Rae Woods (00:02):
From Advisory Board, we are bringing you a live Radio Advisory. My name is Rachel Woods. You can call me Rae.

(00:12):
That isn't a 100% true, because I am back at my home studio, but last week we actually got together in person, for a live event, as part of one of Advisory Board's, big executive summits. We did a completely live reporting. We had a couple of incredible external guests, some voices from Advisory Board, and we put on a fantastic show. That does mean that this episode is longer than usual. It's almost an hour, but I promise it is worth it to get through it all.

(00:45):
We're talking about next generation clinical products, and why they will be disruptive for the industry, in fact, why they will be particularly disruptive in 2023.

(00:56):
Together with my guests. We talk about what that means for providers, we talk about what that means for purchasers, and how the industry can work together to be prepared for these new products. Plus, we have a lot of fun along the way. I am talking about games. I am talking about poles. It is really worth your time. I hope you enjoy this live Radio Advisory episode.

(01:26):
There we go. That's right. That's exactly what we want to see.

(01:35):
All right. We are here to talk about next generation diagnostics and therapeutics, and this isn't your typical podcast episode. This also, isn't your typical conference session. We have of course brought the research and the materials to advance our discussion, but we also want to have a little bit of fun.

(01:57):
And joining me on that fun are our expert panelists. I've got Fanta Cherif. She is Advisory Board's own researcher. She's literally, spent the last year trying to understand, what it means to adapt to next generation therapeutics and diagnostics.

(02:14):
We also have Bill Dreitlein. He's an executive pharmacist, and he works for OptumRx, as the senior director of Pipeline and Drug Surveillance.

(02:23):
And then we have Dr. Yuri Marichich. I did, I butcher that?

Yuri Marichich (02:27):
Pretty close.

Rae Woods (02:28):
I'm just going to call you Dr. Yuri.

(02:30):
Dr. Yuri. He's the chief medical officer and head of development at Pear Therapeutics. If you don't know what Pear is, they are a company that is trying to redefine medicine, by including prescription digital therapeutics. Did you ever think that was possible?

(02:47):
Now our guests are here, again, to talk about, this future state of upcoming products, and I'm calling them next generation products, and that should, automatically, be giving you some Star Trek vibes, right? Next generation. It should be making you think about things that might be science fiction, because the truth is, there are a lot of very cool new products, new devices, that are going to be hitting the market, that just seem like they're out of a science fiction novel. They don't seem real, or maybe, even if they seem like they're in the realm of possibility, it's easy to think, 10 years, 20 years, 50 years into the future, are when we're actually going to have to deal with this in the healthcare ecosystem.

(03:29):
But the truth is, and this is the problem, we are on the cusp of a lot of very cool products about to hit our market. I'm talking about things like deep brain stimulation. I am talking about biomarker testing. I am talking about ultra high cost drugs, digital therapeutics, lots that is out there.

(03:51):
What I'm worried about, is a world where we have no way to deliver or finance those products. Think about what that would mean for patients, that there is a life changing product that is out there that is available, but it's not actually able to get into the hands of the patients, that need it the most.

(04:08):
That's what we're going to talk about avoiding today. I want us to go from a world where we're maybe avoiding the inevitable, to where we're actually embracing next generation products. Now we're going to keep talking about these products and we're going to keep having some fun.

(04:23):
So we have a little bit of a game to kick us off with. The game is, Fact or Fiction. Each of our guests has come with a next generation product. They are going to share it with all of you. It is your job to determine which is science fiction. You ready?

(04:41):
All right. Fanta, you want to kick us off?

Fanta Cherif (04:44):
Sure. Thank you.

(04:45):
So first, we have the smart toilet, which is your number one expert on, going number two. So this product embeds AI into toilets and really helps gastroenterologists really informed treatment for IBD and IBS, so if you're not into home improvement, you can also find this just at your local gastroenterologist office.

Rae Woods (05:04):
Next, we have the next big thing for Pharma, or maybe, it's the next big thing for devices.

Bill Dreitlein (05:11):
I think it's just the next big thing, personal.

Rae Woods (05:13):
You think it's just the next big thing? Either way. It's another story about poop.

Bill Dreitlein (05:17):
Well, this is a companion to the toilet, and this is a vibrating pill. The big problem is constipation. Some people get it, don't know why. Sometimes, the side effect of a drug.

(05:28):
Any nurses in the audience? You probably have dealt with that with people who have, not personally, sorry, but only you have, but people with opioid induced constipation, right? Happens to the best of us.

(05:42):
But with this product is it's a capsule that vibrates, and so you take it, and then it kind of travels down, and it comes with an app, by the way, so you can kind of watch where it goes.

Rae Woods (05:53):
Of course, it does.

Bill Dreitlein (05:54):
Because I guess, at some point, you have to figure, it comes out the other side and you might not want to know that, and what it does is it vibrates and then it kind of stirs things up and helps things move. So hence the interaction with the smart toilet.

(06:08):
It's a whole system. It's a whole ecosystem, end to end.

Rae Woods (06:10):
All an ecosystem. All right, Yuri, round us out, with the thing that everyone is afraid will take over the world, or at least that physicians are afraid are going to take their jobs. Tell us about robots.

Yuri Marichich (06:19):
Yeah, I feel like I need to elevate this conversation as well.

(06:22):
Phage robots. So, robots are replacing everything, and so phage robots are actually, molecular machinery that can attack and inject their own molecular machinery into bacteria, without having the same consequences of resistance to antibiotics and would usher in, a new era antimicrobials.

Rae Woods (06:50):
Sounds pretty cool. All right, audience, it's your turn to get involved. We've got three options for you. The smart toilet, the vibrating pill, or phage robots.

