WEBVTT NOTE duration: "00:52:01.024" NOTE Confidence: 0.9979111 00:00:02.000 --> 00:00:04.319 Okay. Good afternoon, everyone. Let's NOTE Confidence: 0.9979111 00:00:04.319 --> 00:00:05.839 get started. Welcome to the NOTE Confidence: 0.9979111 00:00:05.839 --> 00:00:06.339 last NOTE Confidence: 0.9821057 00:00:07.040 --> 00:00:09.200 research in progress, meeting for NOTE Confidence: 0.9821057 00:00:09.200 --> 00:00:10.480 twenty twenty five. It's great NOTE Confidence: 0.9821057 00:00:10.480 --> 00:00:12.019 to see everyone here and NOTE Confidence: 0.99853104 00:00:12.639 --> 00:00:13.139 online. NOTE Confidence: 0.8532694 00:00:15.224 --> 00:00:15.724 Okay. NOTE Confidence: 0.96225435 00:00:16.945 --> 00:00:17.445 So NOTE Confidence: 0.86651164 00:00:19.545 --> 00:00:20.045 Yeah. NOTE Confidence: 0.9318112 00:00:20.904 --> 00:00:21.864 So I just press, NOTE Confidence: 0.9807391 00:00:24.185 --> 00:00:24.685 Okay. NOTE Confidence: 0.96268994 00:00:26.105 --> 00:00:27.704 Okay. The CME code for NOTE Confidence: 0.96268994 00:00:27.704 --> 00:00:28.985 today's meeting is five five NOTE Confidence: 0.96268994 00:00:28.985 --> 00:00:30.505 six five eight. Five five NOTE Confidence: 0.96268994 00:00:30.505 --> 00:00:31.789 six five eight. NOTE Confidence: 0.9662014 00:00:33.770 --> 00:00:34.890 Just a reminder of our NOTE Confidence: 0.9662014 00:00:34.890 --> 00:00:36.570 re retreat schedule. We just, NOTE Confidence: 0.9662014 00:00:36.809 --> 00:00:39.129 completed our research and scholarship NOTE Confidence: 0.9662014 00:00:39.129 --> 00:00:39.629 retreat NOTE Confidence: 0.88515055 00:00:39.930 --> 00:00:41.610 a couple weeks ago. Have NOTE Confidence: 0.88515055 00:00:41.610 --> 00:00:43.370 your calendars marked for February NOTE Confidence: 0.88515055 00:00:43.370 --> 00:00:43.870 sixth NOTE Confidence: 0.97918683 00:00:44.285 --> 00:00:45.885 for the professional development retreat NOTE Confidence: 0.97918683 00:00:45.885 --> 00:00:47.585 and then the education retreat NOTE Confidence: 0.9680277 00:00:48.605 --> 00:00:49.725 in May. It was great NOTE Confidence: 0.9680277 00:00:49.725 --> 00:00:50.925 seeing everyone at the research NOTE Confidence: 0.9680277 00:00:50.925 --> 00:00:52.145 and scholarship retreat. NOTE Confidence: 0.9561986 00:00:52.925 --> 00:00:55.005 Thanks again, to Carrie Gross NOTE Confidence: 0.9561986 00:00:55.005 --> 00:00:56.605 and Jeanette Tetreault for organizing NOTE Confidence: 0.9561986 00:00:56.605 --> 00:00:57.905 what was really a spectacular NOTE Confidence: 0.9561986 00:00:57.965 --> 00:00:58.465 day NOTE Confidence: 0.999521 00:00:58.970 --> 00:01:00.510 of learning for everybody. NOTE Confidence: 0.94752306 00:01:01.610 --> 00:01:03.390 This is our weekly reminder NOTE Confidence: 0.94752306 00:01:03.450 --> 00:01:04.409 this time of year for NOTE Confidence: 0.94752306 00:01:04.409 --> 00:01:06.090 the FDAQ process. So, NOTE Confidence: 0.9989849 00:01:07.369 --> 00:01:08.729 we're in step one. NOTE Confidence: 0.96386117 00:01:09.050 --> 00:01:10.170 I I've seen a number NOTE Confidence: 0.96386117 00:01:10.170 --> 00:01:10.650 of these, NOTE Confidence: 0.9026764 00:01:11.194 --> 00:01:13.034 completed FDA queue documents come NOTE Confidence: 0.9026764 00:01:13.034 --> 00:01:13.515 in. NOTE Confidence: 0.83504665 00:01:13.994 --> 00:01:14.494 Please, NOTE Confidence: 0.9736189 00:01:15.274 --> 00:01:16.634 get those done. The deadline NOTE Confidence: 0.9736189 00:01:16.634 --> 00:01:17.834 is on the slide there, NOTE Confidence: 0.9736189 00:01:17.994 --> 00:01:19.354 February second. So you do NOTE Confidence: 0.9736189 00:01:19.354 --> 00:01:20.015 have time. NOTE Confidence: 0.9697629 00:01:20.715 --> 00:01:21.755 But it's just a matter NOTE Confidence: 0.9697629 00:01:21.755 --> 00:01:22.795 of sitting down and doing NOTE Confidence: 0.9697629 00:01:22.795 --> 00:01:24.174 it as you all know, NOTE Confidence: 0.99931383 00:01:24.520 --> 00:01:25.240 And the rest of the NOTE Confidence: 0.99931383 00:01:25.240 --> 00:01:26.220 steps are outlined NOTE Confidence: 0.99676627 00:01:26.680 --> 00:01:27.500 on the slide. NOTE Confidence: 0.97749555 00:01:29.240 --> 00:01:30.920 Thanks to all who attended NOTE Confidence: 0.97749555 00:01:30.920 --> 00:01:31.740 our annual, NOTE Confidence: 0.98842067 00:01:32.280 --> 00:01:34.040 section holiday party. It was NOTE Confidence: 0.98842067 00:01:34.040 --> 00:01:34.920 a lot of fun, a NOTE Confidence: 0.98842067 00:01:34.920 --> 00:01:36.280 lot of food. We actually NOTE Confidence: 0.98842067 00:01:36.280 --> 00:01:37.240 ran out of food for NOTE Confidence: 0.98842067 00:01:37.240 --> 00:01:38.545 the first time, but that's NOTE Confidence: 0.98842067 00:01:38.545 --> 00:01:39.604 okay. That means, NOTE Confidence: 0.970462 00:01:40.145 --> 00:01:41.584 people were well fed. And, NOTE Confidence: 0.970462 00:01:41.584 --> 00:01:42.244 of course, NOTE Confidence: 0.9987621 00:01:43.265 --> 00:01:44.244 we have our NOTE Confidence: 0.9383153 00:01:44.944 --> 00:01:46.804 we had our ultrasounds there. NOTE Confidence: 0.86907834 00:01:52.990 --> 00:01:54.369 It's that melody there. NOTE Confidence: 0.6564729 00:01:57.149 --> 00:01:57.810 That's hard. NOTE Confidence: 0.7086766 00:01:59.070 --> 00:01:59.570 So, NOTE Confidence: 0.7336208 00:02:01.229 --> 00:02:02.689 thanks. The ultrasounds. NOTE Confidence: 0.9777247 00:02:05.165 --> 00:02:06.445 Yes. These are this is NOTE Confidence: 0.9777247 00:02:06.445 --> 00:02:08.705 a medical student acapella group. NOTE Confidence: 0.958775 00:02:09.005 --> 00:02:09.805 Now we have a lot NOTE Confidence: 0.958775 00:02:09.805 --> 00:02:11.085 of acapella groups here at NOTE Confidence: 0.958775 00:02:11.085 --> 00:02:12.285 Yale, including at the medical NOTE Confidence: 0.958775 00:02:12.285 --> 00:02:13.885 school. So these guys did NOTE Confidence: 0.958775 00:02:13.885 --> 00:02:14.785 a great job. NOTE Confidence: 0.99804807 00:02:18.600 --> 00:02:19.100 Okay. NOTE Confidence: 0.9915358 00:02:20.520 --> 00:02:21.020 So, NOTE Confidence: 0.999493 00:02:21.639 --> 00:02:23.260 for the next two weeks, NOTE Confidence: 0.96640015 00:02:24.120 --> 00:02:26.040 due to, the Christmas and NOTE Confidence: 0.96640015 00:02:26.040 --> 00:02:27.319 New Year's holidays, we will NOTE Confidence: 0.96640015 00:02:27.319 --> 00:02:28.300 not have meetings. NOTE Confidence: 0.9279334 00:02:29.160 --> 00:02:30.380 So happy holidays, NOTE Confidence: 0.9267126 00:02:31.075 --> 00:02:32.435 to everyone, and, of course, NOTE Confidence: 0.9267126 00:02:32.435 --> 00:02:33.895 a happy New Year. NOTE Confidence: 0.97802067 00:02:35.315 --> 00:02:36.755 And then we'll resume our, NOTE Confidence: 0.97802067 00:02:37.155 --> 00:02:38.675 meetings on January eighth. NOTE Confidence: 0.9781551 00:02:39.395 --> 00:02:40.915 Kelsey Bryant will be speaking NOTE Confidence: 0.9781551 00:02:40.915 --> 00:02:42.435 at our general medicine grand NOTE Confidence: 0.9781551 00:02:42.435 --> 00:02:43.655 rounds at seven thirty. NOTE Confidence: 0.98246044 00:02:44.430 --> 00:02:46.110 I read the hypertension guidelines, NOTE Confidence: 0.98246044 00:02:46.110 --> 00:02:47.650 so you don't have to. NOTE Confidence: 0.98246044 00:02:47.870 --> 00:02:48.850 That'll be good. NOTE Confidence: 0.98751795 00:02:49.310 --> 00:02:50.690 And then Jen Miller, NOTE Confidence: 0.99964875 00:02:50.990 --> 00:02:52.110 will be here. Jen is NOTE Confidence: 0.99964875 00:02:52.110 --> 00:02:52.850 here somewhere. NOTE Confidence: 0.9912159 00:02:53.310 --> 00:02:54.510 Yes. There she is. Hi, NOTE Confidence: 0.9912159 00:02:54.510 --> 00:02:55.010 Jen. NOTE Confidence: 0.9241087 00:02:55.790 --> 00:02:56.990 She will be speaking on NOTE Confidence: 0.9241087 00:02:56.990 --> 00:02:58.750 transparency, access, and ethics in NOTE Confidence: 0.9241087 00:02:58.750 --> 00:03:00.475 the pharmaceutical c sector, NOTE Confidence: 0.95662403 00:03:00.855 --> 00:03:02.694 an update on conceptual development NOTE Confidence: 0.95662403 00:03:02.694 --> 00:03:03.355 and performance NOTE Confidence: 0.9922078 00:03:03.655 --> 00:03:04.155 tracking NOTE Confidence: 0.9184731 00:03:04.455 --> 00:03:06.635 with the good pharma scorecard. NOTE Confidence: 0.9184731 00:03:06.694 --> 00:03:07.355 So that's NOTE Confidence: 0.9871801 00:03:07.895 --> 00:03:08.395 next, NOTE Confidence: 0.9494351 00:03:09.334 --> 00:03:11.415 January eighth, at seven thirty NOTE Confidence: 0.9494351 00:03:11.415 --> 00:03:13.355 and at noon. Be there. NOTE Confidence: 0.9463452 00:03:14.750 --> 00:03:16.690 Here's our usual disclosure slides. NOTE Confidence: 0.9130198 00:03:17.389 --> 00:03:18.850 And we have a special NOTE Confidence: 0.9130198 00:03:18.910 --> 00:03:20.110 out of town guest today. NOTE Confidence: 0.9130198 00:03:20.110 --> 00:03:21.330 I'll have Carrie Gross NOTE Confidence: 0.9661178 00:03:21.790 --> 00:03:23.330 introduce our speaker. Carrie. NOTE Confidence: 0.9486084 00:03:28.424 --> 00:03:29.385 Thank you. I I will NOTE Confidence: 0.9486084 00:03:29.385 --> 00:03:30.845 not be providing the harmonies, NOTE Confidence: 0.9486084 00:03:30.905 --> 00:03:32.745 but we'll be providing a, NOTE Confidence: 0.9486084 00:03:32.985 --> 00:03:34.364 a welcome to our guest, NOTE Confidence: 0.9436745 00:03:34.665 --> 00:03:35.944 Chris Kai. So, NOTE Confidence: 0.982518 00:03:36.905 --> 00:03:38.985 Chris comes to us, well, NOTE Confidence: 0.982518 00:03:38.985 --> 00:03:40.345 now comes to us from, NOTE Confidence: 0.8992285 00:03:41.240 --> 00:03:42.440 Boston and the Brigham where NOTE Confidence: 0.8992285 00:03:42.440 --> 00:03:43.960 he's currently a general medicine NOTE Confidence: 0.8992285 00:03:43.960 --> 00:03:44.460 fellow. NOTE Confidence: 0.9935272 00:03:44.840 --> 00:03:45.740 And, I'm NOTE Confidence: 0.9995773 00:03:46.040 --> 00:03:47.160 excited for a number of NOTE Confidence: 0.9995773 00:03:47.160 --> 00:03:48.280 reasons to have you here. NOTE Confidence: 0.9995773 00:03:48.280 --> 00:03:49.100 First of all, NOTE Confidence: 0.95340645 00:03:49.960 --> 00:03:51.640 just reading your work over NOTE Confidence: 0.95340645 00:03:51.640 --> 00:03:52.780 the years and actually, NOTE Confidence: 0.9681979 00:03:53.475 --> 00:03:55.235 within JAMA Internal Medicine, being NOTE Confidence: 0.9681979 00:03:55.235 --> 00:03:55.955 able to work with you NOTE Confidence: 0.9681979 00:03:55.955 --> 00:03:57.095 on some of your manuscript NOTE Confidence: 0.9681979 00:03:57.235 --> 00:03:58.695 submissions and seeing the, NOTE Confidence: 0.9770309 00:03:59.235 --> 00:04:01.475 terrific, innovative, and impactful work NOTE Confidence: 0.9770309 00:04:01.475 --> 00:04:02.455 you've been doing, NOTE Confidence: 0.95716476 00:04:04.435 --> 00:04:05.495 leaves me really, NOTE Confidence: 0.9985978 00:04:05.875 --> 00:04:07.710 excited about meeting you and NOTE Confidence: 0.9985978 00:04:07.710 --> 00:04:08.930 hearing your talk today. NOTE Confidence: 0.9615686 00:04:09.630 --> 00:04:10.590 Those some of you may NOTE Confidence: 0.9615686 00:04:10.590 --> 00:04:11.890 remember that the original, NOTE Confidence: 0.9781468 00:04:12.590 --> 00:04:13.710 lecture was supposed to be NOTE Confidence: 0.9781468 00:04:13.710 --> 00:04:15.010 six weeks ago, but, NOTE Confidence: 0.67473483 00:04:15.950 --> 00:04:16.450 Chris's NOTE Confidence: 0.6678913 00:04:16.830 --> 00:04:17.890 baby Ezra NOTE Confidence: 0.96531814 00:04:18.670 --> 00:04:19.875 had other plans. It was NOTE Confidence: 0.96531814 00:04:20.115 --> 00:04:21.714 delivered pretty much, like, exactly NOTE Confidence: 0.96531814 00:04:21.714 --> 00:04:22.675 at the same time as NOTE Confidence: 0.96531814 00:04:22.675 --> 00:04:23.955 the the new conference was NOTE Confidence: 0.96531814 00:04:23.955 --> 00:04:24.775 scheduled for. NOTE Confidence: 0.9698216 00:04:25.235 --> 00:04:25.635 So, NOTE Confidence: 0.9747722 00:04:26.595 --> 00:04:27.895 and kudos to NOTE Confidence: 0.99650246 00:04:28.195 --> 00:04:29.795 Ezra for making his voice NOTE Confidence: 0.99650246 00:04:29.795 --> 00:04:30.295 heard. NOTE Confidence: 0.98622656 00:04:32.115 --> 00:04:34.339 Chris began his education, NOTE Confidence: 0.967941 00:04:34.719 --> 00:04:36.240 in Virginia. He's been out NOTE Confidence: 0.967941 00:04:36.240 --> 00:04:38.080 at UCSF for medical school NOTE Confidence: 0.967941 00:04:38.080 --> 00:04:39.279 back here to the Brigham NOTE Confidence: 0.967941 00:04:39.279 --> 00:04:40.659 for residency and, NOTE Confidence: 0.98256236 00:04:41.039 --> 00:04:41.919 on the East Coast, I NOTE Confidence: 0.98256236 00:04:41.919 --> 00:04:43.759 should say, for residency and NOTE Confidence: 0.98256236 00:04:43.759 --> 00:04:44.500 for fellowship. NOTE Confidence: 0.97835577 00:04:45.279 --> 00:04:46.719 And we're really excited to, NOTE Confidence: 0.97835577 00:04:46.960 --> 00:04:48.319 welcome you here to Yale NOTE Confidence: 0.97835577 00:04:48.319 --> 00:04:49.785 to talk about changes in NOTE Confidence: 0.97835577 00:04:49.785 --> 00:04:52.105 medication use after the Inflation NOTE Confidence: 0.97835577 00:04:52.105 --> 00:04:53.165 Reduction Act, NOTE Confidence: 0.92963105 00:04:53.705 --> 00:04:55.565 difference in differences analysis. NOTE Confidence: 0.9983293 00:04:55.945 --> 00:04:56.685 Thank you. NOTE Confidence: 0.9862555 00:05:00.825 --> 00:05:01.325 Okay. NOTE Confidence: 0.94312495 00:05:04.279 --> 00:05:05.240 So thank you so much NOTE Confidence: 0.94312495 00:05:05.240 --> 00:05:06.620 for a very warm introduction. NOTE Confidence: 0.9834825 00:05:07.320 --> 00:05:08.600 I'm thrilled to be here, NOTE Confidence: 0.9834825 00:05:08.600 --> 00:05:09.900 and, I welcome, NOTE Confidence: 0.952068 00:05:10.839 --> 00:05:12.760 any, you know, questions or NOTE Confidence: 0.952068 00:05:12.760 --> 00:05:14.760 feedback and interruptions. So, just NOTE Confidence: 0.952068 00:05:14.760 --> 00:05:16.040 really excited to chat with NOTE Confidence: 0.952068 00:05:16.040 --> 00:05:16.760 you all. So thank you NOTE Confidence: 0.952068 00:05:16.760 --> 00:05:17.740 for having me. NOTE Confidence: 0.9804891 00:05:19.425 --> 00:05:20.545 So I have about thirty NOTE Confidence: 0.9804891 00:05:20.545 --> 00:05:21.985 five to forty minutes of NOTE Confidence: 0.9804891 00:05:21.985 --> 00:05:23.045 material today, NOTE Confidence: 0.92758954 00:05:23.585 --> 00:05:24.085 and, NOTE Confidence: 0.9642401 00:05:24.625 --> 00:05:25.825 breaking it down. We'll spend NOTE Confidence: 0.9642401 00:05:25.825 --> 00:05:26.785 a little bit about my NOTE Confidence: 0.9642401 00:05:26.785 --> 00:05:27.765 personal background, NOTE Confidence: 0.99870396 00:05:29.105 --> 00:05:30.545 review some of the prior NOTE Confidence: 0.99870396 00:05:30.545 --> 00:05:31.665 work I've done as a NOTE Confidence: 0.99870396 00:05:31.665 --> 00:05:32.865 resident and a fellow, NOTE Confidence: 0.9991224 00:05:33.345 --> 00:05:34.085 and then NOTE Confidence: 0.93564194 00:05:34.510 --> 00:05:36.130 spend about twenty five minutes NOTE Confidence: 0.93564194 00:05:36.190 --> 00:05:36.670 on, NOTE Confidence: 0.985139 00:05:37.470 --> 00:05:39.070 some papers on the Inflation NOTE Confidence: 0.985139 00:05:39.070 --> 00:05:40.830 Reduction Act, which, is a NOTE Confidence: 0.985139 00:05:40.830 --> 00:05:42.690 big piece of legislation that NOTE Confidence: 0.985139 00:05:42.910 --> 00:05:44.510 totally changed the way we NOTE Confidence: 0.985139 00:05:44.510 --> 00:05:46.270 pay for prescription drugs for NOTE Confidence: 0.985139 00:05:46.270 --> 00:05:47.250 people with Medicare, NOTE Confidence: 0.92390394 00:05:48.214 --> 00:05:50.055 who represent about fifty million NOTE Confidence: 0.92390394 00:05:50.055 --> 00:05:50.555 people, NOTE Confidence: 0.99582976 00:05:50.935 --> 00:05:51.835 in the US. NOTE Confidence: 0.9748713 00:05:52.855 --> 00:05:54.375 And then I'll end with NOTE Confidence: 0.9748713 00:05:54.375 --> 00:05:55.654 the preview of what I NOTE Confidence: 0.9748713 00:05:55.654 --> 00:05:56.695 hope to do as a NOTE Confidence: 0.9748713 00:05:56.695 --> 00:05:59.255 junior faculty member, which focuses NOTE Confidence: 0.9748713 00:05:59.255 --> 00:06:00.695 on on a k award NOTE Confidence: 0.9748713 00:06:00.695 --> 00:06:02.154 application to the National NOTE Confidence: 0.99411273 00:06:02.979 --> 00:06:04.039 Institute on Aging. NOTE Confidence: 0.9989234 00:06:05.460 --> 00:06:06.740 I wanna thank everyone who NOTE Confidence: 0.9989234 00:06:06.740 --> 00:06:07.960 made this visit possible. NOTE Confidence: 0.86618215 00:06:09.139 --> 00:06:10.979 My son came a little NOTE Confidence: 0.86618215 00:06:10.979 --> 00:06:11.479 early, NOTE Confidence: 0.99736136 00:06:12.419 --> 00:06:13.139 on the day I was NOTE Confidence: 0.99736136 00:06:13.139 --> 00:06:13.860 supposed to be here, and NOTE Confidence: 0.99736136 00:06:13.860 --> 00:06:15.060 so he's very excited. He's NOTE Confidence: 0.99736136 00:06:15.139 --> 00:06:16.120 I know he's exploring NOTE Confidence: 0.9518606 00:06:16.495 --> 00:06:17.615 New Haven with my wife NOTE Confidence: 0.9518606 00:06:17.615 --> 00:06:19.294 right now, and so, these NOTE Confidence: 0.9518606 00:06:19.294 --> 00:06:19.955 are some, NOTE Confidence: 0.7508683 00:06:20.895 --> 00:06:21.395 photos NOTE Confidence: 0.9844539 00:06:21.854 --> 00:06:22.914 to you know, NOTE Confidence: 0.957758 00:06:23.615 --> 00:06:24.335 that I just had to NOTE Confidence: 0.957758 00:06:24.335 --> 00:06:25.235 share. You know? NOTE Confidence: 0.95218635 00:06:28.414 --> 00:06:30.035 So, just for background, NOTE Confidence: 0.99187684 00:06:30.574 --> 00:06:31.890 you know, I grew up NOTE Confidence: 0.99187684 00:06:31.970 --> 00:06:33.170 as the son of two NOTE Confidence: 0.99187684 00:06:33.170 --> 00:06:35.490 Chinese immigrants, and this really NOTE Confidence: 0.99187684 00:06:35.490 --> 00:06:37.190 was tremendously influential. NOTE Confidence: 0.98993313 00:06:38.050 --> 00:06:39.410 I got to see what NOTE Confidence: 0.98993313 00:06:39.410 --> 00:06:40.290 it was like to be NOTE Confidence: 0.98993313 00:06:40.290 --> 00:06:41.190 a new American, NOTE Confidence: 0.9400371 00:06:42.210 --> 00:06:44.050 some of the wonderful things NOTE Confidence: 0.9400371 00:06:44.050 --> 00:06:44.930 that come with that, and NOTE Confidence: 0.9400371 00:06:44.930 --> 00:06:45.915 of course, some of, NOTE Confidence: 0.9919719 00:06:46.714 --> 00:06:47.835 the challenges that come with NOTE Confidence: 0.9919719 00:06:47.835 --> 00:06:48.075 that. NOTE Confidence: 0.95388573 00:06:48.795 --> 00:06:50.635 I remember growing up seeing, NOTE Confidence: 0.95688105 00:06:51.355 --> 00:06:52.635 my parents went through periods NOTE Confidence: 0.95688105 00:06:52.635 --> 00:06:53.515 where they didn't have health NOTE Confidence: 0.95688105 00:06:53.515 --> 00:06:55.195 insurance. And even as a NOTE Confidence: 0.95688105 00:06:55.195 --> 00:06:56.635 young kid, you begin to NOTE Confidence: 0.95688105 00:06:56.635 --> 00:06:58.360 wonder, Oh, wow, like what NOTE Confidence: 0.95688105 00:06:58.440 --> 00:07:00.120 how is this affecting, their NOTE Confidence: 0.95688105 00:07:00.120 --> 00:07:01.400 lives? And I remember one NOTE Confidence: 0.95688105 00:07:01.400 --> 00:07:02.300 story I'll share. NOTE Confidence: 0.9628255 00:07:03.080 --> 00:07:04.279 My mom had a jaw NOTE Confidence: 0.9628255 00:07:04.279 --> 00:07:05.720 tumor where she really delayed NOTE Confidence: 0.9628255 00:07:05.720 --> 00:07:06.919 care because she didn't have NOTE Confidence: 0.9628255 00:07:06.919 --> 00:07:08.139 health insurance. And, NOTE Confidence: 0.9686143 00:07:08.599 --> 00:07:09.800 from a young age that NOTE Confidence: 0.9686143 00:07:09.800 --> 00:07:11.555 got me interested into what, NOTE Confidence: 0.9686143 00:07:11.555 --> 00:07:12.435 you know, what was going NOTE Confidence: 0.9686143 00:07:12.435 --> 00:07:13.474 on and and why, NOTE Confidence: 0.87750643 00:07:14.115 --> 00:07:16.215 why why these larger systems, NOTE Confidence: 0.99694884 00:07:16.835 --> 00:07:17.335 existed. NOTE Confidence: 0.99584895 00:07:19.235 --> 00:07:20.194 I did medical or I NOTE Confidence: 0.99584895 00:07:20.194 --> 00:07:21.875 did undergrad at the University NOTE Confidence: 0.99584895 