What’s Comparative Effectiveness-Greg Snyder

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HB: Alright, so today we have a special guest on the Talk to Your Pharmacist podcast. Our guest, Greg Snyder, is an account manager with a startup pharmacy company, TrueDataRx. Greg is a graduate of the University of Georgia’s College of Pharmacy and obtained his MBA at Duke’s School of Business. He spent time in the pharmaceutical industry and has an understanding of marketing from that perspective, and now, he’s bringing transparency and advising on the most cost-effective medications for at-risk self-insured companies. Greg, welcome to the Talk to Your Pharmacist podcast!

 

GS: Thank you, Hillary. That was a fantastic introduction. Thank you so much.

 

HB: Well, now that our listeners have heard a little bit about your background, you may be able to fill in any gaps from that intro and maybe share a little bit about your personal life.

 

GS: Yeah, yeah. I live here in Murphysboro, Tennessee. I’ve got two beautiful daughters under the age of 4 right now. And just me and my wife relocated here where her family is about a year ago. So that led me to find a company called TrueDataRx.

 

HB: Awesome. And Greg, you might want to share a little bit about maybe kind of some of your background and maybe how you decided to go into your MBA. And then we definitely want to — I’ll ask a little bit more about what TrueDataRx is. But just yeah, a little bit more background because we’re starting to see more and more pharmacists with MBAs, so I think it’s interesting to share kind of your decision to do that or kind of what your background had been prior to that.

 