(06:58):
Again, you get to decide which one of these is actually fake. Go ahead and clap for me if you think that the smart toilet is fake. How about the vibrating pill?

Bill Dreitlein (07:10):
Oh, I sold that. Pretty good.

Rae Woods (07:15):
Phage Robots. It's too futuristic to be fake. Do you want to tell them the truth?

Fanta Cherif (07:22):
They're all real.

Bill Dreitlein (07:22):
They are all real.

Rae Woods (07:26):
They are all real, that's right. They seem like they're out of science fiction, but these are all real products that are either available today, like you can get the smart toilet now, if you want to, or they're in FDA approval. They're in the kind of final stages of development, about to be ready for our own industry to actually use.

(07:45):
Now we're having some fun talking about these products, but the truth is, there's a huge, huge range of what we could be talking about when we say, next generation therapeutics and diagnostics.

(07:57):
Fanta, what do we actually mean when we're talking about this?

Fanta Cherif (08:00):
So, through my research stream, we've kind of identified seven different buckets of what this actually means. So we've broken it down into, at-home diagnostics, biomarker testing, deep brain stimulation, psychedelic assisted therapy, pharmacogenomics, and ultra high cost drugs.

(08:16):
So typically, when we're looking at these products, they really just require a higher level of stakeholder interaction and collaboration. They also, typically, are higher cost, they are indicated to treat really rare and severe disease, sometimes they may be indicated for individual treatment decisions, so maybe deferring, depending on which individual you're actually treating, and then lastly, they really, really, really are changing the routes of administration.

(08:42):
So whether that's through infusions, deep brain stimulation, as we said before, so like helmet caps, brain surgery, et cetera. So really just changing the way we are thinking about care delivery, how we generate evidence, and collect evidence, and how we use evidence, looking at differences in payment models, and then lastly, really challenging how we regulate these things, because there's so much flexibility.

Rae Woods (09:03):
But all these things, to me, they sound great, as somebody who's a patient. We're all also patients. These sound like something that I would welcome, when I think about my own future of healthcare treatment.

(09:17):
My question for you, Bill, and for you Yuri, is, why is this a problem? Why is this going to be disruptive for the industry, if we're not prepared for these next generation products?

Bill Dreitlein (09:28):
Why is it a problem? Well, I guess, in some ways it is, and some ways it's not. I mean, in some ways it helps us do our jobs better, but how it can be a problem, is if we're not aware of it.

(09:39):
I think those are the things that are truly disruptive, when something new and revolutionary comes and we just get blindsided by it. That's the thing that can really upset your business and even put you out of business. Thinking back to the Hep C drugs, innovative, disruptive technology that nobody saw coming, and the byproduct of that was that there were some plants that, almost went out of business, because they weren't prepared for the volume, they weren't prepared for the costs, they weren't prepared for, how do you deal with a one-time course of treatment, that could actually cure an infectious disease, something we have real problems with?

Rae Woods (10:22):
But cost a ton of money.

Bill Dreitlein (10:25):
Yeah, but cost a ton of money.

(10:26):
So there was no question about the value, right? It was clearly valuable to wipe out hepatitis C, we want to do that, but at the cost, then it got to the point where we have to figure out, well, who do we prioritize?

Rae Woods (10:40):
Or value to whom? Valuable to the patient, but yeah.

Bill Dreitlein (10:42):
Yeah.

Rae Woods (10:43):
Yuri, what's your take? Why will this be disruptive for the industry?

Yuri Marichich (10:46):
I think also just looking historically. this is to me, one of the great paradoxes of healthcare is, we have, basically, a whole sector that has been driven by innovation, by new things, but the challenge is we are now starting to, I think, really confront what is astronomical, slash, exponential growth in terms of cost.

(11:09):
And so, to your point, Bill, then there's these questions of value. I think on the provider's side, even though, historically, we've changed a lot and adopted a lot of new things, it's also hard for each one of us as an individual, or for health systems, or clinics to say, yes to, now, one more thing. There's too many things for any individual clinician, let alone an organization to do. And so, now we're saying, Oh, and guess what? We're going to add one more thing.

Rae Woods (11:38):
Yes.

Yuri Marichich (11:38):
The second thing, I think, on the payer side, is trying to really understand these questions of value and balance the concern about over-utilization, with also the fear of not adopting things soon enough, and that's also the paradoxical situation that each payer finds themselves. And so, that's also why you see a lot of both fear of missing out, but fear of being first, at the same time, and everyone's looking around the room to see, who's going to make the first move.

Rae Woods (12:13):
Why should we be focusing on this now? Right? We've all been at Advisory Board's summit event, hearing about all of the challenges and all of the opportunities in healthcare.

(12:22):
Why is it that in 2023, very soon, we need to be prepared for a world where we're going to have more of these products? Why now?

Bill Dreitlein (12:30):
It's not theoretical. All these things, the list that you gave at the beginning, deep brain stimulation, gene therapy, pharmacogenomics.

Rae Woods (12:39):
Yep.

Bill Dreitlein (12:40):
It's here, and that's one of the differences between, the conversation today, and the conversation we might have had 10 years ago. It's here. There are already four gene therapies on the market.

(12:53):
Next year there's going to be eight more.

Rae Woods (12:55):
Wow.

Bill Dreitlein (12:57):
We already have CAR T therapy, we got eight of them, and then they're bleeding into other disease states, and that understanding is now, carrying over into other areas.

(13:08):
So it's important to plan for it, because it's here. It's just going to come in greater quantities in 2023.

Fanta Cherif (13:16):
Yeah, I was going to say something similar. It's almost inherently flawed that we talk about these things, as the next generation, because they're already here. So they're not a problem of the future, they're actually things that we should be preparing for now. It's not enough to just be aware of them, but we actually need to take the steps to make strategic implementation.

