I bet, I bet we would get lots of views on drug price 101. Okay. So now we're ready to go on to the third bill. Absolutely. So the third bill is those vendors that we were talking about, those middleman called PBMs, pharmacy benefit managers. Guess what? In Colorado, they're not regulated. At all? At all. At all. So there is a bill. I helped work on this bill also, but I have colleagues that are actually going to run it. Okay. It is a minimum regulation of PBMs. So right now, the only way we can really tell PBMs what to do is through their contracts with insurers. Even the state of Colorado Medicaid uses a PBM. So PBMs are used for lots of different companies. Right. So I am Kaiser. Okay. They probably use their own PBMs. They do. So that was a bad example. That's okay. I'm United Healthcare. There you go. I'm looking for a PBM to manage bundling and ordering and all that. All the prescription claims. Who bought stuff? Yeah. You got it. All the magic behind the scenes. Yeah. Right. All the excuses for charging extra fees. Exactly. And since this job is not regulated, I can just say, I'm going to be a PBM. And I go interview like a champ and get hired, and I don't have to know anything about this. Well, I don't want to beat up on them too much. Well, no. I will say that they have to have a level of electronic claims processing. They usually have pharmacists that help them with the clinical piece. The problem is some are just overcharging their gouging. And I would say that about my pharma colleagues also. Okay. We've got some pharmacy companies that are not gouging and some that are. But you're absolutely right. That's exactly how it works. If you're a payer of any sort, you need a PBM to send the claims to the pharmacy so that you and I can get our prescriptions filled. Whoa. So when I was a young person, I wrote claims processing software. I probably could pass the interview to do this. You could start your own PBM right now. Oh, let's not. I recommend not. Yes. Okay. So that's the third bill, is regulating PBMs. And other states have done this. And so the fourth bill, very proud of the fourth bill. That bill I'm offering with some coalition, healthcare coalition groups. And it establishes a prescription drug affordability board. We like to affectionately call it the PDAB because he, yes, prescription drug affordability board. So what this board will do is review price increases of pharmaceutical products if they're above a certain threshold. So when a pharmaceutical manufacturer tries to price too high, in our opinion, too high, and this opinion is based on affordability and value, then they will be called in to talk about this before the affordability review board. Okay. So they have to, a vendor has to notify the state. It's actually a pharmaceutical manufacturer. Okay. A pharmaceutical manufacturer is a sort of vendor. It is. Right? Sort of. Maybe manufacturers more or less. Manufacturer. Yeah. Right. That they plan to raise their wholesale price. Yes. That's a good point. So drug prices have all kinds of ways to list their drugs. You can talk about it from wholesale point of view. You can talk about it what's published out there. Sometimes that's called the AWP, the average wholesale price, or the WAC. That's the wholesale acquisition cost. I know. Are they all different or are they just different words? They're all different. Okay. They have their own price, and then you have the maximum allowable cost that's used for generics. So this is why this is so complex. And this is why I'm very happy that we have more healthcare professionals getting into lawmaking because we bring our personal experience into it. That's right. You have to know the right questions to ask or you can't regulate anything. I think so. Yeah. Okay. Well, so. So the PDAB. The PDAB exists. And who's on the PDAB? Great question. So the PDAB, we would like to see professionals that work in assessing the value of drugs, prescription drugs. So we have groups like that now. So let me give you an example. In Europe, European countries are allowed to look at the value of a new prescription drug and they can say we think this is valuable and we think it should cost X, Y, Z. And they're allowed to do that. In the United States, we're not. We are not allowed to negotiate the cost of drugs. However, we have these review boards that are, yes, we have five other states that have review boards and we have a national review board. It's called ICER, the Institute of Comparable Effectiveness Research. And they are doing a terrific job in looking at the value of drugs. So now I'm proposing that Colorado join five other states to have a review board for prescription drug pricing. And here's why. We've got a lot of smart people here in Colorado. We have people that serve on some of these other groups because we have nationally published authors. So I'm hoping that we can use this knowledge that we have here to review when a prescription drug is being targeted to raise the price because we have to keep our drugs affordable. There are so many patients right now. They're choosing between their prescription drugs and buying their groceries. I get that. So let's talk about what effectiveness means for a little bit. Sure. Absolutely. Okay. We have good old Metformin. We do. That is the Glucophage and everybody eats a good little bit. We do. I'm going to call you an honorary pharmacist soon. Not yet. And then let's see, we have Genuvia, right? Yes. Yes. Oh, which is... It's a DPP4 is what they call it. Now you know I'm not an honorary pharmacist because I couldn't even repeat that. And then you have a thing called Janumet, which is the two drugs. Yeah. The two combined. And those are prescribed in similar situations. How do you compare their effectiveness? Well, we look for what's called a clinical endpoint. So without being too technical, I don't want to be... I want to keep it so everybody understands what I'm saying. I want to be too techno. We have