00:07:21.875 --> 00:07:23.155 of Virginia, and I didn't NOTE Confidence: 0.99584895 00:07:23.155 --> 00:07:24.034 really know what I wanted NOTE Confidence: 0.99584895 00:07:24.034 --> 00:07:24.675 to study. I, NOTE Confidence: 0.8807566 00:07:25.630 --> 00:07:26.590 you know, basically, NOTE Confidence: 0.97921294 00:07:27.070 --> 00:07:28.190 did a major that really NOTE Confidence: 0.97921294 00:07:28.190 --> 00:07:29.330 was a lot of anthropology NOTE Confidence: 0.97921294 00:07:29.470 --> 00:07:29.970 classes. NOTE Confidence: 0.9800155 00:07:30.350 --> 00:07:31.790 And I knew that I NOTE Confidence: 0.9800155 00:07:31.790 --> 00:07:33.070 wanted to go into medicine, NOTE Confidence: 0.9800155 00:07:33.070 --> 00:07:34.270 but wasn't sure how to NOTE Confidence: 0.9800155 00:07:34.270 --> 00:07:35.230 bring it all together. NOTE Confidence: 0.9433546 00:07:35.790 --> 00:07:37.230 And it wasn't until medical NOTE Confidence: 0.9433546 00:07:37.230 --> 00:07:39.345 school, I, did a a NOTE Confidence: 0.9433546 00:07:39.345 --> 00:07:40.865 special program at my medical NOTE Confidence: 0.9433546 00:07:40.865 --> 00:07:41.845 school at UCSF, NOTE Confidence: 0.960903 00:07:42.145 --> 00:07:43.425 where you do your rotations NOTE Confidence: 0.960903 00:07:43.425 --> 00:07:45.025 at the county hospital. And, NOTE Confidence: 0.92675906 00:07:45.905 --> 00:07:47.425 I began to say, okay, NOTE Confidence: 0.92675906 00:07:47.425 --> 00:07:48.805 this is, like, very interesting. NOTE Confidence: 0.92675906 00:07:48.865 --> 00:07:49.905 Then I got to see NOTE Confidence: 0.92675906 00:07:49.905 --> 00:07:50.405 firsthand, NOTE Confidence: 0.98899174 00:07:51.389 --> 00:07:53.310 how important health insurance is NOTE Confidence: 0.98899174 00:07:53.310 --> 00:07:53.710 to, NOTE Confidence: 0.9867498 00:07:54.350 --> 00:07:56.350 clinical outcomes. And that was NOTE Confidence: 0.9867498 00:07:56.350 --> 00:07:57.630 really when I decided I'd NOTE Confidence: 0.9867498 00:07:57.630 --> 00:07:58.590 like to go down this NOTE Confidence: 0.9867498 00:07:58.590 --> 00:08:00.270 road of primary care and, NOTE Confidence: 0.9867498 00:08:00.509 --> 00:08:01.330 health policy. NOTE Confidence: 0.9702263 00:08:04.695 --> 00:08:06.455 At the time, Medicare for NOTE Confidence: 0.9702263 00:08:06.455 --> 00:08:07.335 all was really at the NOTE Confidence: 0.9702263 00:08:07.335 --> 00:08:09.515 national forefront of the policy NOTE Confidence: 0.9702263 00:08:09.575 --> 00:08:11.255 discussion, and so I was NOTE Confidence: 0.9702263 00:08:11.255 --> 00:08:12.795 motivated to try to understand NOTE Confidence: 0.9702263 00:08:12.855 --> 00:08:13.975 a little bit the larger NOTE Confidence: 0.9702263 00:08:13.975 --> 00:08:15.575 structural forces which, NOTE Confidence: 0.8834481 00:08:16.295 --> 00:08:18.075 influenced patient care. And so, NOTE Confidence: 0.95363194 00:08:18.695 --> 00:08:20.330 I spent a summer working NOTE Confidence: 0.95363194 00:08:20.330 --> 00:08:21.470 in the House of Representatives NOTE Confidence: 0.95363194 00:08:21.610 --> 00:08:23.210 and working on the Medicare NOTE Confidence: 0.95363194 00:08:23.210 --> 00:08:24.490 for all bill. And my NOTE Confidence: 0.95363194 00:08:24.490 --> 00:08:25.530 goal was to really bring NOTE Confidence: 0.95363194 00:08:25.530 --> 00:08:27.629 an academic lens to a NOTE Confidence: 0.95363194 00:08:27.770 --> 00:08:28.889 healthcare debate, which was NOTE Confidence: 0.95363194 00:08:28.889 --> 00:08:29.949 really being politicized. NOTE Confidence: 0.93819803 00:08:30.330 --> 00:08:32.010 And I, we we did NOTE Confidence: 0.93819803 00:08:32.010 --> 00:08:33.149 studies which found NOTE Confidence: 0.9986118 00:08:33.525 --> 00:08:34.184 the legislation NOTE Confidence: 0.9856766 00:08:34.485 --> 00:08:36.745 could, reduce national health expenditures NOTE Confidence: 0.9856766 00:08:36.885 --> 00:08:38.725 and increase resources for primary NOTE Confidence: 0.9856766 00:08:38.725 --> 00:08:39.385 care. And, NOTE Confidence: 0.9809515 00:08:39.925 --> 00:08:41.285 we we published those in NOTE Confidence: 0.9809515 00:08:41.285 --> 00:08:42.405 journals and shared them with NOTE Confidence: 0.9809515 00:08:42.405 --> 00:08:44.245 lawmakers. And this was the NOTE Confidence: 0.9809515 00:08:44.245 --> 00:08:45.684 first time where I I NOTE Confidence: 0.9809515 00:08:45.684 --> 00:08:46.980 thought, oh, wow. Like, if NOTE Confidence: 0.9809515 00:08:47.059 --> 00:08:48.899 doing research, you can play NOTE Confidence: 0.9809515 00:08:48.899 --> 00:08:49.940 a small part in the NOTE Confidence: 0.9809515 00:08:49.940 --> 00:08:51.620 larger health policy debate. And NOTE Confidence: 0.9809515 00:08:51.620 --> 00:08:53.300 that was very, exciting for NOTE Confidence: 0.9809515 00:08:53.300 --> 00:08:53.800 me. NOTE Confidence: 0.9719478 00:08:55.459 --> 00:08:56.579 I did a residency in NOTE Confidence: 0.9719478 00:08:56.579 --> 00:08:57.860 internal medicine with my now NOTE Confidence: 0.9719478 00:08:57.860 --> 00:08:58.820 wife, and this is one NOTE Confidence: 0.9719478 00:08:58.820 --> 00:09:00.199 of the first pages that, NOTE Confidence: 0.99081355 00:09:01.235 --> 00:09:02.355 we were able to send, NOTE Confidence: 0.99081355 00:09:02.595 --> 00:09:03.415 to each other. NOTE Confidence: 0.9544599 00:09:03.795 --> 00:09:04.675 And I think it's really NOTE Confidence: 0.9544599 00:09:04.675 --> 00:09:05.975 appropriate that it's an FYI NOTE Confidence: 0.9544599 00:09:06.035 --> 00:09:06.995 page. You know, you have NOTE Confidence: 0.9544599 00:09:06.995 --> 00:09:08.355 to be appropriate on the NOTE Confidence: 0.9544599 00:09:08.355 --> 00:09:09.955 level of triage for your NOTE Confidence: 0.9544599 00:09:09.955 --> 00:09:10.855 pages. So, NOTE Confidence: 0.9772703 00:09:11.394 --> 00:09:12.915 I'm glad that I, was NOTE Confidence: 0.9772703 00:09:12.915 --> 00:09:14.115 able to do that, day NOTE Confidence: 0.9772703 00:09:14.115 --> 00:09:15.415 one of intern year. NOTE Confidence: 0.8116256 00:09:17.140 --> 00:09:17.860 I did, NOTE Confidence: 0.9356775 00:09:18.340 --> 00:09:20.340 my, continuity clinic as a NOTE Confidence: 0.9356775 00:09:20.340 --> 00:09:21.800 resident was at FQHC, NOTE Confidence: 0.9883905 00:09:22.660 --> 00:09:23.160 and, NOTE Confidence: 0.9522063 00:09:23.620 --> 00:09:25.059 federally qualified health center in NOTE Confidence: 0.9522063 00:09:25.059 --> 00:09:25.559 Dorchester. NOTE Confidence: 0.9890307 00:09:26.980 --> 00:09:28.545 And this was something that NOTE Confidence: 0.9890307 00:09:28.545 --> 00:09:29.745 was really attractive to me NOTE Confidence: 0.9890307 00:09:29.745 --> 00:09:30.705 when trying to figure out NOTE Confidence: 0.9890307 00:09:30.705 --> 00:09:31.665 where I wanted to train. NOTE Confidence: 0.9890307 00:09:31.665 --> 00:09:32.165 And, NOTE Confidence: 0.99846345 00:09:32.545 --> 00:09:33.445 I just remember NOTE Confidence: 0.92316216 00:09:34.225 --> 00:09:35.425 rotating, you know, in the NOTE Confidence: 0.92316216 00:09:35.425 --> 00:09:35.925 coronary, NOTE Confidence: 0.95380986 00:09:36.545 --> 00:09:37.905 academic medical center and then NOTE Confidence: 0.95380986 00:09:37.905 --> 00:09:39.745 driving thirty minutes. And you NOTE Confidence: 0.95380986 00:09:39.745 --> 00:09:40.865 meet patients who have never NOTE Confidence: 0.95380986 00:09:40.865 --> 00:09:42.360 seen a physician and who NOTE Confidence: 0.95380986 00:09:42.360 --> 00:09:43.960 have, you know, come into NOTE Confidence: 0.95380986 00:09:43.960 --> 00:09:45.640 you with hemoptysis and are NOTE Confidence: 0.95380986 00:09:45.640 --> 00:09:47.660 refugees from other countries. And NOTE Confidence: 0.95380986 00:09:47.720 --> 00:09:49.240 it's a very humbling experience NOTE Confidence: 0.95380986 00:09:49.240 --> 00:09:51.320 and really cemented my interest NOTE Confidence: 0.95380986 00:09:51.320 --> 00:09:52.779 in primary care and, NOTE Confidence: 0.9604508 00:09:53.160 --> 00:09:55.080 working in the social safety NOTE Confidence: 0.9604508 00:09:55.080 --> 00:09:55.580 net. NOTE Confidence: 0.9711463 00:09:57.075 --> 00:09:58.774 And so through these experiences, NOTE Confidence: 0.8697543 00:09:59.075 --> 00:09:59.575 I've, NOTE Confidence: 0.97078514 00:10:00.755 --> 00:10:01.955 zeroed in on what I NOTE Confidence: 0.97078514 00:10:01.955 --> 00:10:03.395 hope is the motivating question NOTE Confidence: 0.97078514 00:10:03.395 --> 00:10:04.274 for my work, which is NOTE Confidence: 0.97078514 00:10:04.274 --> 00:10:05.395 how can we reform the NOTE Confidence: 0.97078514 00:10:05.395 --> 00:10:06.195 way we pay for health NOTE Confidence: 0.97078514 00:10:06.195 --> 00:10:06.515 care, NOTE Confidence: 0.98529446 00:10:07.075 --> 00:10:08.515 in the service of promoting NOTE Confidence: 0.98529446 00:10:08.515 --> 00:10:09.575 justice, efficiency, NOTE Confidence: 0.8985293 00:10:10.115 --> 00:10:11.175 and patient outcomes? NOTE Confidence: 0.9866457 00:10:12.370 --> 00:10:13.910 And I really see Medicare NOTE Confidence: 0.9866457 00:10:14.050 --> 00:10:15.490 as the area that I NOTE Confidence: 0.9866457 00:10:15.490 --> 00:10:16.610 would like to focus on NOTE Confidence: 0.9866457 00:10:16.610 --> 00:10:17.490 the first few years as NOTE Confidence: 0.9866457 00:10:17.490 --> 00:10:18.690 a junior faculty member. NOTE Confidence: 0.96480954 00:10:19.649 --> 00:10:21.010 And though I've branched out NOTE Confidence: 0.96480954 00:10:21.010 --> 00:10:22.529 and looked at other aspects NOTE Confidence: 0.96480954 00:10:22.529 --> 00:10:24.209 of healthcare financing and payment NOTE Confidence: 0.96480954 00:10:24.209 --> 00:10:25.970 reform, like private equity and, NOTE Confidence: 0.9946342 00:10:26.675 --> 00:10:28.295 the generic drug marketplace. NOTE Confidence: 0.96826637 00:10:29.795 --> 00:10:31.254 And in terms of methods, NOTE Confidence: 0.96826637 00:10:31.475 --> 00:10:32.675 as a resident and a NOTE Confidence: 0.96826637 00:10:32.675 --> 00:10:34.355 medical student, I really focused NOTE Confidence: 0.96826637 00:10:34.355 --> 00:10:36.675 on descriptive methods, like time NOTE Confidence: 0.96826637 00:10:36.675 --> 00:10:38.295 trends, systematic reviews, NOTE Confidence: 0.93165594 00:10:38.754 --> 00:10:39.875 and as a fellow, have NOTE Confidence: 0.93165594 00:10:39.875 --> 00:10:41.070 tried to gain more skills NOTE Confidence: 0.93165594 00:10:41.070 --> 00:10:42.770 in quasi experimental methods, NOTE Confidence: 0.9957202 00:10:44.030 --> 00:10:45.010 including pharmacoepidemiology NOTE Confidence: 0.97926944 00:10:45.790 --> 00:10:48.110 and and, techniques from the NOTE Confidence: 0.97926944 00:10:48.110 --> 00:10:48.610 econometrics, NOTE Confidence: 0.8802555 00:10:49.390 --> 00:10:51.330 literature, like difference in differences. NOTE Confidence: 0.9752176 00:10:52.670 --> 00:10:53.644 So hoping to spend a NOTE Confidence: 0.9752176 00:10:53.644 --> 00:10:55.165 few minutes just talking about NOTE Confidence: 0.9752176 00:10:55.165 --> 00:10:56.125 some of the work I've NOTE Confidence: 0.9752176 00:10:56.125 --> 00:10:57.024 done and then, NOTE Confidence: 0.9972845 00:10:57.404 --> 00:10:58.845 dive more deeply into a NOTE Confidence: 0.9972845 00:10:58.845 --> 00:10:59.725 study that I think has NOTE Confidence: 0.9972845 00:10:59.725 --> 00:11:00.944 a lot of clinical relevance, NOTE Confidence: 0.9868204 00:11:01.404 --> 00:11:03.264 on the Inflation Reduction Act. NOTE Confidence: 0.99445033 00:11:04.940 --> 00:11:05.839 So as a resident, NOTE Confidence: 0.94868404 00:11:06.140 --> 00:11:07.500 I did a series of NOTE Confidence: 0.94868404 00:11:07.500 --> 00:11:09.120 studies looking at racial disparities NOTE Confidence: 0.94868404 00:11:09.420 --> 00:11:12.079 and, high value diabetes medications, NOTE Confidence: 0.979282 00:11:13.179 --> 00:11:13.740 finding that, NOTE Confidence: 0.99594516 00:11:14.459 --> 00:11:14.959 unsurprisingly, NOTE Confidence: 0.9650988 00:11:16.140 --> 00:11:17.820 minority patients are less likely NOTE Confidence: 0.9650988 00:11:17.820 --> 00:11:20.000 to receive SGLT twos and NOTE Confidence: 0.9650988 00:11:20.184 --> 00:11:21.005 GLP ones, NOTE Confidence: 0.9760024 00:11:21.705 --> 00:11:22.905 which could be because of NOTE Confidence: 0.9760024 00:11:22.905 --> 00:11:25.245 lower visit rates to, specialist, NOTE Confidence: 0.95617646 00:11:25.625 --> 00:11:26.825 physicians who at the time NOTE Confidence: 0.95617646 00:11:26.825 --> 00:11:27.945 were much more likely to NOTE Confidence: 0.95617646 00:11:27.945 --> 00:11:29.165 prescribe these medications. NOTE Confidence: 0.9903842 00:11:31.305 --> 00:11:33.065 Building on my prior interest NOTE Confidence: 0.9903842 00:11:33.065 --> 00:11:34.205 in Medicare policy, NOTE Confidence: 0.9346468 00:11:35.030 --> 00:11:36.309 did a series of studies NOTE Confidence: 0.9346468 00:11:36.309 --> 00:11:38.870 with, colleagues and, looking at NOTE Confidence: 0.9346468 00:11:38.870 --> 00:11:40.870 the receipt of supplemental benefits, NOTE Confidence: 0.9346468 00:11:40.870 --> 00:11:42.630 dental, vision, and hearing in, NOTE Confidence: 0.9346468 00:11:43.110 --> 00:11:44.010 Medicare Advantage, NOTE Confidence: 0.97668284 00:11:44.950 --> 00:11:46.410 which is a very important NOTE Confidence: 0.97668284 00:11:46.470 --> 00:11:48.585 policy debate because Medicare Advantage NOTE Confidence: 0.97668284 00:11:48.585 --> 00:11:49.865 is paid more to provide NOTE Confidence: 0.97668284 00:11:49.865 --> 00:11:51.065 these benefits. And we found NOTE Confidence: 0.97668284 00:11:51.065 --> 00:11:51.565 that, NOTE Confidence: 0.9830312 00:11:51.945 --> 00:11:53.065 in a series of studies NOTE Confidence: 0.9830312 00:11:53.065 --> 00:11:54.665 that patients don't actually receive NOTE Confidence: 0.9830312 00:11:54.665 --> 00:11:56.025 those benefits at a higher NOTE Confidence: 0.9830312 00:11:56.025 --> 00:11:56.425 rate. NOTE Confidence: 0.9900411 00:11:57.225 --> 00:11:58.525 And so this has implications NOTE Confidence: 0.9900411 00:11:58.585 --> 00:11:59.465 for the way we pay NOTE Confidence: 0.9900411 00:11:59.465 --> 00:12:01.085 for, Medicare Advantage. NOTE Confidence: 0.96644884 00:12:02.559 --> 00:12:03.839 And as a fellow, really NOTE Confidence: 0.96644884 00:12:03.839 --> 00:12:06.019 focused on prescription drug policy NOTE Confidence: 0.96644884 00:12:06.079 --> 00:12:06.579 work. NOTE Confidence: 0.9737438 00:12:06.959 --> 00:12:07.459 So, NOTE Confidence: 0.9702571 00:12:08.160 --> 00:12:09.540 we looked at a program NOTE Confidence: 0.9702571 00:12:09.600 --> 00:12:10.800 that would have capped out NOTE Confidence: 0.9702571 00:12:10.800 --> 00:12:12.160 of pocket costs to two NOTE Confidence: 0.9702571 00:12:12.160 --> 00:12:13.860 dollars for generic medications, NOTE Confidence: 0.9968434 00:12:14.735 --> 00:12:15.695 and found that it would NOTE Confidence: 0.9968434 00:12:15.695 --> 00:12:17.135 only save about ten dollars NOTE Confidence: 0.9968434 00:12:17.135 --> 00:12:17.635 annually, NOTE Confidence: 0.99697095 00:12:18.015 --> 00:12:19.295 for thirty eight percent of NOTE Confidence: 0.99697095 00:12:19.295 --> 00:12:20.355 Medicare beneficiaries. NOTE Confidence: 0.9062864 00:12:21.695 --> 00:12:23.135 And we use this to, NOTE Confidence: 0.9062864 00:12:23.455 --> 00:12:24.575 we shared the results with NOTE Confidence: 0.9062864 00:12:24.575 --> 00:12:25.075 CMS, NOTE Confidence: 0.9612845 00:12:25.774 --> 00:12:27.054 Center for Medicare and Medicaid NOTE Confidence: 0.9612845 00:12:27.054 --> 00:12:29.339 Services Administrators. And we tried NOTE Confidence: 0.9612845 00:12:29.339 --> 00:12:30.860 to use this data to, NOTE Confidence: 0.9612845 00:12:31.100 --> 00:12:33.339 generate more evidence based policy NOTE Confidence: 0.9612845 00:12:33.339 --> 00:12:34.540 proposals and to make the NOTE Confidence: 0.9612845 00:12:34.540 --> 00:12:35.839 policy more generous. NOTE Confidence: 0.94372344 00:12:38.300 --> 00:12:38.959 And finally, NOTE Confidence: 0.9205807 00:12:39.579 --> 00:12:41.339 looking at one one another NOTE Confidence: 0.9205807 00:12:41.339 --> 00:12:42.459 analysis we did was to NOTE Confidence: 0.9205807 00:12:42.459 --> 00:12:43.875 look at, the patent, NOTE Confidence: 0.75832033 00:12:44.255 --> 00:12:44.755 marketplace, NOTE Confidence: 0.9826531 00:12:45.214 --> 00:12:46.815 and we found that we NOTE Confidence: 0.9826531 00:12:46.815 --> 00:12:48.095 looked at one case example NOTE Confidence: 0.9826531 00:12:48.095 --> 00:12:49.535 of doxepin, which is a NOTE Confidence: 0.9826531 00:12:49.535 --> 00:12:50.975 medication for sleep, NOTE Confidence: 0.9844917 00:12:51.694 --> 00:12:53.634 a first line medication recommended NOTE Confidence: 0.9844917 00:12:53.694 --> 00:12:54.675 by sleep societies. NOTE Confidence: 0.960088 00:12:55.550 --> 00:12:56.429 And we looked at a NOTE Confidence: 0.960088 00:12:56.429 --> 00:12:58.189 very interesting scenario where despite NOTE Confidence: 0.960088 00:12:58.189 --> 00:12:59.309 being a fifty year old NOTE Confidence: 0.960088 00:12:59.309 --> 00:12:59.809 medication, NOTE Confidence: 0.95613426 00:13:01.470 --> 00:13:02.670 a dose of Doxepin was NOTE Confidence: 0.95613426 00:13:02.670 --> 00:13:03.870 actually patented, which is a NOTE Confidence: 0.95613426 00:13:03.870 --> 00:13:06.269 very unusual case, where a NOTE Confidence: 0.95613426 00:13:06.269 --> 00:13:08.110 generic medication was patented because NOTE Confidence: 0.95613426 00:13:08.110 --> 00:13:09.809 of a lower dose. And NOTE Confidence: 0.9523248 00:13:10.595 --> 00:13:11.875 we showed that this patent NOTE Confidence: 0.9523248 00:13:11.875 --> 00:13:13.235 likely resulted in much higher NOTE Confidence: 0.9523248 00:13:13.235 --> 00:13:13.735 prices NOTE Confidence: 0.7321397 00:13:14.235 --> 00:13:14.735 and, NOTE Confidence: 0.93765074 00:13:15.554 --> 00:13:17.554 likely limited access to a NOTE Confidence: 0.93765074 00:13:17.554 --> 00:13:18.535 first line medication NOTE Confidence: 0.7856214 00:13:19.074 --> 00:13:19.735 for sleep NOTE Confidence: 0.9403836 00:13:20.355 --> 00:13:21.235 and led to a lot NOTE Confidence: 0.9403836 00:13:21.235 --> 00:13:23.235 of excess spending in addition NOTE Confidence: 0.9403836 00:13:23.235 --> 00:13:23.894 to that. NOTE Confidence: 0.9643791 00:13:25.960 --> 00:13:26.920 You know, one goal that NOTE Confidence: 0.9643791 00:13:26.920 --> 00:13:28.040 I had as a fellow NOTE Confidence: 0.9643791 00:13:28.040 --> 00:13:29.240 was to try to build NOTE Confidence: 0.9643791 00:13:29.240 --> 00:13:30.300 skills in pharmacoepidemiology, NOTE Confidence: 0.9946057 00:13:31.400 --> 00:13:32.779 and target trial emulation NOTE Confidence: 0.8674981 00:13:33.400 --> 00:13:35.260 and propensity score weighting, NOTE Confidence: 0.9953053 00:13:35.880 --> 00:13:36.839 and to try to get NOTE Confidence: 0.9953053 00:13:36.839 --> 00:13:38.440 more at causal questions. And NOTE Confidence: 0.9953053 00:13:38.440 --> 00:13:38.940 so NOTE Confidence: 0.9951598 00:13:40.115 --> 00:13:40.995 to address that, NOTE Confidence: 0.97306997 00:13:41.714 --> 00:13:42.915 we did a new user NOTE Confidence: 0.97306997 00:13:42.915 --> 00:13:43.415 analysis. NOTE Confidence: 0.97751784 00:13:44.035 --> 00:13:45.554 And the basic question for NOTE Confidence: 0.97751784 00:13:45.554 --> 00:13:47.475 this study was looking at, NOTE Confidence: 0.97751784 00:13:47.714 --> 00:13:49.315 does private equity, which are NOTE Confidence: 0.97751784 00:13:49.315 --> 00:13:50.774 investment firms, which, NOTE Confidence: 0.98064864 00:13:51.315 --> 00:13:53.394 have been purchasing hospitals, clinics, NOTE Confidence: 0.98064864 00:13:53.394 --> 00:13:54.375 and nursing homes, NOTE Confidence: 0.99514395 00:13:54.870 --> 00:13:56.309 do they contribute to a NOTE Confidence: 0.99514395 00:13:56.309 --> 00:13:57.910 higher risk of bankruptcy or NOTE Confidence: 0.99514395 00:13:57.910 --> 00:13:58.410 closure? NOTE Confidence: 0.9316441 00:13:59.190 --> 00:13:59.990 And you may have seen NOTE Confidence: 0.9316441 00:13:59.990 --> 00:14:01.030 in the news the closure NOTE Confidence: 0.9316441 00:14:01.030 --> 00:14:02.809 of hospitals like Henneman Hospital NOTE Confidence: 0.9316441 00:14:02.870 --> 00:14:04.630 or Stewart