GS: Yeah. Well, that will be perfect. So I obviously started off in a pharmacy school, like probably many of your listeners have, and kind of felt that retail pharmacy wasn’t for me. And at the time, I think hospital kind of scared me with, ah, I’ve got to do a residency for a year or two? So that kind of, unfortunately, turned me off. It would have been a great route to take, but I guess at the age of 22, you just kind of think of getting out and starting a job and making some money. So with that, I had the privilege, I guess, to be at University of Georgia, where Eli Lilly had a pharmacist that had gone to UGA and was looking to do kind of an internship. And so I had kind of become friendly with him and said I was very interested in sales, kind of was in my background, and wanted to kind of look at that, kind of explore that. So that ended up leading to a rotation in my final year working in a sales aspect with Eli Lilly. And it just seemed like the right fit. I felt like I was going to be impacting not only patients but physicians, who could impact very large breadth of patients. So my scope seemed to be a little bit wider than I was originally thinking of being as a pharmacist. So pursued that. Unfortunately, I graduated in ‘09, and they didn’t have a role for me right out of school. So I looked to some of my friends and opportunities and landed up as a pharmacist at Publix grocery store, which was fantastic. I think the leadership that it gave me working with a team of about five or six on any given day taught me a lot, but I still had that itch to go into pharmaceutical sales. And so I was able to land a role back, actually, where UGA is in Athens area. And I was a specialty rep working in hospitals and working with cardiologists. And I got to work real-time with some of the physicians when I was in the cath lab, and depending on what was the patient had on the table, Effient was the product I sold, Prasugrel, and I could recommend the product to be a logical choice and also the dosing that it had compared to Plavix at the time. Excuse me. But in that role, I had a great time and learned a lot, but I think the biggest thing I learned was I had a lot of questions. And it kind of circled around the business area. Why are we focusing on this product? Why are my three products that I had in my bag, why am I focusing on this one? Just a lot of these business-type things and strategy-type things that I was really interested. And so that brought me to looking to go, excuse me, back to a full-time MBA. And of course, I wanted to go to a top school and I ended up looking for something that had a healthcare realm, and then Duke had a fantastic program. It really focused on very diverse groups. And in my sales role, I saw that very diverse groups really brought in so much learning. All of my teammates were — I was one of the only pharmacists, and my manager made sure to hire a pharmacist because she wanted to bring in that perspective, even though I had my own territory, the rest of the state of Georgia could utilize me. And so I focused on Duke for that reason, and with the healthcare, it just made sense. At my time there, I wanted to go into leadership and have that broader effect on more members and more people, more patients. And Zimmer Biome, that was a company that was in orthopedic company, and I’m a car guy, so I like to work with my hands. And it just seemed like it might have been able to take my background as a pharmacist but also my business background and really put it together. Unfortunately, it really didn’t leverage my pharmacy background as much as I had hoped. And I had a great experience there, I learned unbelievably large amounts in that leadership program, focusing on marketing, account project management, but then also some operations and sales ops. But when I knew that I wanted to do something a little bit more and be able to really leverage my background and make a difference in society, I started looking at kind of the insurance realm. And you may be like, oh, insurance doesn’t sound that interesting. But focusing on the population health. And I ended up finding this company called TrueDataRx, and so I’ll kind of explain now about what it is and kind of my role. So when I was looking for a role, TrueDataRx uses something that I didn’t know about at the time in pharmacy school. And that was called comparative effectiveness research. And that was something that I had always kind of had questions. And what comparative effectiveness research asks is what works best? We all know — Hillary, you know — when you look at a drug approval, it’s usually against a placebo. And so you can make some educated guesses that this product is maybe better, this product may not be as good, this one might have more side effects. But the actual head-to-head comparison was very difficult to do. And so comparative effectiveness research is this body of research that is done throughout the world. Some amazing organizations out of Cochrane Collaboration throughout the world, AHRQ, Icer, which some of you may know of, that looks also at the economic side of things out of Harvard does. And it allows us to look at benefit plans that self-insured employers use and see if their formularies are based properly. And some of you might not know, but when a large company wants to provide insurance to its members, it can choose to be fully insured, which means the company will just pay all of the premiums to the health insurance company, and that’s it. The health insurance company handles everything else. Or a company can be self-insured, if they’re large enough, and they can distribute the risk of the health of their members onto themselves. So they actually are the ones who fund a hospital stay for one of the employees or one of the members of the plan, of families, independents, stuff like that. So there was a great opportunity to work with those companies to provide them this comparative effectiveness research to see if their plans are providing the best health options in terms of medications for their members. And a lot of times, yes, they often are providing the best medications for their members. But there also can be another aspect that you can look at if medications are either just as good, if not better, at solving the same condition, providing care for the same condition. And that’s cost. And as I’m sure many of you know, drug prices are high, and a lot of brands are rising, and specialty is getting really high. So once we find out that a medication may be just as good as one, if not better, and significantly lower costs a lot of times, we want to help the plan design their formulary to maximize the utilization of those drugs. And we do that with different ways. It might be an exclusion with a prior auth to get it if a member really, truly can’t take the other options. Or it’s incentivizing them by having a plan designed so that the highest value medications can be obtained for free for members. And it’s really great to be able to kind of come back at this high level and look at the population of a company. And so we look at all of their pharmacy spend and break it out into classes, break it out into conditions, and as a pharmacist, I get to look at some of these odd drugs when I’m working with companies that are all throughout the U.S. Doctors in certain areas of the country are using new drugs, spend might be high in one area that’s kind of confusing, and it might be some new drug that came out. So getting to have that big picture — and then deep-diving down into that drug and seeing if it’s the most logical for the plan to pay for.

 

HB: Yeah. That is really helpful, Greg. Thanks for giving us a little bit of background. I’m sure there are a couple points to pull out of that that I’ll try to make sure we convey. So a lot of times — or we are seeing often that costs of drugs are rising, and that’s kind of one of the big focus points of the congressional members especially right now. They’re doing some hearings and things and definitely a lot of scrutiny on the pharmaceutical industry.

 

GS: Yep.

 

HB: However, it is a very complex system, as you mentioned where there are a lot of rebates and things that are happening and being passed between the pharmacy benefit managers or PBMs and health plans. And so there’s not a lot of transparency right now about how those deals are happening and how medications are being added to formularies. I mean, obviously, the clinical is priority, but there also weighs in the amount of rebate and things like that. So you know, there is a little bit of some misaligned incentives.


GS: Yes.

 

HB: You might want to speak a little bit more to that.