this measurement that we do with diabetic patients. It's called their A1C measurement. So we can say here is Genuvia, here's Metformin, what do they do to the A1C? So we can compare them. As long as we have a metric that is the same across these drugs for diabetes, we can compare them. And we can do what's called a cost effectiveness review. So let me give you an example. So an A1C, in clinical nomenclature right now, in clinical guidelines, if you're below a seven, you're doing well, right? If you go above that, we got to fix that. Because for every 1% of an A1C that we can drop a patient, you will add years to your life and you will reduce adverse events and things like losing your sight or losing your toes. So circulation, microcirculation. We know that if we can do some of these in cardiovascular, asthma, diabetes, we're going to help the long-term mortality of the patients. So that's how we do a cost effectiveness. So you pay $90 a month and you get a 1% drop. You pay $300 a month and you get that same 1% drop. Which one do you think is more cost effective? The first one, obviously, of course, they're not the same in every patient, right? Correct. Correct. There's always differences. Okay. So you're absolutely right. There's always differences between patients. And that's why we need choice of medication. That's another reason. You've kind of circled around, you've been reading my mind. There's another reason why we need the PDAB. Is because we believe that many times when these price increases happen, they happen in drugs where they're the only drug of its kind. So think of it like a monopoly. You have a new brand drug that comes out, it's the only one of its kind. Some manufacturers charge way too much for that. We need to make it just like your utilities, right? If you only have one electric company. It's regulated. It's regulated. Okay. You're hitting upon the purpose of the PDAB. Alrighty then. And so the last question about this PDAB is where are its teeth? You can talk about that's too high compared to these other equivalent drugs are comparable, I should say. They're not all equivalent. Right. They do. Yeah, it's a great question. We would like to establish an upper threshold limit of how much payers in Colorado will pay for that drug. And now this is still in flux. If you want to run out and look for this bill and say, hey, I want to read about the PDAB, I haven't introduced it yet. Because we're doing a lot of meetings to make sure we cover everything that we need to cover. I knew that because I looked. Yeah. So, we want to try to establish an upper threshold. Because that allows us to say that the value of this drug is a fair value. And so that patients in Coloradans can afford their medication. Okay. And so I'm not sure how that exactly works. So you can publish this kind of a verdict. Oh yeah. This will be public information. It's public information, but does it really prohibit overcharging or does it just steer people away from the overpriced drug? So Colorado Division of Insurance does have control over what it costs to pay for certain services. And so they can set limits. We negotiate with hospitals all the time. We do this kind of negotiation for healthcare across a lot of different areas. So we're just basically saying if we're negotiating for hospital rates, if we're negotiating for doctors' fees, if we're negotiating for behavioral health clinic fees, we should be negotiating on drug pricing. At least setting a limit so that patients are not turned away at the pharmacy for lack of funds. Okay. And you're putting the finished carpentry on this bill now. We are. So you can't say exactly how it's going to go into effect right yet. I can't. I'm just watching for it. I would love that. And come and testify. If you have prescription drug stories, come and testify. Well, I just told you my prescription drug story I've been on to you, Villain. But yeah, okay, let's see. So that's kind of a nice little suite that is aimed at filling the gaps in how prescription drugs are sold and marketed and administered in Colorado. And that means that there are fewer places for money to run through the cracks, as it were. Yeah, it's such a complex issue. It has so many touch points. We felt like we needed to run a complete set of bills to touch the various aspects. And we have other healthcare bills coming. Everyone knows about probably, you know, about the public option that's coming. We have other bills that are going to look at mental health increases to mental health resources. So there's a lot going on with healthcare as there should be. It's again, it's the number one issue in our state. It's the number one issue and for many people it's the number one cost. Absolutely. Okay. All right. So I'm hoping, Marcia, we have time for a little plug on one of my special bills. Well, let me see about the special bill. Okay. We're not waving before the timer, so we're waving over the time. You know what? You're so much fun to talk to, Sonia. I would like to maybe have you back to talk about pollinators because I read that pollinator bill. We could probably slip in two bills because I also have to replace your ride bill that you haven't even seen yet. And they're both environmental bills. Yes. That's a good point. We can make it environmental. So we'll have another environmental session in a while, you know, let's email back and forth and we'll just, we'll decide when we've both got time. Both of them will be like introduced, hopefully. Okay. So yeah. So we can, we can get the details because, you know, in the pollinator bill is, it's very exciting. I think so. Because it's all full of things that you can't, that the bill doesn't do. Right. And yeah, but we can't talk about it because we're done. So, Samia, thank you so much for coming. Of course. This is great. You are just lots of fun. We'll have you back as soon as we can because this is Capital Conversations. I'm Marsha Martin and thanks for watching.