Healthcare in Boston NOTE Confidence: 0.9316441 00:14:04.630 --> 00:14:05.290 and Philadelphia. NOTE Confidence: 0.9808839 00:14:06.550 --> 00:14:07.350 And if you talk to NOTE Confidence: 0.9808839 00:14:07.350 --> 00:14:08.845 people at PE firms, they NOTE Confidence: 0.9808839 00:14:08.845 --> 00:14:10.444 say, well, we really we NOTE Confidence: 0.9808839 00:14:10.444 --> 00:14:11.884 buy hospitals that are going NOTE Confidence: 0.9808839 00:14:11.884 --> 00:14:13.245 to close anyway. We focus NOTE Confidence: 0.9808839 00:14:13.245 --> 00:14:14.545 on distressed assets. NOTE Confidence: 0.9755421 00:14:15.245 --> 00:14:16.365 And to try to address NOTE Confidence: 0.9755421 00:14:16.365 --> 00:14:18.365 that potential confounding, we did NOTE Confidence: 0.9755421 00:14:18.365 --> 00:14:20.144 a new user analysis where NOTE Confidence: 0.9755421 00:14:20.280 --> 00:14:22.140 we looked at healthy hospitals, NOTE Confidence: 0.9755421 00:14:22.200 --> 00:14:23.720 clinics, and nursing homes, which NOTE Confidence: 0.9755421 00:14:23.720 --> 00:14:25.160 had good finances. And we NOTE Confidence: 0.9755421 00:14:25.160 --> 00:14:26.380 compared them to NOTE Confidence: 0.97484785 00:14:26.680 --> 00:14:28.360 other hospitals, clinics, and nursing NOTE Confidence: 0.97484785 00:14:28.360 --> 00:14:29.260 homes that, NOTE Confidence: 0.9547204 00:14:29.640 --> 00:14:31.480 had very similar, finances, but NOTE Confidence: 0.9547204 00:14:31.480 --> 00:14:33.100 were purchased by other, NOTE Confidence: 0.9396827 00:14:34.495 --> 00:14:36.014 for profit firms that were NOTE Confidence: 0.9396827 00:14:36.014 --> 00:14:37.295 for profit, but not private NOTE Confidence: 0.9396827 00:14:37.295 --> 00:14:37.795 equity. NOTE Confidence: 0.9153581 00:14:38.495 --> 00:14:40.915 And we, addressed potential confounding NOTE Confidence: 0.9153581 00:14:40.975 --> 00:14:42.754 using propensity score weighting. NOTE Confidence: 0.92265075 00:14:43.855 --> 00:14:45.134 And using this this new NOTE Confidence: 0.92265075 00:14:45.134 --> 00:14:47.375 user active comparator framework, we NOTE Confidence: 0.92265075 00:14:47.375 --> 00:14:48.894 found that the private equity NOTE Confidence: 0.92265075 00:14:48.894 --> 00:14:49.230 acquired NOTE Confidence: 0.9142551 00:14:49.709 --> 00:14:51.790 healthcare organizations were about three NOTE Confidence: 0.9142551 00:14:51.790 --> 00:14:52.449 times higher, NOTE Confidence: 0.99465466 00:14:52.750 --> 00:14:54.290 more likely to experience, NOTE Confidence: 0.92107594 00:14:54.829 --> 00:14:55.570 the prespecified NOTE Confidence: 0.9729071 00:14:55.949 --> 00:14:58.269 composite outcome of, bankruptcy or NOTE Confidence: 0.9729071 00:14:58.269 --> 00:14:58.769 closure. NOTE Confidence: 0.9588355 00:14:59.470 --> 00:15:00.350 So we hope that this NOTE Confidence: 0.9588355 00:15:00.350 --> 00:15:02.610 contributes to literature and, ongoing, NOTE Confidence: 0.94997084 00:15:03.070 --> 00:15:05.745 congressional legislation, which would regulate, NOTE Confidence: 0.9567438 00:15:06.125 --> 00:15:07.805 these investment firms, which, NOTE Confidence: 0.99857664 00:15:08.285 --> 00:15:09.884 could potentially be contributing to NOTE Confidence: 0.99857664 00:15:09.884 --> 00:15:11.084 a higher risk of bankruptcy NOTE Confidence: 0.99857664 00:15:11.084 --> 00:15:11.745 or closure. NOTE Confidence: 0.9652959 00:15:14.125 --> 00:15:15.324 So a little bit about NOTE Confidence: 0.9652959 00:15:15.324 --> 00:15:16.764 my background and and now NOTE Confidence: 0.9652959 00:15:16.764 --> 00:15:18.925 hoping to focus on, what NOTE Confidence: 0.9652959 00:15:18.925 --> 00:15:19.964 I think is gonna be NOTE Confidence: 0.9652959 00:15:19.964 --> 00:15:21.610 the the focus of my NOTE Confidence: 0.9652959 00:15:21.610 --> 00:15:22.649 early years as a FACT NOTE Confidence: 0.9652959 00:15:22.649 --> 00:15:24.330 team member, and that's Medicare NOTE Confidence: 0.9652959 00:15:24.330 --> 00:15:25.630 policy and specifically NOTE Confidence: 0.9801676 00:15:26.250 --> 00:15:27.950 looking at the Inflation Reduction NOTE Confidence: 0.9801676 00:15:28.010 --> 00:15:28.510 Act. NOTE Confidence: 0.9252573 00:15:29.930 --> 00:15:31.450 So as many of you NOTE Confidence: 0.9252573 00:15:31.450 --> 00:15:32.625 may know, this is a NOTE Confidence: 0.9494664 00:15:33.105 --> 00:15:34.305 the Inflation Reduction Act is NOTE Confidence: 0.9494664 00:15:34.305 --> 00:15:35.345 a really big piece of NOTE Confidence: 0.9494664 00:15:35.345 --> 00:15:36.785 legislation. It was passed in NOTE Confidence: 0.9494664 00:15:36.785 --> 00:15:37.765 twenty twenty two. NOTE Confidence: 0.96433324 00:15:38.465 --> 00:15:39.985 It touched many parts of NOTE Confidence: 0.96433324 00:15:39.985 --> 00:15:40.645 the economy. NOTE Confidence: 0.9868173 00:15:41.025 --> 00:15:41.905 It took a lot of NOTE Confidence: 0.9868173 00:15:41.905 --> 00:15:43.425 political will to get across NOTE Confidence: 0.9868173 00:15:43.425 --> 00:15:44.965 the finish line. And so, NOTE Confidence: 0.92257047 00:15:45.640 --> 00:15:47.160 important to understand what it NOTE Confidence: 0.92257047 00:15:47.160 --> 00:15:48.360 did it did not do, NOTE Confidence: 0.92257047 00:15:48.600 --> 00:15:49.800 and also to, NOTE Confidence: 0.96252406 00:15:50.520 --> 00:15:51.240 make sure we get it NOTE Confidence: 0.96252406 00:15:51.240 --> 00:15:52.680 right, because it's probably the NOTE Confidence: 0.96252406 00:15:52.680 --> 00:15:53.800 largest piece of health care NOTE Confidence: 0.96252406 00:15:53.800 --> 00:15:55.560 legislation since the Affordable Care NOTE Confidence: 0.96252406 00:15:55.560 --> 00:15:56.060 Act. NOTE Confidence: 0.9541673 00:15:56.840 --> 00:15:58.535 And so we'll be focusing NOTE Confidence: 0.9541673 00:15:58.535 --> 00:16:00.055 on Medicare Part D, which NOTE Confidence: 0.9541673 00:16:00.055 --> 00:16:01.915 is the prescription drug benefit NOTE Confidence: 0.9541673 00:16:02.055 --> 00:16:04.055 for, that the Inflation Reduction NOTE Confidence: 0.9541673 00:16:04.055 --> 00:16:05.115 Act, reformed. NOTE Confidence: 0.99501365 00:16:06.055 --> 00:16:07.815 And just for background, Medicare NOTE Confidence: 0.99501365 00:16:07.815 --> 00:16:09.195 Part D, it's a voluntary NOTE Confidence: 0.99501365 00:16:09.415 --> 00:16:11.015 prescription drug benefit. And so NOTE Confidence: 0.99501365 00:16:11.015 --> 00:16:12.214 when you become eligible for NOTE Confidence: 0.99501365 00:16:12.214 --> 00:16:13.515 Medicare, you can buy NOTE Confidence: 0.9799396 00:16:14.270 --> 00:16:16.110 insurance to cover your prescription NOTE Confidence: 0.9799396 00:16:16.110 --> 00:16:18.270 drugs, and fifty million people NOTE Confidence: 0.9799396 00:16:18.270 --> 00:16:19.010 in the country NOTE Confidence: 0.93156433 00:16:19.470 --> 00:16:20.910 have some sort of Medicare NOTE Confidence: 0.93156433 00:16:20.910 --> 00:16:21.650 part d. NOTE Confidence: 0.9956934 00:16:22.270 --> 00:16:23.550 This is a public benefit. NOTE Confidence: 0.9956934 00:16:23.550 --> 00:16:24.510 We all pay for it NOTE Confidence: 0.9956934 00:16:24.510 --> 00:16:26.030 with our tax dollars, and NOTE Confidence: 0.9956934 00:16:26.030 --> 00:16:27.550 it is administered through private NOTE Confidence: 0.9956934 00:16:27.550 --> 00:16:28.050 plans. NOTE Confidence: 0.9802525 00:16:29.165 --> 00:16:30.045 And there are two types NOTE Confidence: 0.9802525 00:16:30.045 --> 00:16:31.325 of private plans. You can NOTE Confidence: 0.9802525 00:16:31.325 --> 00:16:33.345 get Medicare Advantage, which provides NOTE Confidence: 0.9802525 00:16:33.404 --> 00:16:35.024 wraparound care, inpatient, NOTE Confidence: 0.9940926 00:16:35.404 --> 00:16:35.904 outpatient, NOTE Confidence: 0.9405221 00:16:36.845 --> 00:16:38.765 and prescription drug, or you NOTE Confidence: 0.9405221 00:16:38.765 --> 00:16:40.680 can get traditional Medicare and NOTE Confidence: 0.9405221 00:16:40.760 --> 00:16:41.880 supplement it. So a little NOTE Confidence: 0.9405221 00:16:41.880 --> 00:16:43.880 complicated, but they're all private NOTE Confidence: 0.9405221 00:16:43.880 --> 00:16:44.380 plans, NOTE Confidence: 0.9591435 00:16:44.760 --> 00:16:45.580 and beneficiaries NOTE Confidence: 0.9963571 00:16:45.960 --> 00:16:47.180 shop for them through, NOTE Confidence: 0.99885154 00:16:47.560 --> 00:16:48.700 a regional marketplace. NOTE Confidence: 0.9732927 00:16:50.360 --> 00:16:52.200 And so that is the NOTE Confidence: 0.9732927 00:16:52.200 --> 00:16:53.320 background. And what was the NOTE Confidence: 0.9732927 00:16:53.320 --> 00:16:55.160 problem the legislation was aiming NOTE Confidence: 0.9732927 00:16:55.160 --> 00:16:56.485 to address, which, well, that NOTE Confidence: 0.9732927 00:16:56.485 --> 00:16:58.405 is Medicare patients historically have NOTE Confidence: 0.9732927 00:16:58.405 --> 00:16:59.605 paid very high out of NOTE Confidence: 0.9732927 00:16:59.605 --> 00:17:00.885 pocket costs if they took NOTE Confidence: 0.9732927 00:17:00.885 --> 00:17:01.865 expensive drugs. NOTE Confidence: 0.9180331 00:17:02.485 --> 00:17:03.285 And so it's a very NOTE Confidence: 0.9180331 00:17:03.285 --> 00:17:04.825 complicated benefit historically. NOTE Confidence: 0.9613964 00:17:05.925 --> 00:17:07.145 There was the deductible, NOTE Confidence: 0.93278074 00:17:07.845 --> 00:17:09.750 there was initial coverage, and NOTE Confidence: 0.93278074 00:17:09.750 --> 00:17:11.109 then somehow it got worse NOTE Confidence: 0.93278074 00:17:11.109 --> 00:17:12.070 after a while. You may NOTE Confidence: 0.93278074 00:17:12.070 --> 00:17:12.869 have heard of the donut NOTE Confidence: 0.93278074 00:17:12.869 --> 00:17:13.990 hole, and then there was NOTE Confidence: 0.93278074 00:17:13.990 --> 00:17:15.369 the catastrophic phase. NOTE Confidence: 0.9500112 00:17:16.070 --> 00:17:17.590 The bottom line is that NOTE Confidence: 0.9500112 00:17:17.590 --> 00:17:18.090 historically, NOTE Confidence: 0.95786685 00:17:18.710 --> 00:17:20.150 costs were not capped. And NOTE Confidence: 0.95786685 00:17:20.150 --> 00:17:21.750 so you could pay ten, NOTE Confidence: 0.95786685 00:17:21.750 --> 00:17:23.430 fifteen, twenty thousand dollars out NOTE Confidence: 0.95786685 00:17:23.430 --> 00:17:24.615 of pocket if you were NOTE Confidence: 0.95786685 00:17:24.855 --> 00:17:26.135 unfortunate enough to, you know, NOTE Confidence: 0.95786685 00:17:26.135 --> 00:17:27.815 be diagnosed with cancer or NOTE Confidence: 0.95786685 00:17:27.815 --> 00:17:29.355 if you had rheumatoid arthritis, NOTE Confidence: 0.95786685 00:17:29.494 --> 00:17:30.375 if you were taking an NOTE Confidence: 0.95786685 00:17:30.375 --> 00:17:31.434 expensive medication. NOTE Confidence: 0.97528714 00:17:32.855 --> 00:17:34.215 And you paid five percent NOTE Confidence: 0.97528714 00:17:34.215 --> 00:17:34.715 indefinitely, NOTE Confidence: 0.997824 00:17:35.015 --> 00:17:36.135 even in the most generous NOTE Confidence: 0.997824 00:17:36.135 --> 00:17:37.755 phase, the catastrophic phase. NOTE Confidence: 0.98341244 00:17:38.295 --> 00:17:40.000 And so that's a lot NOTE Confidence: 0.98341244 00:17:40.000 --> 00:17:41.600 of wonky information, a very NOTE Confidence: 0.98341244 00:17:41.600 --> 00:17:42.880 complicated benefit. And I think NOTE Confidence: 0.98341244 00:17:42.880 --> 00:17:44.660 it's really helpful to illustrate, NOTE Confidence: 0.9831516 00:17:45.040 --> 00:17:46.320 this with some patients who NOTE Confidence: 0.9831516 00:17:46.320 --> 00:17:48.500 you, likely have seen. So, NOTE Confidence: 0.98075485 00:17:48.880 --> 00:17:50.080 we'll take Mr. A on NOTE Confidence: 0.98075485 00:17:50.080 --> 00:17:51.440 the left. He's a seven NOTE Confidence: 0.98075485 00:17:51.440 --> 00:17:52.900 year old man with hypertension, NOTE Confidence: 0.98075485 00:17:53.040 --> 00:17:54.500 atrial fibrillation, hyperlipidemia. NOTE Confidence: 0.98188096 00:17:55.414 --> 00:17:57.575 And then, Mrs. B, same NOTE Confidence: 0.98188096 00:17:57.575 --> 00:17:59.174 conditions, but she has chronic NOTE Confidence: 0.98188096 00:17:59.174 --> 00:18:00.315 lymphocytic leukemia. NOTE Confidence: 0.9658569 00:18:01.494 --> 00:18:02.715 And here are the medications NOTE Confidence: 0.9658569 00:18:02.775 --> 00:18:04.375 they take. These are likely NOTE Confidence: 0.9658569 00:18:04.375 --> 00:18:05.655 gonna look familiar to you. NOTE Confidence: 0.9658569 00:18:05.655 --> 00:18:07.034 And then the monthly costs. NOTE Confidence: 0.96764463 00:18:07.970 --> 00:18:09.170 And you'll see right away, NOTE Confidence: 0.96764463 00:18:09.410 --> 00:18:11.410 for mister a, the majority NOTE Confidence: 0.96764463 00:18:11.410 --> 00:18:12.690 of the monthly price, the NOTE Confidence: 0.96764463 00:18:12.690 --> 00:18:13.190 prices, NOTE Confidence: 0.91674834 00:18:13.890 --> 00:18:15.810 are absorbed by apixaban or NOTE Confidence: 0.91674834 00:18:15.810 --> 00:18:17.090 Eliquis brand name. NOTE Confidence: 0.98363674 00:18:17.570 --> 00:18:19.109 And then for missus b, NOTE Confidence: 0.98363674 00:18:19.250 --> 00:18:20.550 she's taking the same medications, NOTE Confidence: 0.98363674 00:18:20.609 --> 00:18:21.990 but now she's taking imbrutinib, NOTE Confidence: 0.9673386 00:18:22.290 --> 00:18:24.195 which is a very costly NOTE Confidence: 0.9673386 00:18:24.255 --> 00:18:26.115 medication effective, but very costly, NOTE Confidence: 0.9673386 00:18:26.415 --> 00:18:27.395 for her CLL. NOTE Confidence: 0.93688685 00:18:28.095 --> 00:18:29.615 And so if those are NOTE Confidence: 0.93688685 00:18:29.615 --> 00:18:30.575 the prices and if you NOTE Confidence: 0.93688685 00:18:30.575 --> 00:18:31.775 just do the algebra that NOTE Confidence: 0.93688685 00:18:31.775 --> 00:18:32.575 we saw on the last NOTE Confidence: 0.93688685 00:18:32.575 --> 00:18:34.575 slide, the complicated benefit, this NOTE Confidence: 0.93688685 00:18:34.575 --> 00:18:35.455 is how much they would NOTE Confidence: 0.93688685 00:18:35.455 --> 00:18:37.169 pay per year. So Mr. NOTE Confidence: 0.93688685 00:18:37.169 --> 00:18:38.289 A is paying about six NOTE Confidence: 0.93688685 00:18:38.289 --> 00:18:39.409 hundred per year and then, NOTE Confidence: 0.93688685 00:18:39.409 --> 00:18:40.769 oh, wow, Mrs. Buchi's paying NOTE Confidence: 0.93688685 00:18:40.769 --> 00:18:41.909 about fifteen thousand. NOTE Confidence: 0.98314095 00:18:42.289 --> 00:18:43.330 And that's because you take NOTE Confidence: 0.98314095 00:18:43.330 --> 00:18:44.389 the price of Imbrutinib NOTE Confidence: 0.9703458 00:18:44.690 --> 00:18:45.570 and you just run it NOTE Confidence: 0.9703458 00:18:45.570 --> 00:18:46.710 through the four phases. NOTE Confidence: 0.97187114 00:18:47.090 --> 00:18:48.529 And because it's a two NOTE Confidence: 0.97187114 00:18:48.529 --> 00:18:49.570 hundred thousand dollars a year NOTE Confidence: 0.97187114 00:18:49.570 --> 00:18:50.929 medication, even if you pay NOTE Confidence: 0.97187114 00:18:50.929 --> 00:18:51.889 a small amount, dollars five NOTE Confidence: 0.97187114 00:18:51.889 --> 00:18:53.445 percent, it just starts to NOTE Confidence: 0.97187114 00:18:53.445 --> 00:18:54.725 really add up. And so NOTE Confidence: 0.97187114 00:18:54.725 --> 00:18:55.924 this is really the problem NOTE Confidence: 0.97187114 00:18:55.924 --> 00:18:56.965 the law zeroed in on. NOTE Confidence: 0.97187114 00:18:56.965 --> 00:18:58.025 We have these patients NOTE Confidence: 0.9204301 00:18:58.405 --> 00:18:59.525 like Mrs. B who are NOTE Confidence: 0.9204301 00:18:59.525 --> 00:19:01.285 paying untenable amounts for their NOTE Confidence: 0.9204301 00:19:01.285 --> 00:19:01.785 medications. NOTE Confidence: 0.98211515 00:19:02.885 --> 00:19:03.765 And so what did the NOTE Confidence: 0.98211515 00:19:03.765 --> 00:19:05.684 law do? It imposed an NOTE Confidence: 0.98211515 00:19:05.684 --> 00:19:07.169 out of pocket cap. And NOTE Confidence: 0.98211515 00:19:07.169 --> 00:19:08.710 so in twenty twenty four, NOTE Confidence: 0.98211515 00:19:08.850 --> 00:19:09.889 that cap was thirty three NOTE Confidence: 0.98211515 00:19:09.889 --> 00:19:10.929 hundred dollars, and then it NOTE Confidence: 0.98211515 00:19:10.929 --> 00:19:12.049 was lowered to two thousand NOTE Confidence: 0.98211515 00:19:12.049 --> 00:19:13.590 dollars in twenty twenty five. NOTE Confidence: 0.97460186 00:19:14.369 --> 00:19:15.730 And an important feature of NOTE Confidence: 0.97460186 00:19:15.730 --> 00:19:17.090 the law was that these NOTE Confidence: 0.97460186 00:19:17.090 --> 00:19:19.009 private plans were now tasked NOTE Confidence: 0.97460186 00:19:19.009 --> 00:19:20.744 with paying a large proportion NOTE Confidence: 0.97460186 00:19:20.744 --> 00:19:22.265 of that. And so now NOTE Confidence: 0.97460186 00:19:22.265 --> 00:19:23.945 these private plans, you go NOTE Confidence: 0.97460186 00:19:23.945 --> 00:19:25.225 on a marketplace, they have NOTE Confidence: 0.97460186 00:19:25.225 --> 00:19:26.425 to pay. It's about sixty NOTE Confidence: 0.97460186 00:19:26.425 --> 00:19:27.945 percent of all costs above NOTE Confidence: 0.97460186 00:19:27.945 --> 00:19:29.545 the cap. And so we're NOTE Confidence: 0.97460186 00:19:29.545 --> 00:19:31.145 asking these private plans, like, NOTE Confidence: 0.97460186 00:19:31.145 --> 00:19:32.105 to in a in a NOTE Confidence: 0.97460186 00:19:32.105 --> 00:19:33.465 noble fashion to to pay NOTE Confidence: 0.97460186 00:19:33.465 --> 00:19:34.905 more to cover patients like NOTE Confidence: 0.97460186 00:19:34.905 --> 00:19:35.740 missus Speed. NOTE Confidence: 0.9910115 00:19:36.440 --> 00:19:37.800 And so this is a NOTE Confidence: 0.9910115 00:19:37.800 --> 00:19:39.320 brand new benefit. Twenty twenty NOTE Confidence: 0.9910115 00:19:39.320 --> 00:19:40.359 five is the first time NOTE Confidence: 0.9910115 00:19:40.359 --> 00:19:41.560 this two thousand dollar out NOTE Confidence: 0.9910115 00:19:41.560 --> 00:19:43.020 of pocket cap was imposed. NOTE Confidence: 0.9910115 00:19:43.080 --> 00:19:43.740 And so, NOTE Confidence: 0.9854784 00:19:44.520 --> 00:19:46.200 some studies that my colleagues NOTE Confidence: 0.9854784 00:19:46.200 --> 00:19:47.400 and I have have attempted NOTE Confidence: 0.9854784 00:19:47.400 --> 00:19:48.619 to do was to assess NOTE Confidence: 0.9854784 00:19:48.915 --> 00:19:50.515 insurer responses. And so we NOTE Confidence: 0.9854784 00:19:50.515 --> 00:19:51.635 know that these are private NOTE Confidence: 0.9854784 00:19:51.635 --> 00:19:52.835 entities. We know that they NOTE Confidence: 0.9854784 00:19:52.835 --> 00:19:53.895 are likely NOTE Confidence: 0.99930656 00:19:54.275 --> 00:19:55.635 to respond in a fairly NOTE Confidence: 0.99930656 00:19:55.635 --> 00:19:56.615 predictable fashion. NOTE Confidence: 0.9956687 00:19:57.235 --> 00:19:58.355 Number one, could they leave NOTE Confidence: 0.9956687 00:19:58.355 --> 00:19:59.015 the marketplace? NOTE Confidence: 0.9964677 00:19:59.715 --> 00:20:01.315 Could they raise deductibles or NOTE Confidence: 0.9964677 00:20:01.315 --> 00:20:02.970 the amount that you have NOTE Confidence: 0.9964677 00:20:02.970 --> 00:20:04.090 to pay as a patient NOTE Confidence: 0.9964677 00:20:04.090 --> 00:20:05.630 before the plan kicks in? NOTE Confidence: 0.9857148 00:20:05.930 --> 00:20:07.390 Could they modify a formulary? NOTE Confidence: 0.9857148 00:20:07.450 --> 00:20:08.250 Could they make it more, NOTE Confidence: 0.9857148 00:20:08.250 --> 00:20:09.450 you know, more difficult or NOTE Confidence: 0.9857148 00:20:09.450 --> 00:20:10.890 more costly to access these NOTE Confidence: 0.9857148 00:20:10.890 --> 00:20:11.390 medications? NOTE Confidence: 0.9045241 00:20:12.010 --> 00:20:13.450 Or premiums, the the gym NOTE Confidence: 0.9045241 00:20:13.450 --> 00:20:15.284 membership, the monthly peep payment NOTE Confidence: 0.9045241 00:20:15.284 --> 00:20:15.684 you have. NOTE Confidence: 0.96742076 00:20:16.484 --> 00:20:18.004 With the asterisk there that NOTE Confidence: 0.96742076 00:20:18.004 --> 00:20:19.365 the law really prevented that NOTE Confidence: 0.96742076 00:20:19.365 --> 00:20:20.804 from happening, they subsidized the NOTE Confidence: 0.96742076 00:20:20.804 --> 00:20:21.284 premiums. NOTE Confidence: 0.99136066 00:20:21.605 --> 00:20:22.565 So