 

GS: Yeah. Sorry to go back — so TrueDataRx, like we want to do what’s best for the patient and best for the payers. And so there are a lot of misaligned incentives, and I’ll go into that in just a second. But TrueDataRx, we want to work — we only take money from the people who hire us. And so that means that we want to do what’s best for them. And if that means saving money or focusing on maybe member disruption if we are going to effect by maybe excluding a certain medication, I mean like you could think of PDE5’s, so the ED medications. Well, now that Viagra’s got a generic can be had for very cheaply — well, not cheap — but under 50% of the cost for a Cialis or Viagra. And so if a plan wants to focus on having the best for their members, maybe they wouldn’t exclude some of the brands. But if they’re a company that may or may not be struggling but really has a certain philosophy at the company that hey, this is a drug that it makes sense to exclude the brands, we do. So we take money from them for just per member, per month, and that’s what keeps us doing what’s best for the client by presenting all of the information in transparency. And why this transparency is needed is — I think you alluded to the misaligned incentives that the current big players in the market have. So PBMs are the ones who generally do the formulary and kind of work on what the benefits plan might be. But when you look at them, they don’t just get paid for the services that they provide. And they don’t just get paid by, hey, per member, per month. They’ll oftentimes have misalignments sometimes with one, owning pharmacies, and so you can think that if a pharmacy benefits plan is going to promote a medication by maybe making it a preferred medication on the plan, it’s probably going to do that to ones that are expensive because they make a spread on that that can be, say, if you’re making 10% on the sale of a drug, are you going to want to sell a cheap generic or a high brand? And because they put the bill back to these self-insured companies, they have this misaligned incentives to promote higher medication drugs. And generally, how a PBM kind of aligns their formulary is really just basic things. And that’s looking at brand-to-generic, and so we know that brands can oftentimes be high, and also, what the FDA says. So if the FDA is just providing — what it simply does is to make sure that a medication, one, achieves an outcome that is statistically significantly better than a placebo, and it’s approved, and it also has to be safe. So those are really the guidelines that PBMs have to work by, and that companies know of brand-to-generic and, oh, is it approved or not for a condition. And so with comparative effectiveness research, we want to bring in clinical data to show the difference between all of the medications — it’s not brand-to-generic — and focus on ones that are super high value and promote those. And we, of course, don’t want to provide, we don’t want to look at the gray areas where, well, this one’s a little bit more risky to take because of side effects or this one’s not quite as effective, but it’s significantly cheaper. It’s like, well, we don’t want to focus on that. We want to go to the lowest hanging ones that are just as good. I mean, you can think of certain classes of medications like PDE5s or even statens that there’s data out there to show that as long as you find the equivalent dosen, they’re all roughly the same. And so why don’t you focus on promoting the lowest cost ones than some of the higher cost ones first? And so that’s why TrueDataRx comes in and tries to bring in the right incentives to a plan fiduciary, show them the actual, clinical data that is not working in our own best interests of making money on the backend because of rebates, like you said. These PBMs can also get larger rebates from these higher priced drugs. And they oftentimes will keep a large part of it versus passing it through 100%. And rebates can come in the forms of many different ways. It can be direct, like, hey, for every script you have of our drug, we’ll give you so much back. But also, there’s a volume amount. Like if you are over 20,000, say, as an example, we’ll give you x amount of dollars. And you can’t necessarily attribute that to a rebate. But then there’s also educational things, grants and different rebates that — kickbacks, they can sometimes be called as well — that PBMs can get from manufacturers that do not get passed back on to the employee, especially, and to the plan. And I think the articles yesterday about government trying to do something about these rebates and making point-of-sale rebates to the customer versus rebates on the backend that would go to the plan rather than to the actual member.

 

HB: Yes. I think that’s a good point that you brought up that a lot of times, these savings are not being passed on to the patient. And you know, Greg, we haven’t talked yet about there’s a great TED Talk, it will be linked in the show notes and on this episode in the description, but your CEO at TrueDataRx did a TED Talk presentation and also walked through or highlighted that the FDA process for approving drugs doesn’t necessarily take into consideration whether one new drug is better than another drug. For instance, there are over 10 ACE inhibitors approved on the market. And you know, just to approve a new one doesn’t necessarily mean that there are any true or real benefits than, you know, lisinopril, which is roughly on the $4 list or very inexpensive. So I think that yeah.

 

GS: Yep.