Yuri Marichich (13:32):
And maybe I'll just add, I think the pace of what is here now, is moving faster. We definitely saw that with COVID, which is organizations who are like, "Yeah, we do a little bit of telemedicine," and all of a sudden that became mainstream, but now we're grappling with, is that still the best way to do it, is the right thing and what case? So in many situations, we're having organizations, who are already above capacity, now trying to figure out how do they be become continuous learning organizations and continuous adopting...

Fanta Cherif (14:06):
I like that.

Yuri Marichich (14:07):
And continuously evaluating, what works and what doesn't.

(14:10):
So it means we also then have to figure out, how do we analyze and run killer experiments to say, yes or no to things, at a scale before, that we never were able to.

Fanta Cherif (14:24):
And on the note of COVID-19, it's also just exacerbated the mental health burden, behavioral disorders are on the rise, lifestyle diseases are on the rise, so a lot of these patients who are facing very severe diseases, need alternative treatment options, so the market is booming because of that.

Rae Woods (15:46):
So, let's talk about how we actually adapt. If this is what is coming, or what is here now, to your point, let's talk about how we actually adapt. And I no longer want to use this royal, we, anymore, because I actually think it's really important to be thinking about different stakeholders and the realities that every stakeholder has.

(16:04):
And that's what's so important for our audience, if I look out at all of you, you're joining us from health plans, from health systems, from hospitals, you've got device manufacturers that are here, we have pharmaceutical companies, we have the whole gamut that's here with us today and who's listening to our podcast.

(16:19):
We're going to break this into two sections. We're going to talk about purchasers, and by that I mean health plans, employers, even consumers themselves. And then we're going to talk about providers.

(16:29):
But here's the thing, There is way too much that we could talk about, right? Far too much to fill in a single podcast episode or a single event. So we want you to actually guide us. I want everybody to pull out their phones. We're going to do a little bit of a poll. There are no right or wrong answers here.

(16:50):
We've got three options when it comes to purchasers. The first is the value framework. How do we actually balance having enough evidence, having the right size of the population, having the right time to impact to actually take on the cost here? Inappropriate utilization, we already brought up. We know that not everyone can or should use these products, so how do we avoid over utilization without overburdening the system?

(17:18):
And the last one is all about risk. How do purchasers guard against catastrophic costs, and allocate the financial burden appropriately, so that they can take on the right amount of risk for these novel products?

(17:32):
Let's go ahead and go to the poll results. Pretty even split, so purchasers have a lot of challenges, is what I'm seeing. Value framework, inappropriate utilization, risk mitigation. Are you surprised by what folks said? Oh, more for risk. Panelists, are you surprised by this?

Bill Dreitlein (17:51):
No.

Fanta Cherif (17:51):
No.

Rae Woods (17:52):
Why are you not surprised?

Bill Dreitlein (17:53):
Because, when we think about next generation things, they always cost more, right? And there's so many unknowns about them, so of course, I can understand how people are worried about risk and my risk.

Rae Woods (18:06):
Yeah.

Bill Dreitlein (18:07):
So it makes some sense.

Fanta Cherif (18:08):
I'm surprised that the value framework isn't number one. I feel like cost and risk mitigation, all comes down to, do we have the evidence, Do we have the justification to pay for this? So I'm actually shocked that, that's not beating everything else.

Rae Woods (18:21):
And they are kind of interrelated.

Fanta Cherif (18:22):
Right, of course.Taking on the risk has to do with the cost. And risk is an interesting one, because we use this word often in healthcare, we use it in value based care, and risk is risky, right? Risk requires taking on risk, but that is not something that executives want to do, that is not something that companies want to do, especially when, to your point, there is a lot of money on the line, so how do you deal with this? How do you deal with balancing, taking on the right amount of risk, knowing that to your Hep C story, that the cost can be catastrophic?

Bill Dreitlein (18:53):
One of the answers to that, is the question earlier. To vent this point about, value frameworks. What value frameworks do, is they help you understand the 360 of that issue. And so, what are the benefits? What are the downsides? What is the risk to that? And tries to, if you're talking about value frameworks that have pull in economics, it puts a number around that and gives you a benchmark, or a frame of reference to pin your risk too. I'm willing to go up to this point, for so much risk.

(19:33):
My point is understanding the thing, whatever the thing is, whether it's gene therapy, or a diagnostic, or what have you, to understand what are the benefits, what are the downsides and what are the financial, what's it going to cost you and what's the financial risk associated with it?

(19:51):
So I think understanding it, would be the first step towards figuring it out.

Yuri Marichich (19:56):
I see the value framework and risk mitigation, really going hand in hand. Risk mitigation is becoming more important, because before we used to think, more all-round catastrophic illness and, for example, long ICU stays.

Rae Woods (20:11):
Yes.

Yuri Marichich (20:12):
But now, given curative therapies, that cost over a million dollars a year, and we think about the time horizon payers are having to think through, for different populations around different mixes, it becomes a very complicated question, particularly when you can't see the future, and Hep C is a great example, because no one knew what that meant, and we don't know that right now with a lot of gene therapies, we don't really know what that's like on CAR T and so, both those areas I think need to have answers.

(20:45):
But I do think there are opportunities where if we can put value frameworks, around different areas, whether it's different types of next generation therapeutics, or other types of diseases, then we can start to actually, quantify and build models, and then determine whether those models are accurate and support them, within also new, for example, reinsurance models.