we didn't think that NOTE Confidence: 0.99136066 00:20:22.565 --> 00:20:23.865 was really going to happen. NOTE Confidence: 0.96204627 00:20:24.804 --> 00:20:26.085 And so that's objective number NOTE Confidence: 0.96204627 00:20:26.085 --> 00:20:27.684 one of my fellowship, a NOTE Confidence: 0.96204627 00:20:27.684 --> 00:20:28.919 series of studies looking at NOTE Confidence: 0.96204627 00:20:28.919 --> 00:20:30.440 what did the insurers do NOTE Confidence: 0.96204627 00:20:30.440 --> 00:20:31.880 when they had to provide NOTE Confidence: 0.96204627 00:20:31.880 --> 00:20:33.340 much more generous coverage. NOTE Confidence: 0.94832915 00:20:34.359 --> 00:20:36.359 We used publicly available data, NOTE Confidence: 0.94832915 00:20:36.600 --> 00:20:37.720 from the Medi Center for NOTE Confidence: 0.94832915 00:20:37.720 --> 00:20:39.320 Medicare and Medicaid Services, and NOTE Confidence: 0.94832915 00:20:39.320 --> 00:20:40.600 we looked at all, of NOTE Confidence: 0.94832915 00:20:40.600 --> 00:20:41.740 these private plans. NOTE Confidence: 0.9735775 00:20:42.494 --> 00:20:44.275 And consistent with those hypothesized NOTE Confidence: 0.9688045 00:20:44.734 --> 00:20:46.595 insurer responses, we calculated, NOTE Confidence: 0.99409634 00:20:47.375 --> 00:20:47.695 the, NOTE Confidence: 0.93497944 00:20:48.175 --> 00:20:49.855 the enrollee weighted and inflation NOTE Confidence: 0.93497944 00:20:49.855 --> 00:20:50.355 adjusted, NOTE Confidence: 0.9741783 00:20:50.655 --> 00:20:51.775 percent of people who were NOTE Confidence: 0.9741783 00:20:51.775 --> 00:20:53.535 affected by their insurer totally NOTE Confidence: 0.9741783 00:20:53.535 --> 00:20:54.035 leaving, NOTE Confidence: 0.959216 00:20:55.119 --> 00:20:56.480 out of pocket costs for NOTE Confidence: 0.959216 00:20:56.480 --> 00:20:57.940 nine top selling medications. NOTE Confidence: 0.9642966 00:20:59.040 --> 00:21:00.080 We looked at whether a NOTE Confidence: 0.9642966 00:21:00.080 --> 00:21:01.119 medication was paid by a NOTE Confidence: 0.9642966 00:21:01.119 --> 00:21:02.400 co payment, which is typically NOTE Confidence: 0.9642966 00:21:02.400 --> 00:21:03.600 a flat amount, thirty to NOTE Confidence: 0.9642966 00:21:03.600 --> 00:21:04.980 forty dollars, or coinsurance, NOTE Confidence: 0.949772 00:21:05.280 --> 00:21:06.800 which is typically a percent NOTE Confidence: 0.949772 00:21:06.800 --> 00:21:08.005 of a drug's cost, NOTE Confidence: 0.99156815 00:21:08.305 --> 00:21:09.685 with the idea that coinsurance NOTE Confidence: 0.99156815 00:21:09.745 --> 00:21:11.185 is typically much more because NOTE Confidence: 0.99156815 00:21:11.185 --> 00:21:12.465 it's, you know, thirty percent NOTE Confidence: 0.99156815 00:21:12.465 --> 00:21:13.665 of a thousand or five NOTE Confidence: 0.99156815 00:21:13.665 --> 00:21:14.705 hundred. So it just ends NOTE Confidence: 0.99156815 00:21:14.705 --> 00:21:15.845 up being much more. NOTE Confidence: 0.9988211 00:21:16.305 --> 00:21:17.185 And then we looked at NOTE Confidence: 0.9988211 00:21:17.185 --> 00:21:18.405 deductibles and premiums. NOTE Confidence: 0.9602195 00:21:19.519 --> 00:21:20.659 We looked at different subgroups NOTE Confidence: 0.9602195 00:21:20.879 --> 00:21:22.480 as well, and this was NOTE Confidence: 0.9602195 00:21:22.480 --> 00:21:24.100 a partially descriptive analysis. NOTE Confidence: 0.98635954 00:21:25.759 --> 00:21:27.359 And so on the x NOTE Confidence: 0.98635954 00:21:27.359 --> 00:21:29.279 axis here, you have year. NOTE Confidence: 0.98635954 00:21:29.279 --> 00:21:30.320 On the y axis, you NOTE Confidence: 0.98635954 00:21:30.320 --> 00:21:31.519 have the percent of people NOTE Confidence: 0.98635954 00:21:31.519 --> 00:21:32.960 who were affected by their NOTE Confidence: 0.98635954 00:21:32.960 --> 00:21:34.965 insurance plan just totally leaving, NOTE Confidence: 0.98635954 00:21:35.184 --> 00:21:35.845 the marketplace. NOTE Confidence: 0.8164237 00:21:37.024 --> 00:21:38.024 And, you know, bef NOTE Confidence: 0.9482128 00:21:38.625 --> 00:21:39.984 a priority that could be NOTE Confidence: 0.9482128 00:21:39.984 --> 00:21:41.264 a really bad thing. Right? NOTE Confidence: 0.9482128 00:21:41.264 --> 00:21:42.625 It leads to disruptions in NOTE Confidence: 0.9482128 00:21:42.625 --> 00:21:43.125 coverage. NOTE Confidence: 0.96704173 00:21:43.825 --> 00:21:45.184 This is a voluntary benefit, NOTE Confidence: 0.96704173 00:21:45.184 --> 00:21:46.225 so people might not even NOTE Confidence: 0.96704173 00:21:46.225 --> 00:21:47.580 know. They may, you know, NOTE Confidence: 0.96704173 00:21:47.820 --> 00:21:49.179 basically, in January, they may NOTE Confidence: 0.96704173 00:21:49.179 --> 00:21:49.899 be like, oh, I don't NOTE Confidence: 0.96704173 00:21:49.899 --> 00:21:51.260 have health insurance anymore for NOTE Confidence: 0.96704173 00:21:51.260 --> 00:21:52.080 my medications. NOTE Confidence: 0.93360794 00:21:52.700 --> 00:21:53.899 And you can see that NOTE Confidence: 0.93360794 00:21:53.899 --> 00:21:55.820 essentially over time, consistent with NOTE Confidence: 0.93360794 00:21:55.820 --> 00:21:57.440 the implementation of the law, NOTE Confidence: 0.93360794 00:21:57.500 --> 00:21:58.539 more and more people are NOTE Confidence: 0.93360794 00:21:58.539 --> 00:22:00.059 affected by their insurer just NOTE Confidence: 0.93360794 00:22:00.059 --> 00:22:01.500 leaving. And so by twenty NOTE Confidence: 0.93360794 00:22:01.500 --> 00:22:03.039 twenty four, the most recent, NOTE Confidence: 0.999075 00:22:03.375 --> 00:22:04.335 year of data we have NOTE Confidence: 0.999075 00:22:04.335 --> 00:22:04.835 available, NOTE Confidence: 0.9899016 00:22:05.695 --> 00:22:06.815 eight percent of people, NOTE Confidence: 0.9993226 00:22:07.215 --> 00:22:07.875 are just NOTE Confidence: 0.9974666 00:22:08.175 --> 00:22:09.155 in that year, NOTE Confidence: 0.97292894 00:22:09.855 --> 00:22:11.855 they had no prescription drug, NOTE Confidence: 0.97292894 00:22:12.095 --> 00:22:13.455 insurance, that their insurer just NOTE Confidence: 0.97292894 00:22:13.455 --> 00:22:15.455 totally left. And so unless NOTE Confidence: 0.97292894 00:22:15.455 --> 00:22:16.950 they took the effort to NOTE Confidence: 0.97292894 00:22:17.029 --> 00:22:18.389 go to open enrollment and NOTE Confidence: 0.97292894 00:22:18.389 --> 00:22:19.750 to find another insurer, they NOTE Confidence: 0.97292894 00:22:19.750 --> 00:22:21.609 they no longer had, prescription NOTE Confidence: 0.97292894 00:22:21.669 --> 00:22:22.889 drug, coverage. NOTE Confidence: 0.9757243 00:22:24.389 --> 00:22:26.070 This, unfortunately, was consistent too NOTE Confidence: 0.9757243 00:22:26.070 --> 00:22:28.090 in different, subgroups of insurance NOTE Confidence: 0.9757243 00:22:28.149 --> 00:22:28.649 plans. NOTE Confidence: 0.97111183 00:22:30.185 --> 00:22:31.625 We looked at deductibles. And NOTE Confidence: 0.97111183 00:22:31.625 --> 00:22:32.585 I I think on the NOTE Confidence: 0.97111183 00:22:32.585 --> 00:22:33.945 x axis here, you see NOTE Confidence: 0.97111183 00:22:33.945 --> 00:22:34.984 year, and on the y NOTE Confidence: 0.97111183 00:22:34.984 --> 00:22:36.984 axis, the inflation adjusted deductible. NOTE Confidence: 0.97111183 00:22:36.984 --> 00:22:37.865 And I think the key NOTE Confidence: 0.97111183 00:22:37.865 --> 00:22:39.225 thing to highlight is there's NOTE Confidence: 0.97111183 00:22:39.225 --> 00:22:40.425 a huge jump for Medicare NOTE Confidence: 0.97111183 00:22:40.425 --> 00:22:42.185 Advantage plans, which were charging NOTE Confidence: 0.97111183 00:22:42.185 --> 00:22:43.625 about sixty six dollars on NOTE Confidence: 0.97111183 00:22:43.625 --> 00:22:45.000 average in twenty twenty four, NOTE Confidence: 0.9703966 00:22:45.480 --> 00:22:46.760 which was trending down. And NOTE Confidence: 0.9703966 00:22:46.760 --> 00:22:48.359 then, there's a large increase NOTE Confidence: 0.9703966 00:22:48.359 --> 00:22:49.400 to twenty twenty five when NOTE Confidence: 0.9703966 00:22:49.400 --> 00:22:50.600 the two thousand dollar cap NOTE Confidence: 0.9703966 00:22:50.600 --> 00:22:51.260 was implemented, NOTE Confidence: 0.99247843 00:22:51.880 --> 00:22:52.920 about a hundred and sixty NOTE Confidence: 0.99247843 00:22:52.920 --> 00:22:53.740 dollar increase. NOTE Confidence: 0.95080376 00:22:54.920 --> 00:22:56.359 In the stand alone plans, NOTE Confidence: 0.95080376 00:22:56.359 --> 00:22:57.880 a more gentle increase that NOTE Confidence: 0.95080376 00:22:57.880 --> 00:22:59.400 really predated when the law NOTE Confidence: 0.95080376 00:22:59.400 --> 00:23:00.060 was implemented. NOTE Confidence: 0.9539914 00:23:02.085 --> 00:23:03.445 Here are nine top selling NOTE Confidence: 0.9539914 00:23:03.445 --> 00:23:05.125 medications, and we we assess NOTE Confidence: 0.9539914 00:23:05.125 --> 00:23:06.244 what the monthly out of NOTE Confidence: 0.9539914 00:23:06.244 --> 00:23:07.545 pocket cost would be. NOTE Confidence: 0.9483859 00:23:08.244 --> 00:23:09.205 And you can see these NOTE Confidence: 0.9483859 00:23:09.205 --> 00:23:11.125 are high value medications. They're NOTE Confidence: 0.9483859 00:23:11.125 --> 00:23:12.425 used to treat diabetes, NOTE Confidence: 0.9794111 00:23:13.045 --> 00:23:13.945 atrial fibrillation. NOTE Confidence: 0.99043286 00:23:15.685 --> 00:23:16.500 They they NOTE Confidence: 0.98193896 00:23:17.140 --> 00:23:18.980 CKD, and they have very NOTE Confidence: 0.98193896 00:23:18.980 --> 00:23:20.119 high clinical value. NOTE Confidence: 0.98160386 00:23:20.500 --> 00:23:21.619 And you can see here NOTE Confidence: 0.98160386 00:23:21.619 --> 00:23:22.119 on, NOTE Confidence: 0.95260775 00:23:23.300 --> 00:23:24.820 the x axis is year NOTE Confidence: 0.95260775 00:23:24.820 --> 00:23:26.020 again, and the y axis, NOTE Confidence: 0.95260775 00:23:26.020 --> 00:23:27.800 the monthly costs. And unfortunately, NOTE Confidence: 0.95260775 00:23:27.859 --> 00:23:29.425 a similar trend where the NOTE Confidence: 0.95260775 00:23:29.425 --> 00:23:30.945 costs are increasing in twenty NOTE Confidence: 0.95260775 00:23:30.945 --> 00:23:32.545 twenty five in both in NOTE Confidence: 0.95260775 00:23:32.545 --> 00:23:33.905 both kinds of plans by NOTE Confidence: 0.95260775 00:23:33.905 --> 00:23:35.125 about thirty three percent. NOTE Confidence: 0.8902688 00:23:38.225 --> 00:23:40.225 This is basically explaining what NOTE Confidence: 0.8902688 00:23:40.225 --> 00:23:40.725 caused, NOTE Confidence: 0.97479284 00:23:41.025 --> 00:23:42.145 these costs to go up. NOTE Confidence: 0.97479284 00:23:42.385 --> 00:23:43.345 This is the percent of NOTE Confidence: 0.97479284 00:23:43.345 --> 00:23:44.950 people who paid coinsurance, which NOTE Confidence: 0.97479284 00:23:44.950 --> 00:23:46.149 is that percent of a NOTE Confidence: 0.97479284 00:23:46.149 --> 00:23:47.049 drug's cost. NOTE Confidence: 0.9596837 00:23:47.350 --> 00:23:48.710 And and, essentially, that is NOTE Confidence: 0.9596837 00:23:48.710 --> 00:23:50.070 what's explaining it. People are NOTE Confidence: 0.9596837 00:23:50.070 --> 00:23:52.149 shifting from these thirty dollar NOTE Confidence: 0.9596837 00:23:52.149 --> 00:23:53.269 co payments per month for NOTE Confidence: 0.9596837 00:23:53.269 --> 00:23:54.950 brand name medications to a NOTE Confidence: 0.9596837 00:23:54.950 --> 00:23:56.389 coinsurance, which could be hundreds NOTE Confidence: 0.9596837 00:23:56.389 --> 00:23:57.769 of dollars per month. NOTE Confidence: 0.97508436 00:23:59.525 --> 00:24:00.484 And just to say it NOTE Confidence: 0.97508436 00:24:00.484 --> 00:24:01.924 briefly, we saw that the NOTE Confidence: 0.97508436 00:24:01.924 --> 00:24:04.005 premiums decreased as expected, and NOTE Confidence: 0.97508436 00:24:04.005 --> 00:24:05.845 they were subsidized by by NOTE Confidence: 0.97508436 00:24:05.845 --> 00:24:06.505 the legislation. NOTE Confidence: 0.9703673 00:24:08.484 --> 00:24:09.605 So a lot of data NOTE Confidence: 0.9703673 00:24:09.605 --> 00:24:10.825 there, and I think illustrative NOTE Confidence: 0.979634 00:24:11.125 --> 00:24:12.484 to take our two example NOTE Confidence: 0.979634 00:24:12.484 --> 00:24:14.250 patients and run them through NOTE Confidence: 0.979634 00:24:14.250 --> 00:24:16.010 those numbers and, and see NOTE Confidence: 0.979634 00:24:16.010 --> 00:24:17.310 what the net effect is. NOTE Confidence: 0.96097285 00:24:18.010 --> 00:24:18.970 As I also think it's NOTE Confidence: 0.96097285 00:24:18.970 --> 00:24:20.650 helpful to know that the NOTE Confidence: 0.96097285 00:24:20.650 --> 00:24:22.410 government estimates only about twenty NOTE Confidence: 0.96097285 00:24:22.410 --> 00:24:23.290 percent of people are gonna NOTE Confidence: 0.96097285 00:24:23.290 --> 00:24:24.410 hit the cap. And so NOTE Confidence: 0.96097285 00:24:24.410 --> 00:24:25.690 most people are like Mr. NOTE Confidence: 0.96097285 00:24:25.690 --> 00:24:27.494 A, They're taking maybe one NOTE Confidence: 0.96097285 00:24:27.494 --> 00:24:29.095 brand name medication and maybe NOTE Confidence: 0.96097285 00:24:29.095 --> 00:24:30.875 a few generic medications. But, NOTE Confidence: 0.8689636 00:24:32.295 --> 00:24:33.494 but all about twenty percent NOTE Confidence: 0.8689636 00:24:33.494 --> 00:24:34.215 of people are, like, gonna NOTE Confidence: 0.8689636 00:24:34.215 --> 00:24:35.515 be like, missus b. NOTE Confidence: 0.94695586 00:24:35.975 --> 00:24:36.775 And when you do the NOTE Confidence: 0.94695586 00:24:36.775 --> 00:24:37.815 math, this is sort of NOTE Confidence: 0.94695586 00:24:37.815 --> 00:24:38.695 the net effect of the NOTE Confidence: 0.94695586 00:24:38.695 --> 00:24:40.010 law in twenty twenty five. NOTE Confidence: 0.9635216 00:24:40.630 --> 00:24:41.450 Both patients, NOTE Confidence: 0.35861343 00:24:42.070 --> 00:24:42.570 experience NOTE Confidence: 0.95177156 00:24:43.190 --> 00:24:44.330 increases in deductibles. NOTE Confidence: 0.9813046 00:24:45.350 --> 00:24:46.390 But the key is that NOTE Confidence: 0.9813046 00:24:46.390 --> 00:24:47.910 patients like mister a are NOTE Confidence: 0.9813046 00:24:47.910 --> 00:24:49.830 not hitting the cap, whereas NOTE Confidence: 0.9813046 00:24:49.830 --> 00:24:51.530 patients like missus b are. NOTE Confidence: 0.9813046 00:24:51.775 --> 00:24:53.295 And so at the end NOTE Confidence: 0.9813046 00:24:53.295 --> 00:24:54.815 of the day, we find NOTE Confidence: 0.9813046 00:24:54.815 --> 00:24:56.095 that if you if based NOTE Confidence: 0.9813046 00:24:56.095 --> 00:24:56.915 on these averages, NOTE Confidence: 0.97824824 00:24:57.934 --> 00:24:58.975 if you're a patient like NOTE Confidence: 0.97824824 00:24:58.975 --> 00:24:59.934 mister a, you're not hitting NOTE Confidence: 0.97824824 00:24:59.934 --> 00:25:00.734 the cap, you may pay NOTE Confidence: 0.97824824 00:25:00.734 --> 00:25:02.434 actually more under this legislation, NOTE Confidence: 0.9903451 00:25:03.135 --> 00:25:04.655 whereas patients like missus b NOTE Confidence: 0.9903451 00:25:04.655 --> 00:25:05.635 are paying less. NOTE Confidence: 0.9526791 00:25:06.095 --> 00:25:06.595 Yeah. NOTE Confidence: 0.80694616 00:25:08.350 --> 00:25:09.790 Thank you, Chris. So twenty NOTE Confidence: 0.80694616 00:25:09.790 --> 00:25:11.090 percent of beneficiary NOTE Confidence: 0.34493396 00:25:11.550 --> 00:25:12.050 are NOTE Confidence: 0.54064614 00:25:12.510 --> 00:25:13.330 on the visa. NOTE Confidence: 0.8811843 00:25:16.429 --> 00:25:17.869 And generally speaking, the purpose NOTE Confidence: 0.8811843 00:25:17.869 --> 00:25:18.530 of insurance NOTE Confidence: 0.9608419 00:25:19.345 --> 00:25:20.165 is that NOTE Confidence: 0.7060444 00:25:21.185 --> 00:25:21.825 the way I put it, NOTE Confidence: 0.7060444 00:25:21.825 --> 00:25:23.185 but the healthy people are NOTE Confidence: 0.7060444 00:25:23.185 --> 00:25:23.765 a subscriber NOTE Confidence: 0.5652918 00:25:24.465 --> 00:25:25.205 of the of the. NOTE Confidence: 0.73964715 00:25:25.905 --> 00:25:27.105 So if we institute a NOTE Confidence: 0.73964715 00:25:27.105 --> 00:25:28.565 new shield, which is, NOTE Confidence: 0.77244014 00:25:29.905 --> 00:25:30.885 we're saying that NOTE Confidence: 0.73269105 00:25:46.554 --> 00:25:48.014 does the out of pocket NOTE Confidence: 0.73269105 00:25:48.075 --> 00:25:49.595 cost from the eighty percent NOTE Confidence: 0.73269105 00:25:49.595 --> 00:25:51.115 of the fifty percent, would NOTE Confidence: 0.73269105 00:25:51.115 --> 00:25:52.095 that totally, NOTE Confidence: 0.7799048 00:25:52.955 --> 00:25:55.215 make up for the reduction NOTE Confidence: 0.7036614 00:25:55.914 --> 00:25:57.375 in patient responsibility? NOTE Confidence: 0.84712774 00:25:59.034 --> 00:26:00.130 Like, Like, is this NOTE Confidence: 0.74640447 00:26:00.430 --> 00:26:02.770 all just a complete unintended NOTE Confidence: 0.74640447 00:26:02.910 --> 00:26:04.190 consequences for it now? The NOTE Confidence: 0.74640447 00:26:04.190 --> 00:26:04.690 beneficiary NOTE Confidence: 0.62921727 00:26:05.070 --> 00:26:05.970 are just completely NOTE Confidence: 0.80594844 00:26:06.670 --> 00:26:08.110 paying the full amount of NOTE Confidence: 0.80594844 00:26:08.110 --> 00:26:08.610 additional, NOTE Confidence: 0.9023128 00:26:09.950 --> 00:26:12.590 additional coverage, or, conversely, is NOTE Confidence: 0.9023128 00:26:12.590 --> 00:26:14.430 this, like, more general tax NOTE Confidence: 0.9023128 00:26:14.430 --> 00:26:14.930 dollars? NOTE Confidence: 0.999296 00:26:16.984 --> 00:26:18.105 Yeah. I think it's a NOTE Confidence: 0.999296 00:26:18.105 --> 00:26:18.924 really good question. NOTE Confidence: 0.9647918 00:26:20.744 --> 00:26:22.184 You know, I think you're NOTE Confidence: 0.9647918 00:26:22.184 --> 00:26:24.105 totally right. That's, like, the NOTE Confidence: 0.9647918 00:26:24.105 --> 00:26:26.105 social purpose of insurance to NOTE Confidence: 0.9647918 00:26:26.105 --> 00:26:27.545 spread risk. And so, you NOTE Confidence: 0.9647918 00:26:27.545 --> 00:26:28.905 know, in some ways, you NOTE Confidence: 0.9647918 00:26:28.905 --> 00:26:29.790 could say, like, NOTE Confidence: 0.95679677 00:26:30.270 --> 00:26:31.710 this is sort of why NOTE Confidence: 0.95679677 00:26:31.710 --> 00:26:32.990 we have insurance, and, like, NOTE Confidence: 0.95679677 00:26:32.990 --> 00:26:33.630 maybe this is not a NOTE Confidence: 0.95679677 00:26:33.630 --> 00:26:34.290 bad thing. NOTE Confidence: 0.99966174 00:26:35.310 --> 00:26:36.450 I think that NOTE Confidence: 0.96781623 00:26:36.830 --> 00:26:38.030 there could be an argument NOTE Confidence: 0.96781623 00:26:38.030 --> 00:26:39.230 that, like, the sum is NOTE Confidence: 0.96781623 00:26:39.230 --> 00:26:40.990 is less than their parts NOTE Confidence: 0.96781623 00:26:40.990 --> 00:26:42.510 because what we see is, NOTE Confidence: 0.96781623 00:26:42.830 --> 00:26:43.869 and it's not shown here, NOTE Confidence: 0.96781623 00:26:43.869 --> 00:26:45.535 but because of a lot NOTE Confidence: 0.96781623 00:26:45.535 --> 00:26:46.655 of plans are leaving the NOTE Confidence: 0.96781623 00:26:46.655 --> 00:26:47.155 marketplace, NOTE Confidence: 0.9989437 00:26:48.015 --> 00:26:49.135 we have a follow-up study NOTE Confidence: 0.9989437 00:26:49.135 --> 00:26:50.035 that shows that NOTE Confidence: 0.99942195 00:26:50.335 --> 00:26:51.955 the lack of competition leads NOTE Confidence: 0.96173126 00:26:52.335 --> 00:26:53.695 to way less generous plans. NOTE Confidence: 0.96173126 00:26:53.695 --> 00:26:54.435 And so, NOTE Confidence: 0.93921345 00:26:55.055 --> 00:26:55.855 that is sort of what NOTE Confidence: 0.93921345 00:26:55.855 --> 00:26:56.655 I mean by the sum NOTE Confidence: 0.93921345 00:26:56.655 --> 00:26:57.615 is not just you know, NOTE Confidence: 0.93921345 00:26:57.615 --> 00:26:58.734 like, I think the amount NOTE Confidence: 0.93921345 00:26:58.734 --> 00:26:59.775 of money that is going NOTE Confidence: 0.93921345 00:26:59.775 --> 00:27:01.590 to the ultimately trickling down NOTE Confidence: 0.93921345 00:27:01.590 --> 00:27:03.030 to beneficiaries could be less NOTE Confidence: 0.93921345 00:27:03.030 --> 00:27:05.109 because competition is is is NOTE Confidence: 0.93921345 00:27:05.109 --> 00:27:06.310 less is one way to NOTE Confidence: 