 Just to make sure everyone is willing and able to help us in the event of an emergency, we just need a verbal yes from all of you. So good morning, everyone. Murray Ross, I'm vice president with Kaiser Permanente, and I lead the Institute for Health Policy, your host today. This is the third in a series of forums that we initiated last fall. We held one on mental health and wellness, one on telehealth, and we're trying to drive some conversations in a different way, and we're very pleased that you're able to join us for the day. I think you'll find it rewarding. We have a pretty tightly packed agenda, and we're going to do our best to stay on time because we have a couple of hard stops for some of our speakers. But we will make time in every session for a question and answer. There are standing mics, and you'll be able to find them. A couple of things. Keith just mentioned the location of the restrooms. Take breaks as you need them. We're not that formal. You can feel free to refresh on coffee and food as you wish. There are a couple of other events going on here at the same time, and we're trying to keep mutual peace between the groups so we don't wander into their events and them into hours. So if you need to make a call, maybe step into the doorway or even outside, it's reasonably warm. Let's see. A couple other things. Lunch will be available at 12.30, and you'll have an extended chance to chat with speakers and your colleagues in the audience. But again, you can feel free to bring sustenance back to your table. And anyone that you see with a blue square button on their lapel is staff, and you can ask them for help with whatever you might possibly need. I'm going to ask our first two speakers to come up, and I'll introduce you guys in a second. I just want to call attention to the handouts on your table. There's a couple of brief papers in there that you may find of interest in public opinion polling on drug pricing and on paper delay. And also, we are live on social media today, and you can see the hashtag drug prices and also KPIHP. That's the Kaiser Permanente Institute for Health Policy. So without further ado, I would like to introduce my colleagues from Kaiser Permanente. First Dr. Steven Perotti, who's Associate Executive Medical Director for the Permanente Medical Group. That's our northern California physicians. And also, Executive Vice President with the Permanente Federation, which is the umbrella group that represents all of the Permanente Medical Groups nationally. And in addition to his clinical responsibilities, he also handles external relations and public policy. And joining him will be Tony Beretta, who is Senior Vice President for National Government Relations with Kaiser Permanente. And for those of you who know him, Tony is one of the national experts in drug pricing. And it is both his passion and his avocation. And you don't get to have two hours for this morning, Tony, but he will be available throughout the day. So gentlemen, thank you. So first of all, I want to extend a warm welcome to all of you. And I really very much appreciate your attendance for this extremely important topic of national import. And I want to actually talk to you from two different perspectives. One is a physician leader, and then also one is a practicing physician. As a physician leader, one of the responsibilities I have in northern California is oversighting of the operations for our 21 hospitals and the 88 contracted skilled nursing facilities that we provide care for our 4.3 million members in northern California. If you look at the rising drug costs that are impacting hospital care in the United States, you only need to look at actually a 2016 American Hospital Association sponsored survey of 720 community hospitals and 1,400 other hospitals that have a group purchasing organization. So a total of almost half of the hospitals in the United States. And the cost of drugs, unit costs over that time period from 2013 to 2016 was 23% year over year. And this wasn't due to innovation in drugs. If you look at the utilization of drugs during that time period, it only went up 1%. If you look at the types of drugs in terms of the unit costs that went up, they went up between 300 and 3,000%. These are not new drugs. They're ones that we've used day in and day out for up to 50 years, sodium nitroproside, isopraternal, Tylenol. This has direct impact on the ability for us to innovate in other parts of health care. Because we've had to change the way we practice to accommodate these drug prices, one of the hospitals that was surveyed actually said that because of this impact on drug pricing, we've not been able to hire 50 nurses or social workers to address the social determinants of care that our patients are facing. Those are the real impacts that are occurring. Within Kaiser Permanente, we've done everything we can to effectively address this question. Whether it is changing our practices or formularies, our order sets, informing our physicians through drug education that's not sponsored by industry, all of those things have been put into place. But we have gathered you here today to address the direct public policy implications and issues that we need to do. This is something that can't be done just at the front line level. This is something that we need all of your help in. I want to talk to you also about the direct patient impact just briefly. I'm in a practicing infectious disease physician and have an HIV practice. And I got a secure message from one of my patients about three weeks ago. He's someone who I've followed for 16 years and actually my colleague who I inherited his practice had taken care of for 10 years before. So he is an HIV survivor before there was highly active antiretroviral therapy, before there were drug cocktails. He was someone who actually had to go on disability and was told that he might die in 1996. And he was saved by medications and the drug cocktails. And today, I'm happy to tell you that he was able to get off disability. And in fact, he has spent the rest of his career working, placing his fellow HIV survivors in homes, in housing, in the district where I work. And he's recently retired. He's now on Medicare Part D coverage. And his secure message to me was, Dr. Perotti, I am so happy that I'm here. I'm retired. I can no longer afford the co-pays for that one pill once a day regimen that you now have me on. Can you recommend some generics that I can take? And all of you know that the generic medications that are available for HIV today, those costs have not come down even though they're generic. His actual co-pays would go up in that setting rather than down. And in fact, we've had to find other ways and other means to help him. But that's the real-world questions that we are facing today. Those are the things that we need to address here. We need to be able to take care of our patients in a value-based manner. So thank you all for coming here today. And I'm going to turn it over to Tony. Great. Thanks, Steve. You know, thanks everybody for being here today. This forum is one of a number of forums that we're holding in a series of subjects. But as Murray