(21:08):
And there are places that have done this for a long time. Germany has a very robust insurance model for secondary insurance, because they see different types of risk pools, amongst different populations, and so we could think of ways where we do that, but it means we have to have a value framework, and it also means that payers have to rethink their business models, because they have to have a level of data, that they didn't normally have. And claims data is completely insufficient, to get you to the level of insight, that you need to have, to build the value framework, and then evaluate risk.

Rae Woods (21:43):
How do they get that data?

Yuri Marichich (21:44):
They have to partner with providers. And this is one of the big catch 22's, because no one wants to go first, and it means they have to trust each other, when historically, they want to instead just cost shift.

Fanta Cherif (21:57):
Yeah, going off of that point, I was going to say, a potential solution for risk mitigation, has been outcomes based contracting, because there's just a lot more, very tedious, outcomes data that they need to collect, to make sure that the outcomes-based contract is actually being met, so that means a higher bar of evidence and that really goes into the value framework as well.

(22:16):
So really making sure that everyone is working together so that there's shared benefit, the patients can also benefit, but that no one really takes on the bear of the risks.

Yuri Marichich (22:24):
And I think just reinforcing that. So we have actually done a number of value based and outcomes based agreements, both on the Medicaid side, as well as on the commercial side. And so, to me it's exciting, because we have the data, so we're very confident in doing that, but we also run into some organizations, who say they want to do it, but they themselves don't have sufficient data, and so, then they get up to that point where they have to make a decision, and then they step back and they say, "Gee, we don't even know how we would adjudicate this in six months or 12 months, so you know what? Let's just go back to the traditional fee for service arrange."

Rae Woods (22:58):
Now, I said that we're talking about purchasers, but we've mostly been having our conversation about health plans. Let's actually break this out into different purchasers, because the risk doesn't have to fall on any one entity here. I don't know that there is a perfect answer here. Frankly, I don't know if there is an answer at all, but how should we think about allocating risk across purchasers, across employers, across even consumers?

Bill Dreitlein (23:20):
There could be opportunities for third parties to create things like, risk pools and there are some companies that are doing that, especially for these high cost therapies where it's like a reinsurance type of thing.

(23:33):
So that's one way to do it. That hasn't gotten a lot of traction, from what I hear and it doesn't really solve the problem of cost, it just kind of spreads it out. So, that's one way to do it, but it's a tough nut to crack and I don't see how you could do it, without some kind of government intervention.

Yuri Marichich (23:54):
The challenge is, again, the old way of doing things was brute force utilization management. So we're going to have pharmacy, we're going to have medical, we're going to have consumer, particularly around what amount of premium, and so very few organizations had that perspective where they were looking at that total cost of care, because it was more brute force utilization management, but if we are going to think about these things, particularly around adopting next generation, then we have to be looking at that total cost, because the approach can't just be for PBM.

Bill Dreitlein (24:30):
Yeah.

Yuri Marichich (24:30):
Well, what other product then do I no longer have to pay for if I adopt this one? That's not really the right answer, but that's their view, because that's all they're looking at. We need to be able to look at also, well did we save on ER or inpatient or other types of services? But if you're not looking at the total cost of care perspective, then you're never going to see it.

Bill Dreitlein (24:52):
The way that the models are currently growing towards the vertical integration, is probably, more incentive to take a holistic approach to it, so it's not just, is the drug covered under the medical or the pharmacy, because the benefit is to the mother organization, shall we say.

(25:11):
So maybe the way that some of the models are growing up, could absorb that approach and maybe we'll break out of that siloed approach and take a more holistic approach to it, I hope you do.

Yuri Marichich (25:25):
I agree, I'm both optimistic and pessimistic. I think that the integration part, gives me reason for optimism, but the pessimism is, that means you're going to ask organizations to completely rethink how they work.

Rae Woods (25:39):
Oh yeah.

Yuri Marichich (25:39):
And it makes me wonder, are these organizations that are just trying to rapidly integrate, really going to have the cognitive ability to say, "And now we're going to have some group that's going to look across all these and actually make intelligent decisions?"

Fanta Cherif (25:54):
Right?

Bill Dreitlein (25:55):
It's funny, the bigger you get, the more likely you are to just retreat into your silo. We got to break down silos, we got to break down silos, and the first thing we do is, we retreat to our own silo. So yeah, it's hard.

Rae Woods (26:07):
I want to switch to focusing on our next stakeholder, which is providers.

(26:12):
Now here we've got four options for you because of course there's no shortage of challenges for providers today. Go ahead and go back to your phones. We're going to repeat this poll, to pick the biggest challenge facing providers.

(26:26):
Is it strategic prioritization? Meaning why should we focus on this at all? There's a laundry list of things that providers can be doing. Why should we be focusing on next-gen products?

(26:36):
Is it making the business case for an individual product? Fanta talked about a huge range of next generation products. How do you even know which one to pick, let alone making the business case for it?

(26:48):
Is it education and training? Keeping clinicians and staff even aware that this is happening, let alone actually train to be able to use it in their daily practice?

(26:59):
Or is it workflow integration and how we seamlessly embed these new products into workflow?

(27:04):
Let's go ahead and see the results. Numbers are moving around a little bit. Okay, I think we've got two clear winners here. Strategic prioritization and workflow integration. Panelists, are you surprised or does this make sense?

Fanta Cherif (27:19):
Interesting.

Bill Dreitlein (27:21):
It does make some sense.

Rae Woods (27:22):
Yeah?

Bill Dreitlein (27:23):
There's so much you have to figure out. So we're talking about the future, right?

Rae Woods (27:26):
Right.

Bill Dreitlein (27:26):
And everybody is, at this point, probably has your 2023 strategy in place, and then you may be thinking, "Oh, did I include these other things that are coming and maybe I need to rethink that and how do I shuffle to account for it?" So it does make that some sense.