0.93921345 00:27:06.310 --> 00:27:06.950 address that. NOTE Confidence: 0.99637634 00:27:07.670 --> 00:27:08.550 And then the other piece NOTE Confidence: 0.99637634 00:27:08.550 --> 00:27:09.510 of it is that, NOTE Confidence: 0.97468585 00:27:10.070 --> 00:27:11.350 you know, that eighty percent NOTE Confidence: 0.97468585 00:27:11.350 --> 00:27:13.205 number is based on estimates, NOTE Confidence: 0.97468585 00:27:13.205 --> 00:27:14.765 historical data. But one worry NOTE Confidence: 0.97468585 00:27:14.765 --> 00:27:15.765 I have is I see NOTE Confidence: 0.97468585 00:27:15.765 --> 00:27:17.605 patients who are like Mr. NOTE Confidence: 0.97468585 00:27:17.605 --> 00:27:18.725 A, but they, NOTE Confidence: 0.959078 00:27:19.605 --> 00:27:20.645 or I'm sorry, are like NOTE Confidence: 0.959078 00:27:20.645 --> 00:27:22.165 Mrs. B, but she is NOTE Confidence: 0.959078 00:27:22.165 --> 00:27:23.365 not there. They're not hitting, NOTE Confidence: 0.959078 00:27:23.365 --> 00:27:24.405 they're not, they don't have NOTE Confidence: 0.959078 00:27:24.405 --> 00:27:25.685 two thousand dollars to pay. NOTE Confidence: 0.959078 00:27:25.685 --> 00:27:27.389 So they may eventually hit NOTE Confidence: 0.959078 00:27:27.389 --> 00:27:28.429 the cap if, if they NOTE Confidence: 0.959078 00:27:28.429 --> 00:27:29.629 just fill their medications, but NOTE Confidence: 0.959078 00:27:29.629 --> 00:27:31.009 they see a higher deductible NOTE Confidence: 0.959078 00:27:31.070 --> 00:27:32.429 and they go to the NOTE Confidence: 0.959078 00:27:32.429 --> 00:27:33.710 pharmacy and they're like, why, NOTE Confidence: 0.959078 00:27:33.710 --> 00:27:35.389 woah, my medications cost way NOTE Confidence: 0.959078 00:27:35.389 --> 00:27:36.669 more. And you want to NOTE Confidence: 0.959078 00:27:36.669 --> 00:27:38.029 say to them, I know, NOTE Confidence: 0.959078 00:27:38.029 --> 00:27:39.205 but if, but in March, NOTE Confidence: 0.959078 00:27:39.205 --> 00:27:40.244 you're gonna hit the cap. NOTE Confidence: 0.959078 00:27:40.244 --> 00:27:41.205 And so you have to NOTE Confidence: 0.959078 00:27:41.205 --> 00:27:42.424 pay through, unfortunately. NOTE Confidence: 0.97801965 00:27:42.884 --> 00:27:43.845 But I think we're gonna NOTE Confidence: 0.97801965 00:27:43.845 --> 00:27:45.445 see a scenario where because NOTE Confidence: 0.97801965 00:27:45.445 --> 00:27:46.884 the deductibles went up, that NOTE Confidence: 0.97801965 00:27:46.884 --> 00:27:48.565 discourages people from filling their NOTE Confidence: 0.97801965 00:27:48.565 --> 00:27:50.725 medications. And that ultimately may NOTE Confidence: 0.97801965 00:27:50.725 --> 00:27:52.164 mean that fewer people than NOTE Confidence: 0.97801965 00:27:52.164 --> 00:27:52.664 expected NOTE Confidence: 0.97578263 00:27:53.080 --> 00:27:54.280 benefit from the law is NOTE Confidence: 0.97578263 00:27:54.280 --> 00:27:55.000 one worry I have. I NOTE Confidence: 0.97578263 00:27:55.000 --> 00:27:55.800 don't know if that is NOTE Confidence: 0.97578263 00:27:55.800 --> 00:27:56.920 gonna bear out, but that, NOTE Confidence: 0.97578263 00:27:56.920 --> 00:27:57.800 I think, could be a NOTE Confidence: 0.97578263 00:27:57.800 --> 00:27:58.940 potential consequence. NOTE Confidence: 0.9374016 00:27:59.320 --> 00:28:00.619 You're gonna measure that? NOTE Confidence: 0.99202394 00:28:01.240 --> 00:28:02.280 I think you really just NOTE Confidence: 0.99202394 00:28:02.280 --> 00:28:03.320 have to go back. And NOTE Confidence: 0.99202394 00:28:03.320 --> 00:28:04.600 so the government that eighty NOTE Confidence: 0.99202394 00:28:04.600 --> 00:28:05.560 percent number is from, like, NOTE Confidence: 0.99202394 00:28:05.560 --> 00:28:07.100 I think, twenty nineteen data. NOTE Confidence: 0.8088012 00:28:08.164 --> 00:28:08.965 Just thinking that I think NOTE Confidence: 0.8088012 00:28:08.965 --> 00:28:10.424 is a very important Yeah. NOTE Confidence: 0.85813904 00:28:11.365 --> 00:28:12.484 That do you have any NOTE Confidence: 0.85813904 00:28:12.484 --> 00:28:13.304 way of detecting? NOTE Confidence: 0.9995154 00:28:13.765 --> 00:28:15.044 Yeah. That's a good question. NOTE Confidence: 0.97996867 00:28:15.365 --> 00:28:17.125 You know, one I'll show NOTE Confidence: 0.97996867 00:28:17.125 --> 00:28:18.645 you some data that suggests NOTE Confidence: 0.97996867 00:28:18.645 --> 00:28:20.325 that, in January twenty twenty NOTE Confidence: 0.97996867 00:28:20.325 --> 00:28:21.605 five, fills go down a NOTE Confidence: 0.97996867 00:28:21.605 --> 00:28:22.484 little bit, but then they NOTE Confidence: 0.97996867 00:28:22.484 --> 00:28:24.030 quickly recover. So that NOTE Confidence: 0.9811653 00:28:24.510 --> 00:28:25.470 we'll have to really wait NOTE Confidence: 0.9811653 00:28:25.470 --> 00:28:26.830 for the claims, the person NOTE Confidence: 0.9811653 00:28:26.830 --> 00:28:28.270 level data. But in population NOTE Confidence: 0.9811653 00:28:28.270 --> 00:28:29.710 level data, we see that NOTE Confidence: 0.9811653 00:28:29.710 --> 00:28:30.770 the fills actually NOTE Confidence: 0.96842086 00:28:31.070 --> 00:28:32.530 decrease, which is concerning. NOTE Confidence: 0.92275226 00:28:35.869 --> 00:28:37.630 Fine. I'll I'll first, two NOTE Confidence: 0.92275226 00:28:37.630 --> 00:28:38.610 questions. First, NOTE Confidence: 0.9405744 00:28:38.975 --> 00:28:40.255 please repeat questions from the NOTE Confidence: 0.9405744 00:28:40.255 --> 00:28:41.935 audience so that Oh, yes. NOTE Confidence: 0.9405744 00:28:41.935 --> 00:28:42.835 Okay. Great. NOTE Confidence: 0.9095271 00:28:43.535 --> 00:28:44.735 Microphone's on, so we should NOTE Confidence: 0.9095271 00:28:44.735 --> 00:28:45.395 be good. NOTE Confidence: 0.7012009 00:28:45.695 --> 00:28:46.335 And second, NOTE Confidence: 0.9886516 00:28:46.655 --> 00:28:47.235 I thought NOTE Confidence: 0.862914 00:28:48.095 --> 00:28:49.615 is for well, David Rosenthal. NOTE Confidence: 0.862914 00:28:49.775 --> 00:28:50.815 Do you wanna just jump NOTE Confidence: 0.862914 00:28:50.815 --> 00:28:51.315 on? NOTE Confidence: 0.9507155 00:28:51.679 --> 00:28:52.720 Yeah. Sure. Thank you so NOTE Confidence: 0.9507155 00:28:52.720 --> 00:28:54.320 much. I just, ibrutinib is NOTE Confidence: 0.9507155 00:28:54.320 --> 00:28:55.200 one of the drugs that's NOTE Confidence: 0.9507155 00:28:55.200 --> 00:28:56.480 gonna, I think, adjust, correct, NOTE Confidence: 0.9507155 00:28:56.480 --> 00:28:57.440 in twenty twenty six. I'm NOTE Confidence: 0.9507155 00:28:57.440 --> 00:28:58.559 just curious how that's gonna NOTE Confidence: 0.9507155 00:28:58.559 --> 00:29:00.559 change these mister a, mister NOTE Confidence: 0.9507155 00:29:00.559 --> 00:29:01.760 b out of pocket costs NOTE Confidence: 0.9507155 00:29:01.760 --> 00:29:02.900 or your your modeling. NOTE Confidence: 0.9482742 00:29:04.054 --> 00:29:05.255 You're totally right. So, yeah, NOTE Confidence: 0.9482742 00:29:05.255 --> 00:29:06.535 it it is it's one NOTE Confidence: 0.9482742 00:29:06.535 --> 00:29:07.815 of the medications, as you NOTE Confidence: 0.9482742 00:29:07.815 --> 00:29:09.015 point out, that is subject NOTE Confidence: 0.9482742 00:29:09.015 --> 00:29:10.794 to price negotiation. So NOTE Confidence: 0.98748296 00:29:11.095 --> 00:29:12.615 a whole separate arm of NOTE Confidence: 0.98748296 00:29:12.615 --> 00:29:14.615 the legislation empowered Medicare to NOTE Confidence: 0.98748296 00:29:14.615 --> 00:29:16.235 negotiate prices. And so NOTE Confidence: 0.9794523 00:29:18.150 --> 00:29:19.850 I think that it hopefully, NOTE Confidence: 0.95753783 00:29:20.550 --> 00:29:21.510 on the one hand, it NOTE Confidence: 0.95753783 00:29:21.510 --> 00:29:22.310 it won't really make a NOTE Confidence: 0.95753783 00:29:22.310 --> 00:29:23.430 difference for missus b. She's NOTE Confidence: 0.95753783 00:29:23.430 --> 00:29:24.550 gonna pay two thousand dollars NOTE Confidence: 0.95753783 00:29:24.550 --> 00:29:26.310 anyway, but I think the NOTE Confidence: 0.95753783 00:29:26.310 --> 00:29:27.510 theory is that, okay, the NOTE Confidence: 0.95753783 00:29:27.510 --> 00:29:29.430 medication costs less, the insurers NOTE Confidence: 0.95753783 00:29:29.430 --> 00:29:30.790 pay less, and then eventually, NOTE Confidence: 0.95753783 00:29:30.790 --> 00:29:32.330 that will help other patients. NOTE Confidence: 0.9161426 00:29:33.674 --> 00:29:34.794 Only a select group of NOTE Confidence: 0.9161426 00:29:34.794 --> 00:29:36.394 medic of medications are, NOTE Confidence: 0.9196737 00:29:36.715 --> 00:29:37.934 eligible for negotiation. NOTE Confidence: 0.96455 00:29:38.235 --> 00:29:39.674 So I think a bigger NOTE Confidence: 0.96455 00:29:39.674 --> 00:29:41.355 picture takeaway from this data NOTE Confidence: 0.96455 00:29:41.355 --> 00:29:42.715 is that we really should NOTE Confidence: 0.96455 00:29:42.715 --> 00:29:44.315 be empowering Medicare to negotiate NOTE Confidence: 0.96455 00:29:44.315 --> 00:29:45.755 all drugs. Right? And that NOTE Confidence: 0.96455 00:29:45.755 --> 00:29:46.635 that is the way to NOTE Confidence: 0.96455 00:29:46.635 --> 00:29:47.515 have your cake and eat NOTE Confidence: 0.96455 00:29:47.515 --> 00:29:49.170 it too. Right? We're we NOTE Confidence: 0.96455 00:29:49.170 --> 00:29:50.210 know of we're trying to NOTE Confidence: 0.96455 00:29:50.210 --> 00:29:50.930 get people to take more NOTE Confidence: 0.96455 00:29:50.930 --> 00:29:52.610 medications. And if you don't NOTE Confidence: 0.96455 00:29:52.610 --> 00:29:53.650 want cost to go up, NOTE Confidence: 0.96455 00:29:53.650 --> 00:29:55.330 you should allow the government, NOTE Confidence: 0.96455 00:29:55.330 --> 00:29:56.690 like any other payer, to NOTE Confidence: 0.96455 00:29:56.690 --> 00:29:57.910 negotiate prices. NOTE Confidence: 0.9818142 00:30:01.365 --> 00:30:02.805 Just to support that point, NOTE Confidence: 0.9818142 00:30:02.805 --> 00:30:03.765 the VA has been able NOTE Confidence: 0.9818142 00:30:03.765 --> 00:30:05.205 to negotiate prices for many NOTE Confidence: 0.9818142 00:30:05.205 --> 00:30:07.125 years and has effectively halved NOTE Confidence: 0.9818142 00:30:07.125 --> 00:30:08.645 the cost. Yeah. So I NOTE Confidence: 0.9818142 00:30:08.645 --> 00:30:10.005 totally agree. That's a very NOTE Confidence: 0.9818142 00:30:10.005 --> 00:30:11.305 good point. Yeah. We have NOTE Confidence: 0.9818142 00:30:11.525 --> 00:30:13.125 a very nice, you know, NOTE Confidence: 0.9818142 00:30:13.205 --> 00:30:14.325 health system to look to NOTE Confidence: 0.9818142 00:30:14.325 --> 00:30:15.890 for for guidance there and NOTE Confidence: 0.9818142 00:30:15.890 --> 00:30:17.490 the, you know, the reasons NOTE Confidence: 0.9818142 00:30:17.490 --> 00:30:17.990 for NOTE Confidence: 0.9417353 00:30:18.450 --> 00:30:19.270 those stipulations. NOTE Confidence: 0.92699254 00:30:20.210 --> 00:30:22.049 Restricting negotiation are are not NOTE Confidence: 0.92699254 00:30:22.049 --> 00:30:23.570 really evidence based or the NOTE Confidence: 0.92699254 00:30:23.570 --> 00:30:24.470 result of lobbying. NOTE Confidence: 0.93716633 00:30:26.289 --> 00:30:27.490 So I wanna make sure NOTE Confidence: 0.93716633 00:30:27.490 --> 00:30:29.010 I get enough time for NOTE Confidence: 0.93716633 00:30:29.010 --> 00:30:30.684 quest, for discussion. So, NOTE Confidence: 0.97167414 00:30:31.485 --> 00:30:32.605 I'm gonna skip ahead to NOTE Confidence: 0.97167414 00:30:32.605 --> 00:30:33.804 the second study I was NOTE Confidence: 0.97167414 00:30:33.804 --> 00:30:35.085 going to present, which is NOTE Confidence: 0.97167414 00:30:35.085 --> 00:30:36.125 to look at the effects NOTE Confidence: 0.97167414 00:30:36.125 --> 00:30:37.085 of the law of medication NOTE Confidence: 0.97167414 00:30:37.085 --> 00:30:38.524 use, which I think is NOTE Confidence: 0.97167414 00:30:38.524 --> 00:30:39.485 actually a little bit more NOTE Confidence: 0.97167414 00:30:39.485 --> 00:30:40.544 interesting. So, NOTE Confidence: 0.96807283 00:30:40.924 --> 00:30:41.965 big picture, this is a NOTE Confidence: 0.96807283 00:30:41.965 --> 00:30:43.965 difference in differences analysis. We NOTE Confidence: 0.96807283 00:30:43.965 --> 00:30:44.580 have a NOTE Confidence: 0.9878163 00:30:45.460 --> 00:30:46.500 control group, and then we NOTE Confidence: 0.9878163 00:30:46.500 --> 00:30:47.860 have a treatment group. We NOTE Confidence: 0.9878163 00:30:47.860 --> 00:30:49.140 see what happens to both NOTE Confidence: 0.9878163 00:30:49.140 --> 00:30:50.580 after an intervention, and then NOTE Confidence: 0.9878163 00:30:50.580 --> 00:30:51.960 we compare those differences. NOTE Confidence: 0.91402537 00:30:53.299 --> 00:30:55.140 We used, a database called NOTE Confidence: 0.91402537 00:30:55.140 --> 00:30:56.419 Symphony Metis, which is a NOTE Confidence: 0.91402537 00:30:56.419 --> 00:30:58.179 retail all pair pharmacy claims NOTE Confidence: 0.91402537 00:30:58.179 --> 00:30:58.679 database. NOTE Confidence: 0.96750784 00:30:59.620 --> 00:31:01.275 And it has data at NOTE Confidence: 0.96750784 00:31:01.275 --> 00:31:02.475 the drug level. So it's NOTE Confidence: 0.96750784 00:31:02.475 --> 00:31:04.655 population data. There's no individual NOTE Confidence: 0.96750784 00:31:04.715 --> 00:31:05.535 level data, NOTE Confidence: 0.9731938 00:31:06.235 --> 00:31:08.075 but it provides very timely NOTE Confidence: 0.9731938 00:31:08.075 --> 00:31:09.515 analyses. We have data from NOTE Confidence: 0.9731938 00:31:09.515 --> 00:31:10.875 actually, like, last week in NOTE Confidence: 0.9731938 00:31:10.875 --> 00:31:11.375 there. NOTE Confidence: 0.885862 00:31:12.475 --> 00:31:13.135 We linked NOTE Confidence: 0.8571495 00:31:13.435 --> 00:31:14.955 that prescription fill data to NOTE Confidence: 0.8571495 00:31:14.955 --> 00:31:15.855 pricing data, NOTE Confidence: 0.9990888 00:31:16.170 --> 00:31:17.690 and we included about three NOTE Confidence: 0.9990888 00:31:17.690 --> 00:31:18.590 thousand medications. NOTE Confidence: 0.9778856 00:31:19.130 --> 00:31:21.130 We excluded medications which had NOTE Confidence: 0.9778856 00:31:21.130 --> 00:31:22.410 no fills in twenty twenty NOTE Confidence: 0.9778856 00:31:22.410 --> 00:31:23.930 two, the first quarter of NOTE Confidence: 0.9778856 00:31:23.930 --> 00:31:25.930 our study period, and also NOTE Confidence: 0.9778856 00:31:25.930 --> 00:31:28.010 vaccine and insulin formulations, which NOTE Confidence: 0.9778856 00:31:28.010 --> 00:31:29.690 underwent separate reforms during the NOTE Confidence: 0.9778856 00:31:29.690 --> 00:31:30.190 period. NOTE Confidence: 0.98367375 00:31:31.055 --> 00:31:32.335 And our key outcome was NOTE Confidence: 0.98367375 00:31:32.335 --> 00:31:34.035 prescription fills per capita. NOTE Confidence: 0.97381246 00:31:34.415 --> 00:31:35.695 And we calculated this as NOTE Confidence: 0.97381246 00:31:35.695 --> 00:31:37.075 a weighted change from baseline. NOTE Confidence: 0.95031476 00:31:38.255 --> 00:31:39.535 And so we were basically NOTE Confidence: 0.95031476 00:31:39.535 --> 00:31:41.155 assessing medication use. NOTE Confidence: 0.9495208 00:31:42.175 --> 00:31:42.995 We hypothesized NOTE Confidence: 0.98452085 00:31:43.375 --> 00:31:44.650 that the higher cost drugs NOTE Confidence: 0.98452085 00:31:44.650 --> 00:31:45.770 would increase more. And so NOTE Confidence: 0.98452085 00:31:45.770 --> 00:31:47.370 we divided medications into different NOTE Confidence: 0.98452085 00:31:47.370 --> 00:31:48.730 buckets based on their monthly NOTE Confidence: 0.98452085 00:31:48.730 --> 00:31:49.230 price. NOTE Confidence: 0.97090757 00:31:49.530 --> 00:31:50.890 And so these are sort NOTE Confidence: 0.97090757 00:31:50.890 --> 00:31:52.330 of arbitrary cutoffs, but we NOTE Confidence: 0.97090757 00:31:52.330 --> 00:31:53.290 tried to make cutoffs that NOTE Confidence: 0.97090757 00:31:53.290 --> 00:31:54.170 were based on out of NOTE Confidence: 0.97090757 00:31:54.170 --> 00:31:55.690 pocket costs. And so, for NOTE Confidence: 0.97090757 00:31:55.690 --> 00:31:56.190 example, NOTE Confidence: 0.98466986 00:31:56.524 --> 00:31:57.965 if a medication costs more NOTE Confidence: 0.98466986 00:31:57.965 --> 00:31:58.845 than eight hundred and thirty NOTE Confidence: 0.98466986 00:31:58.845 --> 00:32:00.205 dollars per month, patients have NOTE Confidence: 0.98466986 00:32:00.205 --> 00:32:01.565 to pay typically more out NOTE Confidence: 0.98466986 00:32:01.565 --> 00:32:02.684 of pocket for that because NOTE Confidence: 0.98466986 00:32:02.684 --> 00:32:03.804 the medication is called a NOTE Confidence: 0.98466986 00:32:03.804 --> 00:32:04.784 specialty medication. NOTE Confidence: 0.937933 00:32:06.684 --> 00:32:07.725 And we did a difference NOTE Confidence: 0.937933 00:32:07.725 --> 00:32:08.384 of difference. NOTE Confidence: 0.96666014 00:32:09.179 --> 00:32:11.020 We chose commercial as our NOTE Confidence: 0.96666014 00:32:11.020 --> 00:32:13.020 control group. The the Inflation NOTE Confidence: 0.96666014 00:32:13.020 --> 00:32:14.140 Reduction Act did not really NOTE Confidence: 0.96666014 00:32:14.140 --> 00:32:15.659 affect the commercial population, so NOTE Confidence: 0.96666014 00:32:15.659 --> 00:32:17.340 we hypothesized that use would NOTE Confidence: 0.96666014 00:32:17.340 --> 00:32:17.840 be, NOTE Confidence: 0.9811278 00:32:18.140 --> 00:32:19.580 fairly stable there, and we NOTE Confidence: 0.9811278 00:32:19.580 --> 00:32:20.620 compared that to use in NOTE Confidence: 0.9811278 00:32:20.620 --> 00:32:21.760 the Medicare population. NOTE Confidence: 0.9695245 00:32:23.105 --> 00:32:24.245 We had some seasonal, NOTE Confidence: 0.99765044 00:32:24.545 --> 00:32:26.005 and drug level fixed effects. NOTE Confidence: 0.8549957 00:32:26.865 --> 00:32:28.225 We evaluated the parallel trends NOTE Confidence: 0.8549957 00:32:28.225 --> 00:32:28.725 assumption, NOTE Confidence: 0.9739294 00:32:29.665 --> 00:32:31.125 just using a simple regression. NOTE Confidence: 0.9891703 00:32:31.985 --> 00:32:32.785 And then we had a NOTE Confidence: 0.9891703 00:32:32.785 --> 00:32:34.565 more conservative value for NOTE Confidence: 0.89566797 00:32:34.865 --> 00:32:36.465 statistical significance given that we NOTE Confidence: 0.89566797 00:32:36.465 --> 00:32:37.350 did four tests, NOTE Confidence: 0.9896886 00:32:38.070 --> 00:32:39.669 consistent with our four different, NOTE Confidence: 0.9988739 00:32:40.070 --> 00:32:41.530 monthly pricing groups. NOTE Confidence: 0.9457683 00:32:42.950 --> 00:32:44.630 We did various subgroup analyses NOTE Confidence: 0.9457683 00:32:44.630 --> 00:32:45.830 looking at the most common NOTE Confidence: 0.9457683 00:32:45.830 --> 00:32:47.370 medications, different diseases. NOTE Confidence: 0.93915105 00:32:48.070 --> 00:32:48.870 And we knew the law NOTE Confidence: 0.93915105 00:32:48.870 --> 00:32:50.390 was implemented in January twenty NOTE Confidence: 0.93915105 00:32:50.390 --> 00:32:51.805 twenty four, and so that NOTE Confidence: 0.93915105 00:32:51.805 --> 00:32:53.325 is when deductibles reset. And NOTE Confidence: 0.93915105 00:32:53.325 --> 00:32:55.165 so that's a potential confounder. NOTE Confidence: 0.93915105 00:32:55.165 --> 00:32:56.365 And so we had a NOTE Confidence: 0.93915105 00:32:56.365 --> 00:32:58.465 falsification analysis where we we NOTE Confidence: 0.93915105 00:32:58.525 --> 00:32:59.565 pretended that the law was NOTE Confidence: 0.93915105 00:32:59.565 --> 00:33:00.685 implemented in twenty twenty three NOTE Confidence: 0.93915105 00:33:00.685 --> 00:33:02.145 and reran all of our NOTE Confidence: 0.93915105 00:33:02.205 --> 00:33:03.725 analyses to see if, okay, NOTE Confidence: 0.93915105 00:33:03.725 --> 00:33:04.845 was it really the the NOTE Confidence: 0.93915105 00:33:04.845 --> 00:33:05.725 year the law was in NOTE Confidence: 0.93915105 00:33:05.725 --> 00:33:06.685 lit, or was it the NOTE Confidence: 0.93915105 00:33:06.685 --> 00:33:07.110 deductibles NOTE Confidence: 0.8967098 00:33:11.110 --> 00:33:12.630 so some some data here, NOTE Confidence: 0.8967098 00:33:12.630 --> 00:33:13.590 this is just the table NOTE Confidence: 0.8967098 00:33:13.590 --> 00:33:14.950 of medications at the drug NOTE Confidence: 0.8967098 00:33:14.950 --> 00:33:16.470 level and set. And you NOTE Confidence: 0.8967098 