suggested, holding a forum on prescription drug pricing is something that's both close to my heart and close to my mind. It's something that I've worked on intensively for the 24 years I've been with Kaiser Permanente and throughout my career. For a big chunk of that career, one of the great honors of my career was to be able to be the lawyer and policy advisor for our pharmacy program. And what I learned in that process was the passion that you just heard from Dr. Peroti and from our pharmacy team is consistent and has been consistent for decades. It flows from a concern for our patients, the people that we're charged with taking care of. And it flows from the frustration of the fact that despite managing pharmaceutical care and pharmaceutical benefits, as effectively as any group of people on planet Earth, it is not enough. We are still not able to get a grip on the rapidly escalating prices of prescription drugs. And this is for an organization and a group of people who truly believe in pharmacotherapy and truly believe that access to prescription drugs is essential to be able to take care of our patients. So we're very happy to come together here to talk again about what's going on, what policy options might be available, and how can we move to ensure both that prescription drugs are developed, that new drugs come to market, that we have a robust research and development facility in this country and around the world, and at the same time, people are able to access the drugs that they need. You know, I was thinking about what's been consistent over the time that I've looked at this subject and what's new. I would say what hasn't changed at all in the last quarter century around prescription drugs and the prescription drug marketplace and prescription drug pricing is we still have the same structural market dysfunctions that exist, which are natural, that you would have in any circumstance when you have government-granted monopolies in order to incent certain behaviors and what happens there. When you have broad third-party coverage of something and the impact that that has, and counterproductive regulations in some cases that systematically lend themselves to increasing the prices for prescription drugs, those things haven't changed. We still face the same challenge of balancing intellectual property protection with access. The things that are new and are different and have changed, and I think that's one of the reasons that we're focused on this today, is that just to be really blunt about it, pharmaceutical economics outruns everything else in the American economy today. I was at a conference a couple of weeks ago and I think it was Bob Galvin who had made an observation that of the Fortune 20 companies, a quarter of them are in the drug distribution business, not pharmaceutical manufacturers, people who are either in the business of wholesaling, warehousing, or paying for benefits for prescription drugs. Now if a quarter of the highest revenue companies in the United States are in the drug distribution business, that tells you that the underlying economics of the products that they're exchanging in this process or the financing that they're developing is very high relative to everything else that's going on in the economy. And I think that is a natural result of the fact that over the last quarter century we have seen systematic increases in costs of prescription drugs relative to everything else and frankly relative to everything else in what is also a rapidly escalating health sector. So there are issues across the health sector around affordability, no question and we're very interested in continuing to work on those issues as well. But pharmaceuticals is far outpacing everything else. The other thing that's new and this is a problem, is just breathtaking pricing decisions by some drug manufacturing companies. Some of the things that we're seeing are things that you would think 20 years ago would not be done simply because of the public outrage that it would generate. For whatever reason, and there's probably theories on why this is, pricing has become unhinged. Pricing is not controlled by gravity the way it once was. And I think part of the reason for that has been a shift in the way that drugs are developed. Drugs once upon a time were developed by large institutional drug manufacturing companies that had large research engines behind them. They brought awesome products to market. They had a public responsibility as large institutions and they did a great job. In the last few years what we've seen is rather than an internal drug industry research and development system, it's become much more scattered across the economy with small biotech developers growing up. And where the drug companies come in is they're forced to bid against each other to acquire the molecules in order to take them the last step to bring them to market. And the bidding that goes on across those companies is a highly competitive process which requires those companies to build huge war chests in order to compete against each other. And that is a piece of what's driving the spiraling in the drug prices because they can and in some respects they have to in order to perpetrate this model. That needs to be questioned and we need to figure out if there's a better and more effective way to bring drugs to market. And the last thing that's different is people care today in a way that they didn't many years ago. Some of the research that we've seen, some of the public opinion research that we've seen is very different than it's been before. And we'll hear about some of this today. 77% of the public, when surveyed, thinks that the cost of prescription drugs are unreasonable. That's way above what we've seen in the past. Most registered voters, whether they're Democrats or Republicans, think that dealing with prescription drugs should be a high priority for the Congress. And we're seeing more voices in the system than we had before. Once upon a time, you did not see patient voices showing up in this conversation concerned about the cost. They would show up concerned about access and whether or not controls on access were problematic. But now we are seeing real stories of real people really affected by the cost of prescription drugs coming forward. So it's easy to be cynical about what can and can't get done here in Washington. But I think we can also draw some hope from what's going on at the state level. We have state legislatures that are taking this issue on. We've seen numerous bills and bills passed around drug pricing transparency. And so that is simply gonna be fully informing what's going on in the marketplace. And it will help bring more attention to this problem and will encourage more people to seek out solutions to the problem. So I wanna, again, thank all of you for being here. I think it's terrific to get a very broad, diverse and thoughtful group of people together to talk about what's a big problem. And we at Kaiser Permanente are very honored to be able to have the time to spend with you. So Murray, without further ado, I think we should get on with the program. There we go, okay. Okay. Thank you.