Rae Woods (27:42):
The results are still coming in and they, it's like the numbers have changed a little bit. Strategic prioritization is still by far the biggest challenge, but it looks like making the business case for individual products and workflow are tied neck and neck.

Fanta Cherif (27:55):
It's interesting, because I feel like making the business case, should have the workflow integration, because workflow integration, basically, is saying that all of these organizations have already been in the process of adoption, but that's not what we're actually hearing. We're hearing that a lot of businesses really don't have the means to adopt a lot of these products, because they're so costly. So it's interesting.

Yuri Marichich (28:18):
So when I look at this, I think of maybe the difference of, how provider organizations innovate. And one of the aspects of different organizations, is whether is it a top-down or is it bottom-up or do you have both?

(28:33):
So top-down organizations are going to take the more strategic prioritization and they're going to look at business lines and services,, that are going to be more revenue generating or going to be more ability to increase their pricing power, and so you can think of an oncology, for example, places building out centers of excellence. I need the next CAR T, I need to be the top bone marrow transplant, I'm going to put out those data points. You think of Cleveland Clinic trying to become a destination for cardiovascular care. And so, you can see there that strategic prioritization is going to take a top view, but on the other hand, if you have organizations that can foster or are willing to foster more at-the-bedside-type innovation, then you have the importance of the business case, because they may be, for example, in a service line or disease area that doesn't make money, and I think this is a huge challenge fanta mentioned earlier, like mental health.

(29:33):
Look at psychiatry departments.

Fanta Cherif (29:35):
Oh yeah.

Yuri Marichich (29:35):
These places just bleed money and so, you don't see the innovation, you don't see the new product adoption, because there's no revenue generation potential, but if you have a place that might foster it, then you can bring forward those business cases. Do you allow organizations to have access to different resources, even if it's just on the IT side? Because you might say, "Hey, I want to do this, but I need to do some workflow."

Rae Woods (30:00):
I hope that our audience is interested, or at least, bought into the idea that, next generation products are something that they should prepare for. That's why you're here, hopefully, but that's not to say that your leadership teams are, necessarily, bought in themselves.

(30:14):
So when it comes to being able to prioritize doing this at all, this strategic prioritization, what advice do you have for our listeners to take back to their leadership teams, to get them to actually focus on some of these next generation products, because the pipeline is full?

Bill Dreitlein (30:28):
I think we could probably learn a little bit from, how drugs typically launch, in that drugs don't typically go from zero to a 100% uptake. It's usually pretty slow in the first year, as the word gets out, as clinicians get comfortable with it, as the system understands it and can absorb it, so what's different about 2023, is we have so many coming.

(30:52):
So I think 2023 is probably going to be a year where we have to learn how to... It could be a learning year where, yes, these things are coming, and, in some degree, they're already here, so if you're worried about gene therapy, look at what do we already have? We've got, Zolgensma, we've got LUXTURNA, we've got the new one for beta thalassemia, so there are some that you can look at as a test case and see, well, how can we absorb that? Can we do that? Can we duplicate that? Can we scale it? Do we know that hemophilia is coming? So do we have a hemophilia business? Do we have a hemophilia treatment center? That would be the where I would encourage people to look at, those areas where that these things are going to hit and start thinking around that, and maybe use 2023 as a way to get familiar with that, so that as these things launch, you won't be too far behind.

Fanta Cherif (31:45):
Yeah, I agree. I was going to say something along the lines of, just focusing on the learning, so looking at the pipeline data and really embedding yourself into, again, with education and training, really looking how we can actually use these things in practice.

Rae Woods (31:57):
Share this podcast episode, as to be a start to education.

Fanta Cherif (32:02):
It also has a level of just cultural sensitivity and competence. So even if we have all of these products that are in the market, are we actually prepared to apply them and actually use them in a safe and effective way? Will patients have access to this? What patients are reprioritizing for these products, et cetera? So really putting our heads down to really see, what's coming in the market, and which patients will benefit from them the most.

Yuri Marichich (32:23):
I would say three things. So one is not, can we afford to, but can we afford not to, because it's a competitive place out there for provider organizations.

(32:34):
Two is, is it going to change how we are able to, both acquire and keep patients? Because the whole front door for healthcare is changing rapidly and patients have a lot more choice, and so if we don't adapt and adopt, we may actually lose those patients and we may see all of a sudden, what we thought was a very healthy legacy, evaporate in front of us.

(33:01):
And then three is, then we can't keep doing things the same way, and this gets to workflow, the provider shortages are not going to get better.

(33:10):
I think anyone who thinks, oh, we'll eventually get back up to prior staffing and we'll have the same capacity, is just not recognizing fundamental shifts in the workflow force.

(33:20):
So we have to be thinking then about, not just how do we keep doing what is going to be more and more, but how do we do it differently, and how do we do it smarter?

Rae Woods (33:28):
Let's talk about making the business case for individual products. So, if we can't afford not to do this, which I do believe, and I hope you believe as well, there's a difference between, then getting down into what specific things should I do next, at my organization, especially since there's such a laundry list of possibilities, and especially since, let's be honest, I think a lot of providers, either in the room or listening, have been burned by that pitch deck that said, this is going to solve all of your problems, this device, this new product, this new technology, and then what happens?

(33:58):
So, what advice do you have for folks that are looking at, maybe different pitch decks, looking at different products that they could be using and trying to prioritize which one should they start with?

Fanta Cherif (34:08):
I would say weighing just the benefit for individual patients versus population, so who are we serving, and really weighing between the benefits and the cost. Does it make sense for your organization? Where is this fitting best, in their care cascades? And really just seeing what is that value proposition. Again, going back to the value framework, really looking at the different segment of that, working in collaboration with other stakeholders, and making sure that it makes sense for your organization to move forward.