00:33:16.549 --> 00:33:17.590 you'll note that the low NOTE Confidence: 0.8967098 00:33:17.590 --> 00:33:18.549 cost drugs, less than a NOTE Confidence: 0.8967098 00:33:18.549 --> 00:33:19.935 hundred dollars per month, NOTE Confidence: 0.99541855 00:33:20.495 --> 00:33:21.615 are the most common. About NOTE Confidence: 0.99541855 00:33:21.615 --> 00:33:22.655 half of the cohort is NOTE Confidence: 0.99541855 00:33:22.655 --> 00:33:23.155 there. NOTE Confidence: 0.9914063 00:33:23.535 --> 00:33:24.175 And then by the time NOTE Confidence: 0.9914063 00:33:24.175 --> 00:33:24.895 you get to the very NOTE Confidence: 0.9914063 00:33:24.895 --> 00:33:25.875 high cost drugs, NOTE Confidence: 0.98384726 00:33:26.655 --> 00:33:27.455 it's only a hundred and NOTE Confidence: 0.98384726 00:33:27.455 --> 00:33:28.995 fifty medications, but they're responsible NOTE Confidence: 0.98384726 00:33:29.135 --> 00:33:30.335 for a large proportion of NOTE Confidence: 0.98384726 00:33:30.335 --> 00:33:30.835 spending. NOTE Confidence: 0.9793792 00:33:31.615 --> 00:33:32.815 And to add some color, NOTE Confidence: 0.9793792 00:33:32.815 --> 00:33:33.695 you see these are the NOTE Confidence: 0.9793792 00:33:33.695 --> 00:33:35.360 most common medications, atorvastatin, NOTE Confidence: 0.99012166 00:33:36.700 --> 00:33:37.200 apixaban, NOTE Confidence: 0.9145195 00:33:38.860 --> 00:33:40.220 Biktarvy. And I like to NOTE Confidence: 0.9145195 00:33:40.220 --> 00:33:41.420 use the generic name, but NOTE Confidence: 0.9145195 00:33:41.420 --> 00:33:42.300 the brand name is, like, NOTE Confidence: 0.9145195 00:33:42.300 --> 00:33:43.340 so catchy when there are NOTE Confidence: 0.9145195 00:33:43.340 --> 00:33:44.540 three drugs, so I just NOTE Confidence: 0.9145195 00:33:44.540 --> 00:33:45.280 kinda cave. NOTE Confidence: 0.9548021 00:33:45.980 --> 00:33:47.835 And then, Ofev, which is NOTE Confidence: 0.9548021 00:33:47.835 --> 00:33:49.695 a medication for, interstitial, NOTE Confidence: 0.9985683 00:33:50.315 --> 00:33:51.054 lung disease. NOTE Confidence: 0.9586722 00:33:52.955 --> 00:33:54.235 We evaluated what's called the NOTE Confidence: 0.9586722 00:33:54.235 --> 00:33:55.835 parallel trends assumption. We wanna NOTE Confidence: 0.9586722 00:33:55.835 --> 00:33:56.955 make sure that the two NOTE Confidence: 0.9586722 00:33:56.955 --> 00:33:57.855 groups are NOTE Confidence: 0.9473073 00:33:58.635 --> 00:34:00.155 moving in parallel prior to NOTE Confidence: 0.9473073 00:34:00.155 --> 00:34:01.455 the law of being implemented. NOTE Confidence: 0.95646894 00:34:02.500 --> 00:34:03.860 And so that is ideal, NOTE Confidence: 0.95646894 00:34:03.860 --> 00:34:04.580 right, if one is going NOTE Confidence: 0.95646894 00:34:04.580 --> 00:34:05.380 up and one's going down. NOTE Confidence: 0.95646894 00:34:05.380 --> 00:34:06.179 And how can you really NOTE Confidence: 0.95646894 00:34:06.179 --> 00:34:07.860 tell if if it's the NOTE Confidence: 0.95646894 00:34:07.860 --> 00:34:08.920 if it's the policy? NOTE Confidence: 0.9689188 00:34:09.219 --> 00:34:10.520 And this is the statistical NOTE Confidence: 0.9689188 00:34:10.580 --> 00:34:12.040 test we did, which suggests NOTE Confidence: 0.88316983 00:34:12.500 --> 00:34:14.280 that, controlled for seasonality, NOTE Confidence: 0.9977484 00:34:14.580 --> 00:34:16.020 the two groups were essentially NOTE Confidence: 0.9977484 00:34:16.020 --> 00:34:16.520 moving NOTE Confidence: 0.9925957 00:34:17.305 --> 00:34:18.364 in in parallel. NOTE Confidence: 0.95752794 00:34:19.065 --> 00:34:20.344 I think it's more intuitive NOTE Confidence: 0.95752794 00:34:20.344 --> 00:34:21.145 just to look at it NOTE Confidence: 0.95752794 00:34:21.145 --> 00:34:22.525 visually. And so here's, NOTE Confidence: 0.99286926 00:34:23.065 --> 00:34:25.065 here's the the preliminary results NOTE Confidence: 0.99286926 00:34:25.065 --> 00:34:26.364 based on that data. NOTE Confidence: 0.9918248 00:34:27.145 --> 00:34:28.185 A lot in this slide, NOTE Confidence: 0.9918248 00:34:28.185 --> 00:34:29.385 I'll walk you through it. NOTE Confidence: 0.9918248 00:34:29.625 --> 00:34:30.985 The blue is commercial, which NOTE Confidence: 0.9918248 00:34:30.985 --> 00:34:32.369 is our control group. And NOTE Confidence: 0.9918248 00:34:32.369 --> 00:34:32.869 so NOTE Confidence: 0.9759976 00:34:33.170 --> 00:34:34.130 and then the red is NOTE Confidence: 0.9759976 00:34:34.130 --> 00:34:35.509 our treatment group, Medicare. NOTE Confidence: 0.9941221 00:34:36.130 --> 00:34:37.410 And so what you have NOTE Confidence: 0.9941221 00:34:37.410 --> 00:34:38.930 on the x axis is NOTE Confidence: 0.9941221 00:34:38.930 --> 00:34:39.890 time, and then on the NOTE Confidence: 0.9941221 00:34:39.890 --> 00:34:41.410 y axis, a change from NOTE Confidence: 0.9941221 00:34:41.410 --> 00:34:41.910 baseline. NOTE Confidence: 0.99209374 00:34:42.690 --> 00:34:44.130 So everything starts at zero NOTE Confidence: 0.99209374 00:34:44.130 --> 00:34:45.489 because that's the baseline. And NOTE Confidence: 0.99209374 00:34:45.489 --> 00:34:46.255 then over time, NOTE Confidence: 0.9844452 00:34:46.975 --> 00:34:48.094 you see growth in use NOTE Confidence: 0.9844452 00:34:48.094 --> 00:34:49.855 or, you know, decreases in NOTE Confidence: 0.9844452 00:34:49.855 --> 00:34:51.215 use. And this is all NOTE Confidence: 0.9844452 00:34:51.215 --> 00:34:52.734 before the policy was implemented. NOTE Confidence: 0.9844452 00:34:52.734 --> 00:34:53.234 So NOTE Confidence: 0.98130757 00:34:53.614 --> 00:34:54.575 what you would hope for NOTE Confidence: 0.98130757 00:34:54.575 --> 00:34:56.094 from a research perspective is NOTE Confidence: 0.98130757 00:34:56.094 --> 00:34:56.975 that the two groups, if NOTE Confidence: 0.98130757 00:34:56.975 --> 00:34:58.175 they don't overlap, at least NOTE Confidence: 0.98130757 00:34:58.175 --> 00:34:59.135 they, they are moving in NOTE Confidence: 0.98130757 00:34:59.135 --> 00:34:59.635 parallel. NOTE Confidence: 0.89116013 00:35:00.480 --> 00:35:02.020 And you can see qualitatively, NOTE Confidence: 0.9765974 00:35:02.400 --> 00:35:03.520 the big caveat is the NOTE Confidence: 0.9765974 00:35:03.520 --> 00:35:04.960 confidence intervals are very wide, NOTE Confidence: 0.9765974 00:35:04.960 --> 00:35:07.120 but qualitatively, they they match NOTE Confidence: 0.9765974 00:35:07.120 --> 00:35:08.400 the statistical test that you NOTE Confidence: 0.9765974 00:35:08.400 --> 00:35:09.360 saw on the prior slide. NOTE Confidence: 0.9765974 00:35:09.360 --> 00:35:11.040 The two groups are moving NOTE Confidence: 0.9765974 00:35:11.040 --> 00:35:11.540 similar. NOTE Confidence: 0.9519809 00:35:13.635 --> 00:35:14.515 Sorry to interrupt. NOTE Confidence: 0.96704566 00:35:14.835 --> 00:35:16.114 How do you account for NOTE Confidence: 0.96704566 00:35:16.114 --> 00:35:17.395 the I I know it's NOTE Confidence: 0.96704566 00:35:17.395 --> 00:35:20.275 marginal increases in numeric numbers NOTE Confidence: 0.96704566 00:35:20.275 --> 00:35:22.114 of eligible Medicare adults over NOTE Confidence: 0.96704566 00:35:22.114 --> 00:35:23.635 time as the population is NOTE Confidence: 0.96704566 00:35:23.635 --> 00:35:25.235 aging slightly just in terms NOTE Confidence: 0.96704566 00:35:25.235 --> 00:35:26.215 of thinking about NOTE Confidence: 0.8525914 00:35:27.020 --> 00:35:27.520 change? NOTE Confidence: 0.9313585 00:35:28.140 --> 00:35:29.020 Yeah. So that's a good NOTE Confidence: 0.9313585 00:35:29.020 --> 00:35:30.080 question. And, NOTE Confidence: 0.98608524 00:35:31.099 --> 00:35:31.980 what I should have said NOTE Confidence: 0.98608524 00:35:31.980 --> 00:35:33.119 is that this was NOTE Confidence: 0.9087979 00:35:33.980 --> 00:35:35.660 a a prescription fills per NOTE Confidence: 0.9087979 00:35:35.660 --> 00:35:36.160 capita. NOTE Confidence: 0.9404313 00:35:36.540 --> 00:35:37.900 Yeah. So we, yeah, we NOTE Confidence: 0.9404313 00:35:37.900 --> 00:35:38.219 added, NOTE Confidence: 0.8396607 00:35:39.900 --> 00:35:40.140 that, NOTE Confidence: 0.9009587 00:35:41.099 --> 00:35:41.599 denominator. NOTE Confidence: 0.9488953 00:35:43.134 --> 00:35:44.094 And I should've I should've NOTE Confidence: 0.9488953 00:35:44.094 --> 00:35:44.894 said that on the prior NOTE Confidence: 0.9488953 00:35:44.894 --> 00:35:45.394 slide. NOTE Confidence: 0.9279328 00:35:46.414 --> 00:35:47.614 Okay. So that's all. This NOTE Confidence: 0.9279328 00:35:47.614 --> 00:35:48.494 is all before the law, NOTE Confidence: 0.9279328 00:35:48.494 --> 00:35:49.535 and they are if I've NOTE Confidence: 0.9279328 00:35:49.694 --> 00:35:50.974 you know, my argument that NOTE Confidence: 0.9279328 00:35:50.974 --> 00:35:52.255 they're very similar, and then NOTE Confidence: 0.9279328 00:35:52.255 --> 00:35:53.214 this is after the law NOTE Confidence: 0.9279328 00:35:53.214 --> 00:35:53.875 was implemented. NOTE Confidence: 0.9388021 00:35:55.000 --> 00:35:56.280 And so I'll walk you NOTE Confidence: 0.9388021 00:35:56.280 --> 00:35:57.560 through and then just quote, NOTE Confidence: 0.9388021 00:35:57.560 --> 00:35:58.920 like what the picture suggests, NOTE Confidence: 0.9388021 00:35:58.920 --> 00:35:59.720 and then we'll add some NOTE Confidence: 0.9388021 00:35:59.720 --> 00:36:01.239 numbers to this. And one NOTE Confidence: 0.9388021 00:36:01.239 --> 00:36:02.680 is here's the low cost NOTE Confidence: 0.9388021 00:36:02.680 --> 00:36:04.280 medications. I would argue they NOTE Confidence: 0.9388021 00:36:04.280 --> 00:36:05.800 are very similar. There's not NOTE Confidence: 0.9388021 00:36:05.800 --> 00:36:06.620 really a change. NOTE Confidence: 0.9267251 00:36:06.920 --> 00:36:08.540 Medium, there is some divergence, NOTE Confidence: 0.9267251 00:36:08.760 --> 00:36:09.965 but it's hard to tell. NOTE Confidence: 0.9267251 00:36:09.965 --> 00:36:11.425 The common denominators are wide. NOTE Confidence: 0.9687756 00:36:11.725 --> 00:36:13.005 High, maybe a little bit NOTE Confidence: 0.9687756 00:36:13.005 --> 00:36:14.285 more. And then very high, NOTE Confidence: 0.9687756 00:36:14.285 --> 00:36:15.805 you see a clear divergence NOTE Confidence: 0.9687756 00:36:15.805 --> 00:36:17.805 where the very high cost NOTE Confidence: 0.9687756 00:36:17.805 --> 00:36:19.405 medication use is soaring in NOTE Confidence: 0.9687756 00:36:19.405 --> 00:36:21.344 the Medicare population where it's NOTE Confidence: 0.9687756 00:36:21.405 --> 00:36:22.685 maybe going down or the NOTE Confidence: 0.9687756 00:36:22.685 --> 00:36:23.745 same in commercial. NOTE Confidence: 0.99794334 00:36:25.100 --> 00:36:26.140 And so this is adding NOTE Confidence: 0.99794334 00:36:26.140 --> 00:36:27.020 some numbers to that. NOTE Confidence: 0.98643297 00:36:27.660 --> 00:36:28.780 What you see here is NOTE Confidence: 0.98643297 00:36:28.780 --> 00:36:29.980 the difference in difference in NOTE Confidence: 0.98643297 00:36:29.980 --> 00:36:31.580 the post intervention period. That's NOTE Confidence: 0.98643297 00:36:31.580 --> 00:36:33.420 the summary metric here. And NOTE Confidence: 0.98643297 00:36:33.420 --> 00:36:35.280 then the dots just represent NOTE Confidence: 0.98643297 00:36:35.420 --> 00:36:37.200 that over time. And so NOTE Confidence: 0.98643297 00:36:37.464 --> 00:36:39.085 overall, the low cost medications, NOTE Confidence: 0.99183583 00:36:39.625 --> 00:36:40.585 there was a one percent NOTE Confidence: 0.99183583 00:36:40.585 --> 00:36:41.944 point estimate, but it wasn't NOTE Confidence: 0.99183583 00:36:41.944 --> 00:36:42.444 significant. NOTE Confidence: 0.98803324 00:36:43.464 --> 00:36:43.964 Medium, NOTE Confidence: 0.974301 00:36:45.065 --> 00:36:46.684 four percent, but not significant. NOTE Confidence: 0.9965735 00:36:47.385 --> 00:36:47.885 High, NOTE Confidence: 0.98543185 00:36:48.425 --> 00:36:49.964 six percent, but not significant. NOTE Confidence: 0.98543185 00:36:50.025 --> 00:36:51.484 And then the very high, NOTE Confidence: 0.98543185 00:36:51.545 --> 00:36:53.190 consistent with our last graph, NOTE Confidence: 0.98543185 00:36:53.190 --> 00:36:54.550 you see a a sixteen NOTE Confidence: 0.98543185 00:36:54.550 --> 00:36:55.930 percent difference in difference, NOTE Confidence: 0.9918314 00:36:56.950 --> 00:36:58.810 which is is statistically significant. NOTE Confidence: 0.87687254 00:37:01.510 --> 00:37:02.010 So, NOTE Confidence: 0.999522 00:37:02.710 --> 00:37:03.770 that's a good question. NOTE Confidence: 0.9841077 00:37:04.550 --> 00:37:05.589 You know, what we see NOTE Confidence: 0.9841077 00:37:05.589 --> 00:37:06.469 is that, you know, use NOTE Confidence: 0.9841077 00:37:06.469 --> 00:37:07.690 is going up in both NOTE Confidence: 0.9841077 00:37:07.925 --> 00:37:09.125 groups. And so NOTE Confidence: 0.638961 00:37:09.605 --> 00:37:10.105 Exactly. NOTE Confidence: 0.64187574 00:37:10.885 --> 00:37:11.625 Start covering. NOTE Confidence: 0.97509545 00:37:12.405 --> 00:37:13.465 Right. So I NOTE Confidence: 0.9776199 00:37:14.565 --> 00:37:15.765 we we should definitely do NOTE Confidence: 0.9776199 00:37:15.765 --> 00:37:16.905 a, like, a sensitivity NOTE Confidence: 0.9967073 00:37:17.205 --> 00:37:17.705 there. NOTE Confidence: 0.98328227 00:37:19.205 --> 00:37:20.585 You know, it's weighted by NOTE Confidence: 0.9769398 00:37:21.230 --> 00:37:22.690 it's weighted by prescriptions. NOTE Confidence: 0.9974687 00:37:23.950 --> 00:37:24.690 And so NOTE Confidence: 0.66856116 00:37:26.589 --> 00:37:27.089 because, NOTE Confidence: 0.99898523 00:37:28.029 --> 00:37:28.529 Medicare NOTE Confidence: 0.9646244 00:37:28.910 --> 00:37:30.349 hadn't covered it for weight NOTE Confidence: 0.9646244 00:37:30.349 --> 00:37:31.630 loss, and so the very NOTE Confidence: 0.9646244 00:37:31.630 --> 00:37:33.549 expensive versions that we talked NOTE Confidence: 0.9646244 00:37:33.710 --> 00:37:34.690 That's true. Yeah. NOTE Confidence: 0.95029217 00:37:35.275 --> 00:37:37.375 Probably not very much simple. NOTE Confidence: 0.95029217 00:37:37.594 --> 00:37:38.094 Yeah. NOTE Confidence: 0.976655 00:37:39.114 --> 00:37:40.235 Yeah. So I I should NOTE Confidence: 0.976655 00:37:40.235 --> 00:37:41.535 go back and do that. NOTE Confidence: 0.9873132 00:37:45.114 --> 00:37:46.235 Yeah. My my guess is NOTE Confidence: 0.9873132 00:37:46.235 --> 00:37:47.675 that, you know, despite being NOTE Confidence: 0.9873132 00:37:47.675 --> 00:37:49.535 very costly, they represent, NOTE Confidence: 0.98088604 00:37:50.280 --> 00:37:51.400 like, less than one percent, NOTE Confidence: 0.98088604 00:37:51.400 --> 00:37:52.520 I would guess, of total NOTE Confidence: 0.98088604 00:37:52.520 --> 00:37:53.880 prescriptions. So my guess is NOTE Confidence: 0.98088604 00:37:53.880 --> 00:37:54.760 that the numbers would be NOTE Confidence: 0.98088604 00:37:54.760 --> 00:37:55.960 very similar, but maybe that NOTE Confidence: 0.98088604 00:37:55.960 --> 00:37:56.920 would be, like, a separate NOTE Confidence: 0.98088604 00:37:56.920 --> 00:37:58.040 analysis you could just do NOTE Confidence: 0.98088604 00:37:58.040 --> 00:37:59.340 and and show, like, NOTE Confidence: 0.97232836 00:37:59.719 --> 00:38:00.840 what percent of the cost NOTE Confidence: 0.97232836 00:38:00.840 --> 00:38:02.520 is being attributed to that. NOTE Confidence: 0.97232836 00:38:02.840 --> 00:38:03.960 But thank you for pointing NOTE Confidence: 0.97232836 00:38:03.960 --> 00:38:05.344 that. Okay. I should write NOTE Confidence: 0.97232836 00:38:05.425 --> 00:38:07.085 this down to NOTE Confidence: 0.92469704 00:38:07.805 --> 00:38:08.925 One more question. Just so NOTE Confidence: 0.92469704 00:38:08.925 --> 00:38:11.005 your summary estimates are all NOTE Confidence: 0.92469704 00:38:11.005 --> 00:38:12.765 five quarters averaged, but you're NOTE Confidence: 0.92469704 00:38:12.765 --> 00:38:13.744 clearly seeing NOTE Confidence: 0.9463629 00:38:14.045 --> 00:38:15.165 it's not like you're not NOTE Confidence: 0.9463629 00:38:15.165 --> 00:38:16.445 just reporting on your fifth NOTE Confidence: 0.9463629 00:38:16.445 --> 00:38:16.945 quarter. NOTE Confidence: 0.97941744 00:38:17.420 --> 00:38:17.920 Right? NOTE Confidence: 0.93724775 00:38:18.540 --> 00:38:20.060 Yeah. So I think that's NOTE Confidence: 0.93724775 00:38:20.060 --> 00:38:21.100 a really good point too NOTE Confidence: 0.93724775 00:38:21.100 --> 00:38:22.400 that, you know, clearly, NOTE Confidence: 0.994977 00:38:22.700 --> 00:38:24.060 the trend is not stable NOTE Confidence: 0.994977 00:38:24.060 --> 00:38:24.719 over time. NOTE Confidence: 0.972347 00:38:25.739 --> 00:38:26.780 And, I mean, so one NOTE Confidence: 0.972347 00:38:26.780 --> 00:38:27.580 way you could think about NOTE Confidence: 0.972347 00:38:27.580 --> 00:38:28.219 it is you could look NOTE Confidence: 0.972347 00:38:28.219 --> 00:38:29.260 at the most recent quarter NOTE Confidence: 0.972347 00:38:29.260 --> 00:38:30.700 as the most illustrative. And NOTE Confidence: 0.972347 00:38:30.700 --> 00:38:30.860 so, NOTE Confidence: 0.98709136 00:38:31.895 --> 00:38:33.015 thank you for pointing that NOTE Confidence: 0.98709136 00:38:33.015 --> 00:38:34.775 out. And so when you NOTE Confidence: 0.98709136 00:38:34.775 --> 00:38:35.734 look at that, it's like, NOTE Confidence: 0.98709136 00:38:35.734 --> 00:38:37.255 okay. Now it's the if NOTE Confidence: 0.98709136 00:38:37.255 --> 00:38:38.214 you just go straight to NOTE Confidence: 0.98709136 00:38:38.214 --> 00:38:39.175 the very high cost group, NOTE Confidence: 0.98709136 00:38:39.175 --> 00:38:40.214 it's a thirty five percent NOTE Confidence: 0.98709136 00:38:40.214 --> 00:38:41.734 increase, which is I think NOTE Confidence: 0.98709136 00:38:41.734 --> 00:38:43.094 that's, like, pretty significant, and NOTE Confidence: 0.98709136 00:38:43.094 --> 00:38:44.295 you see the clear dose NOTE Confidence: 0.98709136 00:38:44.295 --> 00:38:45.355 response too. NOTE Confidence: 0.9691482 00:38:46.530 --> 00:38:47.489 And this is based on NOTE Confidence: 0.9691482 00:38:47.489 --> 00:38:48.850 June twenty twenty five data, NOTE Confidence: 0.9691482 00:38:48.850 --> 00:38:49.810 and so we could update NOTE Confidence: 0.9691482 00:38:49.810 --> 00:38:51.010 this. And I wonder what NOTE Confidence: 0.9691482 00:38:51.090 --> 00:38:51.969 where that number would be. NOTE Confidence: 0.9691482 00:38:51.969 --> 00:38:53.090 Maybe it'd be, like, forty NOTE Confidence: 0.9691482 00:38:53.090 --> 00:38:54.930 percent, fifty percent. We don't NOTE Confidence: 0.9691482 00:38:54.930 --> 00:38:55.430 know. NOTE Confidence: 0.9595414 00:38:57.170 --> 00:38:57.650 And so NOTE Confidence: 0.8936309 00:38:58.290 --> 00:38:59.570 It would change. Not relative. NOTE Confidence: 0.8936309 00:38:59.570 --> 00:39:01.105 Right? That's a thirty five NOTE Confidence: 0.8936309 00:39:01.105 --> 00:39:02.785 percentage point difference between the NOTE Confidence: 0.8936309 00:39:02.785 --> 00:39:03.285 two. NOTE Confidence: 0.97560155 00:39:03.745 --> 00:39:05.505 Right. An absolute thirty five NOTE Confidence: 0.97560155 00:39:05.505 --> 00:39:07.105 percent. Yeah. Which I think NOTE Confidence: 0.97560155 00:39:07.105 --> 00:39:08.165 is quite large. NOTE Confidence: 0.83467954 00:39:10.305 --> 00:39:11.125 And so, NOTE Confidence: 0.95363015 00:39:12.145 --> 00:39:13.265 we'll get into the implications NOTE Confidence: 0.95363015 00:39:13.265 --> 00:39:13.905 of that, which I think NOTE Confidence: 0.95363015 00:39:13.905 --> 00:39:15.505 are interesting. So this is, NOTE Confidence: 0.95363015 00:39:15.505 --> 00:39:16.590 like, our false test. We NOTE Confidence: 0.95363015 00:39:16.590 --> 00:39:17.630 wanted to see, was it NOTE Confidence: 0.95363015 00:39:17.630 --> 00:39:19.150 really the law, or was NOTE Confidence: 0.95363015 00:39:19.150 --> 00:39:20.350 it just twenty twenty three? NOTE Confidence: 0.95363015 00:39:20.350 --> 00:39:21.470 And I think the takeaway NOTE Confidence: 0.95363015 00:39:21.470 --> 00:39:23.150 is visually, you see not NOTE Confidence: 0.95363015 00:39:23.150 --> 00:39:23.950 much is going on in NOTE Confidence: 0.95363015 00:39:23.950 --> 00:39:25.390 twenty twenty three. And when NOTE Confidence: 0.95363015 00:39:25.390 --> 00:39:26.690 you repeat all the analyses, NOTE Confidence: 0.92957455 00:39:27.150 --> 