Bill Dreitlein (34:34):
You'd bring up the pitch deck, because I think that's probably a good practical one, because I'm sure everybody has probably seen those, or had somebody come into your office and give them to you. You can probably have a couple different reactions to those. Some very negative and some positive. I see a lot of them in my role.

(34:51):
So there are some things that I think are pretty good there. One is, especially around some of these rare diseases, the company typically knows the disease better than most people, and so, you can probably understand a little bit about the disease state, the underpinnings of the biology, the genetics, that's probably pretty helpful.

(35:10):
The other thing is the actual target patient population. Every single pitch deck is going to say the same thing. They're going to say, this is the universe, this is how many people are with the disease, and with the disease, this is how many people are diagnosed, this is how many people seek treatment, and it gets down to a really small number where you say, Oh, it's really small, so it's not going to really hit your bottom line, but that's kind of what it is.

(35:30):
But it can give you a sense, and you can see it with a educated eye, because you're smart people, and for those who create these pitch decks who might be listening, recognize that the people reading them are smart people, and so they will, clearly see through the marketing spin.

(35:46):
But, you can look and pretty clearly see, okay, this is the universe of who could benefit. Yes, a small number of people are treated today, but really the market that they'll be going after, is a little bigger than that, and so it can give you some quantitative numbers around that that could be helpful.

(36:03):
And now, of course, you have to adapt that to your own population and understand, how does that match up with whom you have and whom you're serving, so understanding your own book of business is really important in that regard.

(36:16):
And then, of course, the data around theirs, they have to be truthful,

(36:19):
About some of the things that are there. But the thing I think you would probably benefit greatly from is for some of these disease states, the scale that they use might be unique to that disease state, and so, that's an opportunity where you can probably learn a little bit from the company. Why did you pick that scale? Probably, because the FDA made him pick that, not because it's used in clinical practice, but from a regulatory perspective, they have to use that particular scale to get through the FDA.

(36:44):
But you can understand a little bit about it, and that's an opportunity to press them on that to understand, well, what does the data actually mean? So by understanding that scale, you can understand what the data says and what it doesn't say.

(36:57):
So those pitch decks, they can be helpful if you can kind of cut through some of the market spin that, inevitably, is just part of the process.

Rae Woods (37:41):
Now, we've been talking, thus far, about individual stakeholders, but I want to move on to talking about the ecosystem together. If I'm honest, when we hear challenges crop up from real people in the healthcare industry, we tend to start to notice that people are pointing fingers at one another, right? It's easier to think about somebody else's problem that they have, than actually trying to solve my own, which is the theme of our next game.

(38:19):
If anybody has seen Jimmy Kimmel's late night show, he has a segment that's called Mean Tweets. It's literally where celebrities read off mean tweets about themselves. This is a game that, for legal purposes, is merely inspired by that, where we have actually developed some faux tweets, but they represent very real feelings and very real fears, that healthcare leaders have, when it comes to adopting these next generation products.

(38:47):
So, I'm actually going to invite my panelists to read off some of the tweets that we have developed.

Fanta Cherif (38:53):
I want to do this, but I know my leadership is going to say no.

Rae Woods (39:00):
And let's do one more from you.

Fanta Cherif (39:02):
I mean, this all sounds good, but can someone else go first?

Rae Woods (39:06):
Yuri, do you want to go next?

Yuri Marichich (39:08):
I'm already battling COVID and disruption and you want me to do more work? Got to

Fanta Cherif (39:13):
You've got to do the eyeball.

Yuri Marichich (39:17):
Yeah, it might help patient outcomes, but we don't have the money, resources or change management.

Rae Woods (39:25):
All right, Bill.

Bill Dreitlein (39:27):
All of this innovation sounds cool, but I'm not even able to access what's already in the market. Why should I be excited?

Rae Woods (39:34):
You don't get an emoji for this one, sorry. And the last one.

Bill Dreitlein (39:39):
I want to pay for these things, but let's be honest, the savings horizon is way too far in the future, to make this worth it.

Rae Woods (39:46):
All right, audience, be honest with me. Look at these tweets, think about what you just heard and actually clap. I want you to clap, if you have felt any of these sentiments in the last year. It can be about next generation products, it can be about anything in healthcare. Go ahead and clap if you felt this way.

(40:02):
Okay, you're clapping for a while. All right, who's felt this way in the last hour? Who's felt this way in this session? Be honest.

(40:17):
What do you take of the tone of these tweets? What do you take of the reaction of our audience, that these are very real feelings that folks have?

Bill Dreitlein (40:24):
Yeah,

Fanta Cherif (40:24):
I personally resonate with the consumer one, so as great as all of these products sound, if I'm not able to actually access it and if it's actually not able to be marketed to patients who will benefit from it, then what's the point of all of this? What's the point of this conversation? What's the point of the value framework? If there's not that health equity lens embedded into it, All of this is kind of pointless.

Rae Woods (40:46):
What do you think of the sentiment in the market, that this is so hard, that people are feeling tired, and that they can't do it and somebody else should go first?

Bill Dreitlein (40:54):
Yeah, it's very real. What I'm hearing is like, you got to be kidding me. Come on, I can't do this. Or for whatever reason.

Rae Woods (41:00):
That's exactly what you were getting at, right? With our margins this slim, you want me to do what?

Bill Dreitlein (41:04):
Yeah, it's very real. And I think that we, the collective we, need to recognize that.

(41:10):
So as a payer, I work for OptumRx, we need to be conscious of what's going on in the larger society. If I'm a developer, I need to be conscious of the impact and recognize that, yeah, I'm coming in with this innovation, but this person probably has already heard five others this week.

Rae Woods (41:30):
Yeah,

Bill Dreitlein (41:30):
There's a cumulative effect of that, on what we can just humanly absorb.

Rae Woods (41:34):
Yeah, there's context that the other side tends to be missing, because we do live in our silos, we do live in our insular part of the system and so, we need to understand the challenges that the purchasers are facing, challenges that the providers are facing.

Bill Dreitlein (41:49):
Okay.

Rae Woods (41:49):
How does this come up in your own work and how do you address some of these barriers, when you hear real feelings like this?

Yuri Marichich (41:56):
Yeah, I'll both say, I mean, I think this is an example of healthcare wide burnout.

Rae Woods (42:03):
Yeah.

Yuri Marichich (42:03):
There's just burnout across groups. Everyone's been having to try and figure out answers to really challenging questions and you don't see the end horizon. And so, I think to both, your, and Bill's discussion, just moments ago, you do have to understand that context and you have to put yourself, not only in their seat, but you have to actually get to a point of dialogue, where you can understand, what are the barriers they face within their organization and help them overcome.

(42:34):
And I think a key area, particularly in next-gen diagnostics and therapeutics, is understanding what the decision making process is in those organizations, what the consequences are to people who take risk in those organizations, and then how do you help them maybe even think about that structure. You have many organizations out there that, let's face it, if you don't mess up for two years, you're going to get your next promotion. So, why would you stick your neck out, in an organization like that? Just play it safe.

(43:05):
And so, you can then help those organizations say, well, maybe there's a decision making structure where no one individual has to stick their neck out. We can help everyone do it together and then the organization can move forward. Also, do you have an organization that says we're going to reward experimentation?

Rae Woods (43:22):
Yes.

Yuri Marichich (43:22):
We're going to reward people who run a number of experiments and we're going to recognize, some of them are going to fail, and some of them are going to be okay, and then some are going to be a success, and then we need to show the rest of the organization, that we're going to actually incentivize and reward those people, who do take those risks and run those experiments, but you really have to understand what are the different metrics and it's fascinating because you see organizations have very different success criteria.

(43:49):
So you can't just say, this worked for Optum, now this is going to work for another one, you have to learn from them, which means you have to be a good listener.

Rae Woods (43:57):
That's such a good point, being a good listener, to be able to understand the context of the other person that you're talking to, the other organization, the other stakeholder.

(44:04):
How do you actually want them to work together practically, so that we can actually embrace some of these next generation products?

Yuri Marichich (44:10):
For our experience is, one, getting them to share that information. So you have to...

Rae Woods (44:16):
Who's them in this case?

Yuri Marichich (44:16):
Oh, sorry. So let's say a payer.

Rae Woods (44:17):
Okay.

Yuri Marichich (44:17):
Let's say a payer. You have to help them share with you, for example, what are the criteria and how they may be struggling. For example, to review a new product class? And I can be very specific here, like prescription digital therapeutics are completely new, and every payer is now starting to think about, or somewhere in that adoption curve, we have seen, for example, state medicaids adopt, we're seeing commercial insurance adopt, pharmacy benefit adopt, but there's many that are in different stages of this process and they have very basic questions. Does this go through P and T? Is this on medical? Is this on pharmacy? Who review cybersecurity? And so, you need to listen to those, and then help understand, and help them come up with solutions within their organization.

(45:07):
And then, also, help them see the value and think through some of the consequences, like, well, how are we going to manage over utilization? How are we going to think about if we want to put in a value based agreement, what are the data there? So, putting yourself in their shoes and helping them.

(45:23):
The other thing that's really important is, healthcare is not a tell-me field, it's a show-me field. And so, bringing case studies of other organizations that have had success, that will also be very important, because now you start to tap into rather the fear of being first. It's the fear of missing out.

Rae Woods (45:45):
Yeah. Fanta, Bill, what kinds of things do you want the industry to work together on, as we adapt to these next gen products?

Fanta Cherif (45:52):
I think first and foremost, just coming together early and often, so really, honing in on that collaboration and partnership, working towards that shared definition of value, so that things are mutually beneficial, so we don't have things like who goes first, because everyone wants to go first. We all want to benefit from this product.

(46:08):
So, I would probably say that really honing in on, what partnership looks like, and how we can work together to really define value together.

Yuri Marichich (46:16):
I want to really like plus 10 that, so this is really important, particularly for providers and payers. I'm going to give everyone an example. I will not mention any of the organizations, but there was a payer organization who wanted to introduce a new approach and they went and met with a provider, that they actually thought was a pretty high quality provider, and said, We'd like to talk to you about a pilot. And the first thing out of the pilot delivery organization or provider organization's leadership was, no, we'd first to talk to you about the 80% of our claims that you rejected last year. There was no partnership that was going to happen there, because they did not have a partnership at all, let alone one build on trust.

(46:59):
So trying to help those organizations instead, figure out how are we going to solve this mutual problem together is critical, but it's really hard.

Rae Woods (47:08):
Right?

Bill Dreitlein (47:09):
Yeah, I think I'll pick up on that, but I want to take a little bit of a different tact in that, there's an element, like when I hear, "How can we partner together?" I am very skeptical when I hear that, because usually, I'm in the position of, somebody coming to me and saying, "How can we partner with you?" Which really means, how can we get on formulary? How can I give you $2 and get five back?

(47:31):
In our business, there is a natural tension and distrust between the two sides, and so, I think it's great to have early conversation and often, but I'm usually the one having those conversations, and I have multiple every week, whereas every company has an army of people, so the conversation we're having here, is recognizing what the other side is dealing with, and helping to kind of understand that. So, that's why I think things like this are really helpful, because it helps people understand the other side.