00:39:28.190 there's a lot of noise, NOTE Confidence: 0.92957455 00:39:28.190 --> 00:39:29.790 but the point estimates essentially NOTE Confidence: 0.92957455 00:39:29.790 --> 00:39:31.070 are are small or are NOTE Confidence: 0.92957455 00:39:31.070 --> 00:39:33.035 they, decrease over time. NOTE Confidence: 0.94414526 00:39:34.775 --> 00:39:35.815 And so I'll bring it NOTE Confidence: 0.94414526 00:39:35.815 --> 00:39:36.775 back to the patients we NOTE Confidence: 0.94414526 00:39:36.775 --> 00:39:37.895 saw at the very beginning. NOTE Confidence: 0.94414526 00:39:37.895 --> 00:39:39.734 Here are the medication, some NOTE Confidence: 0.94414526 00:39:39.734 --> 00:39:41.494 very common medications those patients NOTE Confidence: 0.94414526 00:39:41.494 --> 00:39:42.375 were taking as, NOTE Confidence: 0.97939444 00:39:43.335 --> 00:39:43.835 amlodipine NOTE Confidence: 0.92093873 00:39:44.214 --> 00:39:44.489 use. NOTE Confidence: 0.9191272 00:39:45.050 --> 00:39:46.170 We found, you can see NOTE Confidence: 0.9191272 00:39:46.170 --> 00:39:47.770 here's the individual level difference NOTE Confidence: 0.9191272 00:39:47.770 --> 00:39:48.969 in difference. We saw a NOTE Confidence: 0.9191272 00:39:48.969 --> 00:39:50.110 three percent increase. NOTE Confidence: 0.7625377 00:39:50.810 --> 00:39:51.310 Apixaban, NOTE Confidence: 0.978267 00:39:51.850 --> 00:39:52.910 about a five percent. NOTE Confidence: 0.95692027 00:39:53.770 --> 00:39:55.610 I'll put aside Biktarvy for NOTE Confidence: 0.95692027 00:39:55.610 --> 00:39:56.730 a moment and return to NOTE Confidence: 0.95692027 00:39:56.730 --> 00:39:58.735 it. But Ibrutinib use went NOTE Confidence: 0.95692027 00:39:58.735 --> 00:40:00.515 about eighteen percent. And so, NOTE Confidence: 0.97510415 00:40:00.895 --> 00:40:02.335 that is the classic, you NOTE Confidence: 0.97510415 00:40:02.335 --> 00:40:03.455 know, this is exactly what NOTE Confidence: 0.97510415 00:40:03.455 --> 00:40:04.255 we thought when we had NOTE Confidence: 0.97510415 00:40:04.255 --> 00:40:05.935 our two example patients, mister NOTE Confidence: 0.97510415 00:40:05.935 --> 00:40:07.055 a and missus b. NOTE Confidence: 0.97115403 00:40:07.375 --> 00:40:08.655 At a population level, you NOTE Confidence: 0.97115403 00:40:08.655 --> 00:40:09.935 see a huge increase in NOTE Confidence: 0.97115403 00:40:09.935 --> 00:40:10.975 Ibrutinib use, NOTE Confidence: 0.9696563 00:40:11.540 --> 00:40:12.980 largely because patients like missus NOTE Confidence: 0.9696563 00:40:12.980 --> 00:40:14.180 Bierp, they're probably hitting the NOTE Confidence: 0.9696563 00:40:14.180 --> 00:40:15.380 cap, and they're not having NOTE Confidence: 0.9696563 00:40:15.380 --> 00:40:16.839 to pay more for it. NOTE Confidence: 0.9660889 00:40:17.540 --> 00:40:18.339 And so what do we NOTE Confidence: 0.9660889 00:40:18.339 --> 00:40:19.780 make about the negative result NOTE Confidence: 0.9660889 00:40:19.780 --> 00:40:21.000 for the HIV medications? NOTE Confidence: 0.9548974 00:40:21.540 --> 00:40:22.680 You know, a little disappointing. NOTE Confidence: 0.9548974 00:40:22.739 --> 00:40:23.780 We want people to take NOTE Confidence: 0.9548974 00:40:23.780 --> 00:40:25.140 their Biktarvy. This is a NOTE Confidence: 0.9548974 00:40:25.140 --> 00:40:26.520 very high value medication. NOTE Confidence: 0.9542809 00:40:27.665 --> 00:40:29.025 And indeed, it's actually true NOTE Confidence: 0.9542809 00:40:29.025 --> 00:40:30.005 for all antiretroviral NOTE Confidence: 0.9691994 00:40:30.465 --> 00:40:31.585 medications. When you look at NOTE Confidence: 0.9691994 00:40:31.585 --> 00:40:32.785 the class effect, there is NOTE Confidence: 0.9691994 00:40:32.785 --> 00:40:34.145 no increase. I mean, it's NOTE Confidence: 0.9691994 00:40:34.145 --> 00:40:35.425 the only class of medications NOTE Confidence: 0.9691994 00:40:35.425 --> 00:40:36.885 we don't observe an increase. NOTE Confidence: 0.94542533 00:40:38.065 --> 00:40:39.905 Here's the raw data for NOTE Confidence: 0.94542533 00:40:39.905 --> 00:40:41.765 for the, HIV medications, NOTE Confidence: 0.9956829 00:40:44.950 --> 00:40:46.310 and my interpretation of this NOTE Confidence: 0.9956829 00:40:46.310 --> 00:40:46.970 is that NOTE Confidence: 0.9811761 00:40:47.670 --> 00:40:48.630 maybe in this you know, NOTE Confidence: 0.9811761 00:40:48.630 --> 00:40:50.250 we have Ryan White programs. NOTE Confidence: 0.9811761 00:40:50.310 --> 00:40:51.210 We have Medicaid. NOTE Confidence: 0.943275 00:40:52.950 --> 00:40:53.990 This is a major buffer NOTE Confidence: 0.943275 00:40:53.990 --> 00:40:56.005 here. Yeah. Yeah. I totally NOTE Confidence: 0.943275 00:40:56.005 --> 00:40:57.045 agree. And so I want NOTE Confidence: 0.943275 00:40:57.205 --> 00:40:57.925 this is almost like a NOTE Confidence: 0.943275 00:40:57.925 --> 00:40:59.445 negative control where it's like, NOTE Confidence: 0.943275 00:40:59.445 --> 00:41:00.725 okay. If I had been NOTE Confidence: 0.943275 00:41:00.725 --> 00:41:01.844 smart enough to, you know, NOTE Confidence: 0.943275 00:41:01.844 --> 00:41:03.525 prespecify this, maybe this would NOTE Confidence: 0.943275 00:41:03.525 --> 00:41:04.645 have been a nice negative NOTE Confidence: 0.943275 00:41:04.645 --> 00:41:05.364 control. But, NOTE Confidence: 0.9256784 00:41:06.405 --> 00:41:07.525 you know, post hoc, that's NOTE Confidence: 0.9256784 00:41:07.525 --> 00:41:09.385 how I interpret that data. NOTE Confidence: 0.9677113 00:41:10.320 --> 00:41:10.980 I I NOTE Confidence: 0.9103662 00:41:11.360 --> 00:41:12.880 there are multiple sources of NOTE Confidence: 0.9103662 00:41:12.880 --> 00:41:14.880 of support for HIV meds NOTE Confidence: 0.9103662 00:41:14.880 --> 00:41:16.239 that aren't included in the NOTE Confidence: 0.9103662 00:41:16.239 --> 00:41:18.100 data. So Yeah. Yeah. NOTE Confidence: 0.9845691 00:41:18.560 --> 00:41:19.060 So, NOTE Confidence: 0.98238486 00:41:19.920 --> 00:41:20.960 that's a really good point. NOTE Confidence: 0.98238486 00:41:20.960 --> 00:41:22.320 And so I think big NOTE Confidence: 0.98238486 00:41:22.320 --> 00:41:23.280 picture, you know, there are NOTE Confidence: 0.98238486 00:41:23.280 --> 00:41:24.315 a lot of limitations to NOTE Confidence: 0.98238486 00:41:24.315 --> 00:41:25.675 this population level analysis, and NOTE Confidence: 0.98238486 00:41:25.675 --> 00:41:26.395 I would love to get NOTE Confidence: 0.98238486 00:41:26.395 --> 00:41:27.135 your feedback. NOTE Confidence: 0.9657273 00:41:27.515 --> 00:41:28.474 I'm hoping to follow this NOTE Confidence: 0.9657273 00:41:28.474 --> 00:41:29.915 up with a patient level NOTE Confidence: 0.9657273 00:41:29.915 --> 00:41:31.915 analysis for, my k award NOTE Confidence: 0.9657273 00:41:31.915 --> 00:41:32.415 application. NOTE Confidence: 0.95971036 00:41:33.594 --> 00:41:35.114 And, you know, there these NOTE Confidence: 0.95971036 00:41:35.114 --> 00:41:36.474 two populations are very different. NOTE Confidence: 0.95971036 00:41:36.474 --> 00:41:37.535 Medicare and commercial NOTE Confidence: 0.9390251 00:41:38.239 --> 00:41:39.599 is is a very big NOTE Confidence: 0.9390251 00:41:39.599 --> 00:41:40.099 limitation. NOTE Confidence: 0.97563344 00:41:41.040 --> 00:41:41.920 My hope is that we NOTE Confidence: 0.97563344 00:41:41.920 --> 00:41:43.599 did drug level analyses. And NOTE Confidence: 0.97563344 00:41:43.599 --> 00:41:44.799 so you're just looking at NOTE Confidence: 0.97563344 00:41:44.799 --> 00:41:46.160 people taking napixaban, that that NOTE Confidence: 0.97563344 00:41:46.160 --> 00:41:47.440 is gonna be more similar NOTE Confidence: 0.97563344 00:41:47.440 --> 00:41:48.579 than the two populations NOTE Confidence: 0.9996999 00:41:48.960 --> 00:41:49.619 at large. NOTE Confidence: 0.904909 00:41:51.675 --> 00:41:53.195 So in conclusion, the inflation NOTE Confidence: 0.904909 00:41:53.195 --> 00:41:55.135 reduction act was associated with, NOTE Confidence: 0.9487047 00:41:55.595 --> 00:41:57.035 an increase in medication use, NOTE Confidence: 0.9487047 00:41:57.035 --> 00:41:58.715 particularly for high cost drugs. NOTE Confidence: 0.99562645 00:41:59.435 --> 00:42:01.295 This could represent improved access. NOTE Confidence: 0.99562645 00:42:01.355 --> 00:42:01.855 However, NOTE Confidence: 0.95172054 00:42:02.410 --> 00:42:03.610 not all patients are affected NOTE Confidence: 0.95172054 00:42:03.610 --> 00:42:05.050 equally, and we know that NOTE Confidence: 0.95172054 00:42:05.050 --> 00:42:06.670 insurers may respond again. NOTE Confidence: 0.96562004 00:42:07.210 --> 00:42:08.650 And this could represent both NOTE Confidence: 0.96562004 00:42:08.650 --> 00:42:09.770 high and low value use. NOTE Confidence: 0.96562004 00:42:09.770 --> 00:42:10.810 And so in a follow-up NOTE Confidence: 0.96562004 00:42:10.810 --> 00:42:11.310 analysis, NOTE Confidence: 0.9686274 00:42:11.850 --> 00:42:12.730 we look at the in NOTE Confidence: 0.9686274 00:42:12.730 --> 00:42:14.170 the oncology space, and we NOTE Confidence: 0.9686274 00:42:14.170 --> 00:42:15.290 see that low value care NOTE Confidence: 0.9686274 00:42:15.290 --> 00:42:16.670 actually increases more. NOTE Confidence: 0.98518515 00:42:17.234 --> 00:42:19.255 Medications that don't prolong life, NOTE Confidence: 0.98518515 00:42:19.394 --> 00:42:20.594 that don't improve quality of NOTE Confidence: 0.98518515 00:42:20.594 --> 00:42:21.494 life increase, NOTE Confidence: 0.93543106 00:42:22.194 --> 00:42:24.035 about threefold, whereas the other NOTE Confidence: 0.93543106 00:42:24.035 --> 00:42:24.535 medications, NOTE Confidence: 0.98043776 00:42:25.394 --> 00:42:26.835 twenty percent ish. So, NOTE Confidence: 0.9847474 00:42:27.714 --> 00:42:28.994 I think that is potentially NOTE Confidence: 0.9847474 00:42:28.994 --> 00:42:30.275 concerning. You know, we want NOTE Confidence: 0.9847474 00:42:30.275 --> 00:42:31.239 patients be taking the best NOTE Confidence: 0.9847474 00:42:31.239 --> 00:42:33.000 medications, and, ultimately, everyone is NOTE Confidence: 0.9847474 00:42:33.000 --> 00:42:34.300 paying for that. And so NOTE Confidence: 0.9847474 00:42:34.360 --> 00:42:35.160 I think that could be NOTE Confidence: 0.9847474 00:42:35.160 --> 00:42:37.000 an unintended consequence where low NOTE Confidence: 0.9847474 00:42:37.000 --> 00:42:38.140 value care increases NOTE Confidence: 0.9954887 00:42:38.440 --> 00:42:40.300 after this cap, and then NOTE Confidence: 0.9954887 00:42:40.440 --> 00:42:42.140 that those costs are shifted NOTE Confidence: 0.9954887 00:42:42.200 --> 00:42:42.700 around. NOTE Confidence: 0.92483383 00:42:43.320 --> 00:42:44.145 So So I think there NOTE Confidence: 0.92483383 00:42:44.145 --> 00:42:45.344 definitely are there's a need NOTE Confidence: 0.92483383 00:42:45.344 --> 00:42:46.805 for additional studies, and, NOTE Confidence: 0.980905 00:42:48.065 --> 00:42:49.265 I think a clear implication NOTE Confidence: 0.980905 00:42:49.265 --> 00:42:50.225 of this data is that NOTE Confidence: 0.980905 00:42:50.225 --> 00:42:51.265 there's a need for, NOTE Confidence: 0.9906232 00:42:51.665 --> 00:42:53.125 expanded price negotiation. NOTE Confidence: 0.936367 00:42:54.625 --> 00:42:55.425 Yeah. I have a a NOTE Confidence: 0.936367 00:42:55.425 --> 00:42:56.465 question. I mean, so, obviously, NOTE Confidence: 0.936367 00:42:56.465 --> 00:42:57.665 you have an interesting background. NOTE Confidence: 0.936367 00:42:57.665 --> 00:42:58.465 Were you, like, been on NOTE Confidence: 0.936367 00:42:58.465 --> 00:42:59.185 the Hill or sort of NOTE Confidence: 0.936367 00:42:59.185 --> 00:43:00.520 around around the Hill before. NOTE Confidence: 0.936367 00:43:00.760 --> 00:43:01.960 What's your sense of, like, NOTE Confidence: 0.936367 00:43:01.960 --> 00:43:03.480 when the IRA was written NOTE Confidence: 0.936367 00:43:03.480 --> 00:43:04.359 that this was like, there NOTE Confidence: 0.936367 00:43:04.359 --> 00:43:05.480 was modeling done ahead of NOTE Confidence: 0.936367 00:43:05.480 --> 00:43:06.719 time or they anticipated some NOTE Confidence: 0.936367 00:43:06.719 --> 00:43:08.039 of these changes might happen? NOTE Confidence: 0.936367 00:43:08.039 --> 00:43:08.760 Like, how much is this NOTE Confidence: 0.936367 00:43:08.760 --> 00:43:09.480 like, oh, man. We didn't NOTE Confidence: 0.936367 00:43:09.480 --> 00:43:10.359 know what was gonna happen, NOTE Confidence: 0.936367 00:43:10.359 --> 00:43:11.480 or there's actually kinda what NOTE Confidence: 0.936367 00:43:11.480 --> 00:43:12.839 we expected was gonna happen NOTE Confidence: 0.936367 00:43:12.839 --> 00:43:13.640 when we implemented, NOTE Confidence: 0.9615615 00:43:14.585 --> 00:43:15.724 these policy changes. NOTE Confidence: 0.9613354 00:43:16.105 --> 00:43:17.545 Yeah. It's, so the question NOTE Confidence: 0.9613354 00:43:17.545 --> 00:43:18.424 was, yeah, how much of NOTE Confidence: 0.9613354 00:43:18.424 --> 00:43:19.785 this is was planned and, NOTE Confidence: 0.9613354 00:43:19.785 --> 00:43:20.825 you know, you know, could NOTE Confidence: 0.9613354 00:43:20.825 --> 00:43:21.864 could we have prevented this, NOTE Confidence: 0.9295136 00:43:22.505 --> 00:43:23.305 if I summed that up NOTE Confidence: 0.9295136 00:43:23.305 --> 00:43:24.184 right? And I I think NOTE Confidence: 0.9295136 00:43:24.184 --> 00:43:25.145 it's a really good point. NOTE Confidence: 0.9295136 00:43:25.145 --> 00:43:25.785 You know, some of it NOTE Confidence: 0.9295136 00:43:25.785 --> 00:43:26.844 seems kinda predictable. NOTE Confidence: 0.98211384 00:43:27.944 --> 00:43:28.344 You know, NOTE Confidence: 0.96048015 00:43:29.145 --> 00:43:30.500 the so the law lawmakers NOTE Confidence: 0.96048015 00:43:30.560 --> 00:43:31.920 did plan for the premium NOTE Confidence: 0.96048015 00:43:31.920 --> 00:43:33.280 spikes so that there are NOTE Confidence: 0.96048015 00:43:33.280 --> 00:43:34.739 subsidies to address that, NOTE Confidence: 0.9596125 00:43:35.680 --> 00:43:37.120 probably because premiums are very NOTE Confidence: 0.9596125 00:43:37.120 --> 00:43:38.800 politically salient. You know, peep NOTE Confidence: 0.9596125 00:43:38.880 --> 00:43:41.300 patients experience them every month. NOTE Confidence: 0.9725238 00:43:42.894 --> 00:43:44.194 The, you know, the CBO, NOTE Confidence: 0.9153097 00:43:44.575 --> 00:43:46.335 the Congressional Budget Office found NOTE Confidence: 0.9153097 00:43:46.335 --> 00:43:47.214 that the law would save NOTE Confidence: 0.9153097 00:43:47.214 --> 00:43:49.535 money, actually, in total, driven NOTE Confidence: 0.9153097 00:43:49.535 --> 00:43:51.555 by the negotiated prices. NOTE Confidence: 0.96565586 00:43:52.414 --> 00:43:53.694 I don't think they thought NOTE Confidence: 0.96565586 00:43:53.694 --> 00:43:54.734 that the use would go NOTE Confidence: 0.96565586 00:43:54.734 --> 00:43:55.535 up this much, and so NOTE Confidence: 0.96565586 00:43:55.535 --> 00:43:56.575 I think it's important to NOTE Confidence: 0.96565586 00:43:56.575 --> 00:43:57.635 update that. And, NOTE Confidence: 0.9711116 00:43:58.440 --> 00:43:59.160 they just put out a NOTE Confidence: 0.9711116 00:43:59.160 --> 00:44:00.119 call for data, and we're NOTE Confidence: 0.9711116 00:44:00.119 --> 00:44:01.000 we're gonna meet with the NOTE Confidence: 0.9711116 00:44:01.000 --> 00:44:02.520 CBO to kinda see, like, NOTE Confidence: 0.9711116 00:44:02.520 --> 00:44:03.960 compare our models and see NOTE Confidence: 0.9711116 00:44:03.960 --> 00:44:05.560 what if anything, like, if NOTE Confidence: 0.9711116 00:44:05.560 --> 00:44:07.180 there were any differences there. NOTE Confidence: 0.9355458 00:44:08.920 --> 00:44:10.215 And so that is sort NOTE Confidence: 0.9355458 00:44:10.215 --> 00:44:11.015 of what I I think. NOTE Confidence: 0.9355458 00:44:11.015 --> 00:44:12.055 I think that people thought NOTE Confidence: 0.9355458 00:44:12.055 --> 00:44:12.855 the premiums would go up, NOTE Confidence: 0.9355458 00:44:12.855 --> 00:44:13.735 and they tried to address NOTE Confidence: 0.9355458 00:44:13.735 --> 00:44:14.695 it, but it's, like, kinda NOTE Confidence: 0.9355458 00:44:14.695 --> 00:44:16.395 whack a mole situation, unfortunately. NOTE Confidence: 0.9928794 00:44:18.375 --> 00:44:19.575 Do you have any thoughts NOTE Confidence: 0.9928794 00:44:19.575 --> 00:44:20.775 about future work in the NOTE Confidence: 0.9928794 00:44:20.775 --> 00:44:21.815 sense of, like, given these NOTE Confidence: 0.9928794 00:44:21.815 --> 00:44:22.315 results, NOTE Confidence: 0.9468525 00:44:22.850 --> 00:44:25.090 thinking about either inappropriate versus NOTE Confidence: 0.9468525 00:44:25.090 --> 00:44:27.190 appropriate medication prescribing and or NOTE Confidence: 0.9468525 00:44:27.410 --> 00:44:27.910 are, NOTE Confidence: 0.9284108 00:44:28.930 --> 00:44:30.790 prescribers, clinicians substituting NOTE Confidence: 0.9835793 00:44:31.170 --> 00:44:32.450 higher cost meds now that NOTE Confidence: 0.9835793 00:44:32.450 --> 00:44:34.050 they know their patients can NOTE Confidence: 0.9835793 00:44:34.050 --> 00:44:35.090 afford them? And so they're NOTE Confidence: 0.9835793 00:44:35.090 --> 00:44:35.830 less likely NOTE Confidence: 0.99782777 00:44:36.130 --> 00:44:36.790 to prescribe NOTE Confidence: 0.93466187 00:44:37.485 --> 00:44:39.245 therapeutic alternatives as in generics NOTE Confidence: 0.93466187 00:44:39.245 --> 00:44:40.285 or whatever and and just NOTE Confidence: 0.93466187 00:44:40.285 --> 00:44:41.245 like, oh, now you can NOTE Confidence: 0.93466187 00:44:41.245 --> 00:44:42.405 have the Cadillac. Everyone gets NOTE Confidence: 0.93466187 00:44:42.405 --> 00:44:43.025 a Cadillac. NOTE Confidence: 0.99715734 00:44:43.565 --> 00:44:45.485 Yeah. Yeah. And so I NOTE Confidence: 0.99715734 00:44:45.485 --> 00:44:46.765 think that's really a good NOTE Confidence: 0.99715734 00:44:46.765 --> 00:44:47.245 question. NOTE Confidence: 0.96420074 00:44:47.565 --> 00:44:48.765 I mean, a couple things. NOTE Confidence: 0.96420074 00:44:48.765 --> 00:44:50.670 Like, one is, like, there's NOTE Confidence: 0.96420074 00:44:50.670 --> 00:44:52.450 there's now a clear incentive NOTE Confidence: 0.96420074 00:44:52.510 --> 00:44:53.469 if you are if you NOTE Confidence: 0.96420074 00:44:53.469 --> 00:44:54.829 have cancer and you're taking NOTE Confidence: 0.96420074 00:44:54.829 --> 00:44:56.109 an infusion and there is NOTE Confidence: 0.96420074 00:44:56.109 --> 00:44:57.170 an oral medication. NOTE Confidence: 0.9511154 00:44:57.710 --> 00:44:59.150 So infusions are not subject NOTE Confidence: 0.9511154 00:44:59.150 --> 00:45:00.349 to this cap, the part NOTE Confidence: 0.9511154 00:45:00.510 --> 00:45:02.130 their part b. So NOTE Confidence: 0.94830483 00:45:02.705 --> 00:45:04.065 I that's, like, something that NOTE Confidence: 0.94830483 00:45:04.065 --> 00:45:04.984 you could look at if NOTE Confidence: 0.94830483 00:45:05.185 --> 00:45:06.465 is there a substitution between NOTE Confidence: 0.94830483 00:45:06.465 --> 00:45:08.225 infusions and to to part NOTE Confidence: 0.94830483 00:45:08.225 --> 00:45:09.905 d? Like, there's one. And NOTE Confidence: 0.94830483 00:45:09.905 --> 00:45:11.025 then as you pointed out NOTE Confidence: 0.94830483 00:45:11.025 --> 00:45:11.844 within class, NOTE Confidence: 0.96707493 00:45:12.625 --> 00:45:13.665 I didn't put put it NOTE Confidence: 0.96707493 00:45:13.665 --> 00:45:14.485 on on NOTE Confidence: 0.9697519 00:45:14.810 --> 00:45:15.850 in my slides, but I NOTE Confidence: 0.9697519 00:45:15.850 --> 00:45:16.969 I I believe, like, brand NOTE Confidence: 0.9697519 00:45:16.969 --> 00:45:18.730 name proton pump inhibitor use, NOTE Confidence: 0.9697519 00:45:18.730 --> 00:45:20.090 I saw, like, goes way NOTE Confidence: 0.9697519 00:45:20.090 --> 00:45:21.609 up, which is obviously low NOTE Confidence: 0.9697519 00:45:21.609 --> 00:45:22.969 value when you have generic NOTE Confidence: 0.9697519 00:45:22.969 --> 00:45:24.830 alternatives that are clinically interchangeable. NOTE Confidence: 0.9697519 00:45:24.969 --> 00:45:26.410 So there's probably a lot NOTE Confidence: 0.9697519 00:45:26.410 --> 00:45:27.630 you could do there. NOTE Confidence: 0.917225 00:45:28.614 --> 00:45:29.915 You know, other examples, NOTE Confidence: 0.9410225 00:45:30.295 --> 00:45:31.435 I think