Rae Woods (48:07):
Yeah.

Bill Dreitlein (48:07):
Drugs don't work, people don't take them. Connected to that is the providers who have to deal with it and the systems that have to absorb it.

(48:15):
So if we're insensitive to that and we're not working, where we can, as technology grows and as we become smarter about how to work, to eliminate the minutiae to make people's jobs better and easier, so they can absorb these things, we got to do that. We're missing the mission if we're not doing that.

(48:34):
And sometimes it's in small things, we have a PA that's got five steps. Why do we have five steps? Maybe we can get rid of two of those. And these are the conversations we do have with our P and T committee who reviews those, who are practicing clinicians, so that's where sometimes the tension between the employer, the payer, the sponsor, they want to control costs, and then the tension with the clinician comes to bear and we try to figure out how can we do it better and how can we come compromise? It's kind of a system-wide thing.

Rae Woods (49:08):
I do want to ask one more question of our expert panelists. At Advisory Board, we want to change the way that health leaders see, think, and act.

(49:17):
My question for you is, when it comes to next generation products, what's the most important thing about, how you want folks to see this problem and think about the solution?

Bill Dreitlein (49:28):
I think I'd like people to see this from the lens of, this is where we're going. So if I step backwards, several years ago the rage was personalized medicine, personalized medicine. We just un-coded the human genome and now we can do genome sequencing for a thousand dollars, instead of a billion, and that's going to change things, And we'll be able to know everybody's genetic makeup, and then it's spawned 23 and Me, and then ancestry.com, so you can connect that, on a personal basis and then have some fun with that.

(49:56):
We had this thing called personalized medicine that was kind of the idea, but now it's just medicine.

Rae Woods (50:01):
Yeah.

Bill Dreitlein (50:01):
It's just medicine. Drugs that are for cancer, are now, for cancer that has a specific biomarker. We've shifted in some ways to, where does the cancer appear? What organ is it in? What tissue does it come from, to, does it have this biomarker? And some drugs are being developed, and it doesn't matter whether it's in a lung, the brain, the wherever, if it's got that biomarker, you can use that drug.

(50:25):
So eventually, what we're learning now with these second generation or next generation technologies, will eventually bleed over into the therapies of today.

(50:36):
Let me give you one more example that's a little more current. CAR T therapy. That was very revolutionary, right? Way back when, when I first started practicing as a pharmacist, was cytotoxic chemotherapy, kill the cancer before you kill the patient.

(50:48):
But then you kind of evolved and we got to the point where we've got this CAR T therapy, we're harnessing the body's T-cells. Eventually we'll have off-the-shelf types of things, that'll make it easier to deliver that.

(51:01):
Or there's a drug approved just the other day, Teclistamab, which is a bispecific. I kind of uses the same idea, where it uses a monoclonal antibody to grab the T-cell and grab the tumor and kind of put them together, so the T-cell can do its thing. It's very toxic, but that's another step in that direction.

(51:20):
And so, this is how medicine, this is how it goes. Eventually, what's far reaching, today just becomes how we do things. So it's a worthwhile investment, I guess is how I'm thinking of it.

Rae Woods (51:30):
Yuri, what's your most important takeaway?

Yuri Marichich (51:32):
This may be a slightly different take. I will admit I'm a technophile, so it would be awesome if all these really cool technologies were adopted, but the challenge is we can't, in healthcare, we can't adopt every next thing. And so, we have to decide which things we're going to adopt, and which things we're not, or which things we're going to adopt today, and which things we might reconsider in the future.

(51:53):
And so for me, it comes down, regardless of the type of technology, less about what the actual technology is and more about what it does. So, how does it improve access? How does improve outcomes and what is its value? And I think if we keep that framework and then we actually, use data to evaluate it, that is a very objective and quantifiable way, that can help organizations to actually then scale and systematize, how they decide to adopt things, because there's many things that seem inevitable, where things may change, or other things may overcome, so we need to have those types of frameworks to help us.

Fanta Cherif (52:33):
Right. I'm sort of piggybacking off of Bill's point actually. So sorry to contradict you.

Yuri Marichich (52:39):
That's all right.

Fanta Cherif (52:40):
Personally, I feel like next generation therapeutics, I think I opened with this as well. I feel like it's this generation problem. It's the future is now, as we've already seen, Bill, you mentioned before, the market is booming. The speed at which market entry is happening right now is very crazy, so organizations need to be preparing for it. It's not enough to just be aware of them.

(53:01):
And then secondly, I would just hone in on the access apart where, although we're seeing the market booming, patients need to be able to access these products, so we should be thinking about all of these things, in a very patient-centric way.

Rae Woods (53:15):
Well, let's give a big round of applause for my expert panelists, for sure. Thank you so much for coming on Radio Advisory. Planning and recording this episode was, honestly, so much fun. It was great to be there in person with our experts and with our audience, to really understand and discuss, one of the major challenges in healthcare.

(53:42):
If you're interested in us doing more episodes like this, more live events, make sure you leave us a rating and a review. I want to hear if we should do this again.

(53:54):
And please remember, as always, Advisory Board is here to help.

(54:02):
If you like Radio Advisory, please share this episode with your network and subscribe wherever you get your podcasts. Leave us a rating and review, it really helps other people find this episode and find our podcast.

(54:16):
Radio Advisory is a production of Advisory Board. This episode was produced by me, Rae Woods, as well as Katy Anderson and Kristin Myers. This episode was edited by Dan Tayag, with technical support by Chris Phelps and Joe Shrum. Additional support was provided by Fanta Cherif and Solomon Banjo.

(54:36):
Thanks for listening.