in our dataset, NOTE Confidence: 0.9835205 00:45:31.895 --> 00:45:33.575 you know, antipsychotic use goes NOTE Confidence: 0.9835205 00:45:33.575 --> 00:45:35.035 up for long acting injectables, NOTE Confidence: 0.9835205 00:45:35.094 --> 00:45:36.295 which are very expensive. And NOTE Confidence: 0.9835205 00:45:36.295 --> 00:45:37.735 so I think that's an NOTE Confidence: 0.9835205 00:45:37.735 --> 00:45:39.175 open question of whether that NOTE Confidence: 0.9835205 00:45:39.175 --> 00:45:39.975 is a good or bad NOTE Confidence: 0.9835205 00:45:39.975 --> 00:45:40.855 thing. It could be good NOTE Confidence: 0.9835205 00:45:40.855 --> 00:45:42.055 if you're switching from the NOTE Confidence: 0.9835205 00:45:42.055 --> 00:45:43.655 orals to the LAIs, and, NOTE Confidence: 0.9835205 00:45:43.655 --> 00:45:45.089 like, that seems great. Like, NOTE Confidence: 0.9835205 00:45:45.089 --> 00:45:46.529 now patients who cannot afford NOTE Confidence: 0.9835205 00:45:46.529 --> 00:45:48.289 that are are getting that. NOTE Confidence: 0.9835205 00:45:48.450 --> 00:45:49.170 It could be bad if NOTE Confidence: 0.9835205 00:45:49.170 --> 00:45:50.609 it just enables people to NOTE Confidence: 0.9835205 00:45:50.609 --> 00:45:51.510 get antipsychotics NOTE Confidence: 0.9721068 00:45:52.049 --> 00:45:53.250 that are, of course, associated NOTE Confidence: 0.9721068 00:45:53.250 --> 00:45:54.450 with mortality. And so I NOTE Confidence: 0.9721068 00:45:54.529 --> 00:45:55.410 there's, like, a lot you NOTE Confidence: 0.9721068 00:45:55.410 --> 00:45:56.710 could you could do NOTE Confidence: 0.8594381 00:45:57.435 --> 00:45:57.935 there, NOTE Confidence: 0.9580837 00:45:58.315 --> 00:45:59.114 and I'd love to get NOTE Confidence: 0.9580837 00:45:59.114 --> 00:46:00.795 your feedback on, like, you NOTE Confidence: 0.9580837 00:46:00.795 --> 00:46:01.835 know, are any of these NOTE Confidence: 0.9580837 00:46:01.835 --> 00:46:03.114 interesting or what I should NOTE Confidence: 0.9580837 00:46:03.114 --> 00:46:03.775 do next. NOTE Confidence: 0.94215137 00:46:04.315 --> 00:46:05.435 So build building off of NOTE Confidence: 0.94215137 00:46:05.435 --> 00:46:06.635 that of Joe's question and NOTE Confidence: 0.94215137 00:46:06.635 --> 00:46:08.255 and your answer, so concomitant NOTE Confidence: 0.96191674 00:46:08.635 --> 00:46:10.075 with this sort of timeline NOTE Confidence: 0.96191674 00:46:10.075 --> 00:46:11.535 in the last few years, NOTE Confidence: 0.9936945 00:46:11.989 --> 00:46:13.510 These real time prescription benefits NOTE Confidence: 0.9936945 00:46:13.510 --> 00:46:14.950 are now being integrated into NOTE Confidence: 0.9936945 00:46:14.950 --> 00:46:16.069 EHRs and are about to NOTE Confidence: 0.9936945 00:46:16.069 --> 00:46:17.770 be mandated to be, NOTE Confidence: 0.96649694 00:46:18.789 --> 00:46:20.650 included. And and I wonder NOTE Confidence: 0.9211297 00:46:20.950 --> 00:46:22.250 how you build in that, NOTE Confidence: 0.9025236 00:46:22.789 --> 00:46:23.989 the impact of those on NOTE Confidence: 0.9025236 00:46:23.989 --> 00:46:25.670 prescribing, especially when it comes NOTE Confidence: 0.9025236 00:46:25.670 --> 00:46:26.890 to within class alternate NOTE Confidence: 0.95571655 00:46:27.494 --> 00:46:28.454 alternatives. Because that's what they're NOTE Confidence: 0.95571655 00:46:28.454 --> 00:46:29.335 meant to do. Right? They're NOTE Confidence: 0.95571655 00:46:29.335 --> 00:46:31.434 meant to trigger clinicians NOTE Confidence: 0.9623815 00:46:31.894 --> 00:46:33.594 to choose lower cost options, NOTE Confidence: 0.98687696 00:46:34.535 --> 00:46:36.555 or lower cost pharmacies. But, NOTE Confidence: 0.9826639 00:46:37.894 --> 00:46:38.855 anyway, I I think it's NOTE Confidence: 0.9826639 00:46:38.855 --> 00:46:40.614 important to Yeah. Incorporate that NOTE Confidence: 0.9826639 00:46:40.614 --> 00:46:41.575 or think about that as NOTE Confidence: 0.9826639 00:46:41.575 --> 00:46:42.930 we I think that'd be NOTE Confidence: 0.9826639 00:46:42.930 --> 00:46:44.070 a really interesting study, NOTE Confidence: 0.9992219 00:46:44.690 --> 00:46:45.190 and NOTE Confidence: 0.9573418 00:46:46.450 --> 00:46:47.330 I guess you would need NOTE Confidence: 0.9573418 00:46:47.330 --> 00:46:48.790 EHR data to do it. NOTE Confidence: 0.8986863 00:46:50.050 --> 00:46:50.550 And, NOTE Confidence: 0.93492955 00:46:52.930 --> 00:46:53.810 I mean, I think on NOTE Confidence: 0.93492955 00:46:53.810 --> 00:46:55.330 a population level, it's it's NOTE Confidence: 0.93492955 00:46:55.330 --> 00:46:56.770 worth asking, like, should some NOTE Confidence: 0.93492955 00:46:56.770 --> 00:46:58.425 medications not be subject to NOTE Confidence: 0.93492955 00:46:58.425 --> 00:46:59.545 the cap if they're like NOTE Confidence: 0.93492955 00:46:59.625 --> 00:47:00.665 like, maybe, like, brand name NOTE Confidence: 0.93492955 00:47:00.665 --> 00:47:02.344 proton pump inhibitors, we don't NOTE Confidence: 0.93492955 00:47:02.344 --> 00:47:03.465 cap costs for that. And NOTE Confidence: 0.93492955 00:47:03.465 --> 00:47:03.965 then, NOTE Confidence: 0.94884545 00:47:04.265 --> 00:47:05.225 you know, maybe it leads NOTE Confidence: 0.94884545 00:47:05.225 --> 00:47:06.585 to a week delay when NOTE Confidence: 0.94884545 00:47:06.585 --> 00:47:08.185 you, you know, maybe you NOTE Confidence: 0.94884545 00:47:08.185 --> 00:47:09.385 you it's frustrating as a NOTE Confidence: 0.94884545 00:47:09.385 --> 00:47:10.425 clinician and as a patient. NOTE Confidence: 0.94884545 00:47:10.425 --> 00:47:11.385 You don't get your proton NOTE Confidence: 0.94884545 00:47:11.385 --> 00:47:12.585 pump inhibitor for a week NOTE Confidence: 0.94884545 00:47:12.585 --> 00:47:14.070 because you clicked the you NOTE Confidence: 0.94884545 00:47:14.070 --> 00:47:14.950 know, you clicked it and, NOTE Confidence: 0.94884545 00:47:14.950 --> 00:47:15.989 oh, it's not covered and NOTE Confidence: 0.94884545 00:47:15.989 --> 00:47:16.790 you have to go through NOTE Confidence: 0.94884545 00:47:16.790 --> 00:47:19.270 that. But ultimately, relatively low NOTE Confidence: 0.94884545 00:47:19.270 --> 00:47:20.890 stakes for most patients, and NOTE Confidence: 0.94884545 00:47:21.030 --> 00:47:22.150 it is sort of something NOTE Confidence: 0.94884545 00:47:22.150 --> 00:47:23.510 that is clearly not indicated. NOTE Confidence: 0.94884545 00:47:23.510 --> 00:47:24.550 So stuff like that, I NOTE Confidence: 0.94884545 00:47:24.550 --> 00:47:26.090 think, could be reasonable. NOTE Confidence: 0.9751499 00:47:26.630 --> 00:47:28.395 But, you know, it's it's NOTE Confidence: 0.9751499 00:47:28.395 --> 00:47:29.215 tough to NOTE Confidence: 0.98139966 00:47:29.515 --> 00:47:31.055 change laws and to implement NOTE Confidence: 0.98139966 00:47:31.114 --> 00:47:32.415 with that amount of nuance. NOTE Confidence: 0.9733272 00:47:33.355 --> 00:47:34.235 So I don't know. I NOTE Confidence: 0.9733272 00:47:34.235 --> 00:47:34.955 I think that's a really NOTE Confidence: 0.9733272 00:47:34.955 --> 00:47:36.075 good question. I think those NOTE Confidence: 0.9733272 00:47:36.075 --> 00:47:37.195 tools are probably gonna be NOTE Confidence: 0.9733272 00:47:37.195 --> 00:47:37.855 very helpful. NOTE Confidence: 0.94144005 00:47:38.715 --> 00:47:39.515 I mean, I think in NOTE Confidence: 0.94144005 00:47:39.515 --> 00:47:41.275 a related point is to NOTE Confidence: 0.94144005 00:47:41.275 --> 00:47:42.975 what extent have these changes NOTE Confidence: 0.9427358 00:47:43.950 --> 00:47:45.570 exacerbated the problem of polypharmacy? NOTE Confidence: 0.96649325 00:47:46.989 --> 00:47:47.430 Yeah. NOTE Confidence: 0.8023932 00:47:47.869 --> 00:47:49.250 Low value use anyway. NOTE Confidence: 0.9678638 00:47:50.590 --> 00:47:51.550 It's sort of a double NOTE Confidence: 0.9678638 00:47:51.550 --> 00:47:53.469 whammy. Yes. Yeah. Totally. So NOTE Confidence: 0.9678638 00:47:53.469 --> 00:47:54.510 you could look at potentially NOTE Confidence: 0.9678638 00:47:54.510 --> 00:47:56.290 inappropriate medication use and NOTE Confidence: 0.99229807 00:47:57.390 --> 00:47:57.890 yeah. NOTE Confidence: 0.9103968 00:47:59.635 --> 00:48:00.515 This is really interesting. I NOTE Confidence: 0.9103968 00:48:00.515 --> 00:48:01.795 was curious, though, in in NOTE Confidence: 0.9103968 00:48:01.795 --> 00:48:02.515 looking at, like, some of NOTE Confidence: 0.9103968 00:48:02.515 --> 00:48:03.635 these plans and especially the NOTE Confidence: 0.9103968 00:48:03.635 --> 00:48:05.075 commercial plans, maybe more so NOTE Confidence: 0.9103968 00:48:05.075 --> 00:48:06.275 than Medicare or even met NOTE Confidence: 0.9103968 00:48:06.355 --> 00:48:08.055 MA, like, looking at utilization NOTE Confidence: 0.9103968 00:48:08.194 --> 00:48:09.875 managements or techniques that they've NOTE Confidence: 0.9103968 00:48:09.875 --> 00:48:11.315 been employing to actually dissuade NOTE Confidence: 0.9103968 00:48:11.315 --> 00:48:12.275 you low value care. Because NOTE Confidence: 0.9103968 00:48:12.275 --> 00:48:13.950 you'd imagine where the brand NOTE Confidence: 0.9103968 00:48:13.950 --> 00:48:15.570 name, like, program pump inhibitors, NOTE Confidence: 0.9103968 00:48:15.869 --> 00:48:16.590 they would just say, we're NOTE Confidence: 0.9103968 00:48:16.590 --> 00:48:17.469 just gonna move it to, NOTE Confidence: 0.9103968 00:48:17.469 --> 00:48:18.989 like, a different tier, right, NOTE Confidence: 0.9103968 00:48:18.989 --> 00:48:20.030 and, like, put in fire NOTE Confidence: 0.9103968 00:48:20.030 --> 00:48:21.150 off and put in these NOTE Confidence: 0.9103968 00:48:21.150 --> 00:48:22.050 sorts of barriers. NOTE Confidence: 0.9610216 00:48:22.510 --> 00:48:23.390 So are you seeing in NOTE Confidence: 0.9610216 00:48:23.390 --> 00:48:24.530 response to this NOTE Confidence: 0.95144415 00:48:25.230 --> 00:48:27.405 changes from how formulas are NOTE Confidence: 0.95144415 00:48:27.405 --> 00:48:28.065 being structured NOTE Confidence: 0.99850434 00:48:28.525 --> 00:48:29.425 as a result NOTE Confidence: 0.9797752 00:48:29.725 --> 00:48:30.765 of, like, the caps and NOTE Confidence: 0.9797752 00:48:30.765 --> 00:48:31.265 whatnot? NOTE Confidence: 0.99813604 00:48:32.364 --> 00:48:32.765 Yeah. NOTE Confidence: 0.99695563 00:48:33.405 --> 00:48:34.945 We didn't assess that. NOTE Confidence: 0.9691534 00:48:35.805 --> 00:48:37.485 Other colleagues have looked at, NOTE Confidence: 0.98753524 00:48:38.125 --> 00:48:39.805 changes in prior auth for NOTE Confidence: 0.98753524 00:48:39.805 --> 00:48:41.950 medications and have, for whatever NOTE Confidence: 0.98753524 00:48:41.950 --> 00:48:43.630 reason, they didn't really change. NOTE Confidence: 0.98753524 00:48:43.630 --> 00:48:44.350 So I don't I was NOTE Confidence: 0.98753524 00:48:44.350 --> 00:48:45.469 actually surprised by that. NOTE Confidence: 0.9088469 00:48:46.030 --> 00:48:47.890 The cohort of medications that, NOTE Confidence: 0.9088469 00:48:48.190 --> 00:48:48.989 this is work by, like, NOTE Confidence: 0.9088469 00:48:48.989 --> 00:48:49.810 Stacy Dusetzina NOTE Confidence: 0.9221215 00:48:50.270 --> 00:48:51.170 that she's led, NOTE Confidence: 0.9183412 00:48:52.350 --> 00:48:53.550 were, like, top selling brand NOTE Confidence: 0.9183412 00:48:53.550 --> 00:48:54.670 name medications. So, NOTE Confidence: 0.97238934 00:48:56.375 --> 00:48:57.734 maybe prior auth change for NOTE Confidence: 0.97238934 00:48:57.734 --> 00:48:58.855 other medications, but, NOTE Confidence: 0.9952645 00:48:59.494 --> 00:49:00.535 we didn't see that. And NOTE Confidence: 0.9952645 00:49:00.535 --> 00:49:02.454 then, the formulary tier point NOTE Confidence: 0.9952645 00:49:02.454 --> 00:49:03.335 you make is is good NOTE Confidence: 0.9952645 00:49:03.415 --> 00:49:04.395 is a good one. NOTE Confidence: 0.9354832 00:49:05.015 --> 00:49:05.494 We, NOTE Confidence: 0.9936536 00:49:05.815 --> 00:49:06.775 let me see if I NOTE Confidence: 0.9936536 00:49:06.775 --> 00:49:07.515 have this. NOTE Confidence: 0.913253 00:49:08.855 --> 00:49:09.835 We looked at NOTE Confidence: 0.9511709 00:49:11.319 --> 00:49:11.819 different, NOTE Confidence: 0.9559707 00:49:17.000 --> 00:49:18.599 these are different tiers for NOTE Confidence: 0.9559707 00:49:18.599 --> 00:49:20.039 different medications and, NOTE Confidence: 0.9514855 00:49:21.480 --> 00:49:22.140 oh, sorry. NOTE Confidence: 0.93372804 00:49:22.440 --> 00:49:23.325 This is the next slide. NOTE Confidence: 0.93372804 00:49:23.325 --> 00:49:24.204 Slide. So this is on NOTE Confidence: 0.93372804 00:49:24.204 --> 00:49:25.405 the x axis. You have NOTE Confidence: 0.93372804 00:49:25.405 --> 00:49:26.364 year, and then the y NOTE Confidence: 0.93372804 00:49:26.364 --> 00:49:27.964 axis, the the tier. NOTE Confidence: 0.97560906 00:49:28.285 --> 00:49:29.724 And none of these medications NOTE Confidence: 0.97560906 00:49:29.724 --> 00:49:31.244 really changed their tier before NOTE Confidence: 0.97560906 00:49:31.244 --> 00:49:32.464 and after the law. So, NOTE Confidence: 0.924528 00:49:32.925 --> 00:49:33.724 you can see the lot NOTE Confidence: 0.924528 00:49:33.805 --> 00:49:34.925 it basically, the lines are NOTE Confidence: 0.924528 00:49:34.925 --> 00:49:36.765 basically just, like, straight lines. NOTE Confidence: 0.924528 00:49:36.765 --> 00:49:37.005 So, NOTE Confidence: 0.94481593 00:49:37.750 --> 00:49:38.790 maybe we should do that NOTE Confidence: 0.94481593 00:49:38.790 --> 00:49:39.989 for more medications, but at NOTE Confidence: 0.94481593 00:49:39.989 --> 00:49:41.030 least on first pass, they NOTE Confidence: 0.94481593 00:49:41.030 --> 00:49:42.090 didn't really change. NOTE Confidence: 0.95677614 00:49:48.469 --> 00:49:49.910 Okay. I'll take silence as NOTE Confidence: 0.95677614 00:49:49.910 --> 00:49:50.410 approval. NOTE Confidence: 0.8327036 00:49:53.775 --> 00:49:54.895 Okay. I'll just, NOTE Confidence: 0.9849351 00:49:55.375 --> 00:49:56.594 outline my future, NOTE Confidence: 0.9775597 00:49:57.214 --> 00:49:58.494 plans, which is really to NOTE Confidence: 0.9775597 00:49:58.494 --> 00:49:59.935 focus on a k award NOTE Confidence: 0.9775597 00:49:59.935 --> 00:50:00.435 application. NOTE Confidence: 0.9573106 00:50:00.815 --> 00:50:01.935 I'm hoping to apply for NOTE Confidence: 0.9573106 00:50:01.935 --> 00:50:02.915 a Beeson award, NOTE Confidence: 0.9294847 00:50:04.094 --> 00:50:04.915 this October. NOTE Confidence: 0.9787776 00:50:05.535 --> 00:50:06.275 And then, NOTE Confidence: 0.78242093 00:50:07.055 --> 00:50:07.454 so, NOTE Confidence: 0.9936867 00:50:08.469 --> 00:50:10.170 here are the illustrative faculty NOTE Confidence: 0.9936867 00:50:10.230 --> 00:50:11.030 I would like to work NOTE Confidence: 0.9936867 00:50:11.030 --> 00:50:11.510 with, NOTE Confidence: 0.9238544 00:50:11.989 --> 00:50:13.770 and my training and research NOTE Confidence: 0.9238544 00:50:13.830 --> 00:50:14.330 aims. NOTE Confidence: 0.96216965 00:50:15.670 --> 00:50:16.950 I really wanna focus on NOTE Confidence: 0.96216965 00:50:16.950 --> 00:50:18.469 getting better at causal inference, NOTE Confidence: 0.96216965 00:50:18.469 --> 00:50:20.070 and so training aim one NOTE Confidence: 0.96216965 00:50:20.070 --> 00:50:20.390 would be, NOTE Confidence: 0.9137393 00:50:21.114 --> 00:50:22.955 looking at methods and, or NOTE Confidence: 0.9137393 00:50:22.955 --> 00:50:23.775 sorry, matching, NOTE Confidence: 0.98927325 00:50:24.795 --> 00:50:26.155 and then two is to NOTE Confidence: 0.98927325 00:50:26.155 --> 00:50:27.614 deepen my knowledge of geriatric, NOTE Confidence: 0.88365364 00:50:28.235 --> 00:50:29.295 specific outcomes, NOTE Confidence: 0.98653954 00:50:30.475 --> 00:50:31.195 and then my, NOTE Confidence: 0.95999664 00:50:31.755 --> 00:50:33.246 actual research aims. I think NOTE Confidence: 0.95999664 00:50:33.246 --> 00:50:34.908 I you know, all of NOTE Confidence: 0.95999664 00:50:34.908 --> 00:50:36.292 this is interesting population level NOTE Confidence: 0.95999664 00:50:36.292 --> 00:50:37.676 data, but really important to NOTE Confidence: 0.95999664 00:50:37.676 --> 00:50:39.060 validate and expand upon it NOTE Confidence: 0.95999664 00:50:39.060 --> 00:50:40.444 in the Part d claims NOTE Confidence: 0.95999664 00:50:40.444 --> 00:50:41.829 data. And so you can NOTE Confidence: 0.95999664 00:50:41.829 --> 00:50:43.213 see the research aims are NOTE Confidence: 0.95999664 00:50:43.213 --> 00:50:44.874 to, you know, assess changes NOTE Confidence: 0.95999664 00:50:44.874 --> 00:50:46.344 in use, assess changes in NOTE Confidence: 0.95999664 00:50:46.344 --> 00:50:48.905 outcomes, and then, assess, treatment NOTE Confidence: 0.95999664 00:50:48.905 --> 00:50:49.405 heterogeneity. NOTE Confidence: 0.975094 00:50:50.825 --> 00:50:52.185 And then what I'm hoping NOTE Confidence: 0.975094 00:50:52.185 --> 00:50:53.305 to do, in a few NOTE Confidence: 0.975094 00:50:53.305 --> 00:50:54.745 years, if the NIA still NOTE Confidence: 0.975094 00:50:54.745 --> 00:50:56.105 exists, would be to apply NOTE Confidence: 0.975094 00:50:56.105 --> 00:50:57.405 for an r o one. NOTE Confidence: 0.9812655 00:50:58.930 --> 00:51:00.610 And then here's sort of NOTE Confidence: 0.9812655 00:51:00.610 --> 00:51:02.050 my timeline. I'm hoping to NOTE Confidence: 0.9812655 00:51:02.050 --> 00:51:03.270 apply for that in, NOTE Confidence: 0.9976112 00:51:03.810 --> 00:51:04.930 this October, which I know NOTE Confidence: 0.9976112 00:51:04.930 --> 00:51:05.670 is aggressive, NOTE Confidence: 0.99756527 00:51:06.130 --> 00:51:07.250 but starting to work on NOTE Confidence: 0.99756527 00:51:07.250 --> 00:51:07.989 that now. NOTE Confidence: 0.97572446 00:51:08.690 --> 00:51:09.350 And then, NOTE Confidence: 0.98330927 00:51:10.130 --> 00:51:11.170 I just submitted a grant NOTE Confidence: 0.98330927 00:51:11.170 --> 00:51:12.265 with with colleagues that would NOTE Confidence: 0.98330927 00:51:12.265 --> 00:51:13.625 be portable to to look NOTE Confidence: 0.98330927 00:51:13.625 --> 00:51:14.125 at NOTE Confidence: 0.94867253 00:51:14.585 --> 00:51:15.945 parts of the Inflation Reduction NOTE Confidence: 0.94867253 00:51:15.945 --> 00:51:17.945 Act in partnership with, Express NOTE Confidence: 0.94867253 00:51:17.945 --> 00:51:19.225 Scripts, which is a PBM, NOTE Confidence: 0.94867253 00:51:19.225 --> 00:51:20.685 a pharmacy benefit manager. NOTE Confidence: 0.9812724 00:51:21.225 --> 00:51:22.265 There is a program that NOTE Confidence: 0.9812724 00:51:22.265 --> 00:51:23.305 would smooth out of pocket NOTE Confidence: 0.9812724 00:51:23.305 --> 00:51:24.665 costs over the calendar year NOTE Confidence: 0.9812724 00:51:24.665 --> 00:51:25.625 that could address some of NOTE Confidence: 0.9812724 00:51:25.625 --> 00:51:26.125 this. NOTE Confidence: 0.9666991 00:51:26.585 --> 00:51:27.670 So that's sort of the NOTE Confidence: 0.9666991 00:51:27.670 --> 00:51:29.190 timeline of what I'm hoping NOTE Confidence: 0.9666991 00:51:29.190 --> 00:51:30.550 to, to do in the NOTE Confidence: 0.9666991 00:51:30.550 --> 00:51:31.690 next couple of years. NOTE Confidence: 0.9887721 00:51:33.190 --> 00:51:33.690 Okay. NOTE Confidence: 0.99547386 00:51:34.710 --> 00:51:36.090 At the risk of overstuffing NOTE Confidence: 0.96787065 00:51:36.469 --> 00:51:37.830 this time period with too NOTE Confidence: 0.96787065 00:51:37.830 --> 00:51:39.494 many more slides, I'll pause NOTE Confidence: 0.96787065 00:51:39.494 --> 00:51:40.535 there. And and thank you NOTE Confidence: 0.96787065 00:51:40.535 --> 00:51:41.734 all for for your feedback. NOTE Confidence: 0.96787065 00:51:41.734 --> 00:51:42.775 It's truly an, NOTE Confidence: 0.89322776 00:51:43.494 --> 00:51:45.015 obviously a privilege to present, NOTE Confidence: 0.9829726 00:51:45.494 --> 00:51:47.255 and, you know, your engagement NOTE Confidence: 0.9829726 00:51:47.255 --> 00:51:48.135 means a lot. So I'll NOTE Confidence: 0.9829726 00:51:48.135 --> 00:51:49.494 I'll go back and make NOTE Confidence: 0.9829726 00:51:49.494 --> 00:51:50.234 those changes, NOTE Confidence: 0.95988417 00:51:50.775 --> 00:51:52.055 to to this to this NOTE Confidence: 0.95988417 00:51:52.055 --> 00:51:53.174 paper. And so I really NOTE Confidence: 0.95988417 00:51:53.174 --> 00:51:54.714 appreciate all your time.