 

HB: That’s an important thing to take away is that, you know, we may have a whole lot of drugs that are available in a class, and just because they’re available doesn’t mean that one is necessarily been approved that’s better than the other. You’ve got to really dig in and look at some of this comparative effectiveness research to make some of those good financial and clinical decisions. Another thing that you touched on was focusing on the drug spend, so you know, these health plans or self-insured companies, you know, how to control their drug spend. And right now, we’re seeing a lot of the focus being on hospital drug spend and how do they control that. So it would be interesting to see if they’re using some of the same principles that TrueDataRx is using when they’re trying to control some of that. I know they’ve got some analytics that they can run, the different companies, but it would be neat to apply the principles and the techniques that you’re using with comparative effectiveness research across the board in all of the different areas where pharmacy formularies are utilized.

 

GS: Yeah, yeah. And we also can work with ACOs, which are Accountable Care Organizations, who are at risk for pharmacy costs, and use our analytics on their information as well. If we get raw claims data, which PBMs have very easy access to. I mean, health plans, you can think of health plans doing the same thing, as long as we have our very comprehensive repository of data, we can apply our analytics to it and find out where the spend is, what it is, and classify it to the conditions and find out if there is an alternative. So luckily, with comparative effectiveness research, it looks at everything. And can we take those 1,000-page reports and compile it down to our analytics? Yes, with our statisticians and our medical team, we can combine that information and make it very actionable for all things, including hospital spend, even in the medical area.

 

HB: Awesome. So Greg, what are some roles that you’ve seen that a pharmacist can really excel at? You’ve had a lot of I guess nontraditional roles, per say.

 

GS: Yeah. I think after being in this role, I’ve found so many opportunities for pharmacists looking for jobs in this area as well is being clinical like account manager, a clinical consultant, and working at this higher population level. So TrueDataRx is where I’m kind of account manager. It’s a small startup, so I wear a hat that changes hourly a lot of times. And so I use my pharmacy hat, my pharmaceutical experience hat, to analyze some of the data. So once we do run claims data through our analytics, I still will have to go through and look and make sure what would be appropriate, depending on the kind of clients. Do they want to say all PPIs should be paid for by the member at OTC? Or well, we really like to provide the best benefits for our employees, that’s one of the biggest perks we have. We want to be able to provide maybe omeprazole at a 0% copay for the member. And so I’m still looking at that kind of information. I’m reviewing the clinical evidence reviews that our company creates from those 1,000-page reports from Cochrane, organize it and seeing where opportunities are for making recommendations of, hey, you have a couple members with low impact by providing this as a free medication, possibly, or maybe excluding this or having a prior authorization fee required for this medication can save significant money. So that’s an area that I love so much, and it feel a lot more clinical than I ever thought I would get to be as a retail pharmacist. So that’s really exciting. And all PBMs, I mean, there are definitely PBMs that are more transparent, and their incentives are not as misaligned. So they’re ones out there that, please look at those as opportunities to be clinical, be a little more business-oriented, and look for those. I mean, just start with PBMs. I mean, transparent PBMs is a great way to serve. And look and see if there are ones in your neck of the woods that have a headquarters that you could possibly just throw your resume out there. It’s a great opportunity where you’d get to really focus on helping a lot of people to be on the best medications.

 

HB: Yeah, that’s helpful to share some other areas where pharmacists could make a big impact and some strategies for how to find those. So Greg, as our final question, what is some advice that you would tell your younger self or for other pharmacists who are just getting started in their careers?

 

GS: Yeah, I would say, I mean, network is the obvious one. But really look outside the box. Don’t judge anything that you think right off the bat. For me, it was insurance. I was like, oh, insurance where we’re dealing with money, all we’re going to be doing is wanting to reduce the health by reducing access. Like that’s not necessarily true if you find the right companies. And being a pharmacist, you’re going to be focused on those areas of providing the best clinical advice, not just focusing on the bottom line. And so I would tell myself, and I would tell younger pharmacists, really look at all the opportunities out there. I think population health is an area that really excites me because you do have such a broad reach on so many lives. I can really help members get some really valuable medications at a reduced cost or just be on the best medication for them and save them money. I mean, when you look at a lot of these health plans that have 20% coinsurance, some of these members can be a $2,000 a month drug, and they don’t know that there’s a $20 a month drug that they can pay $2 instead of $200 for. And so that has really been exciting to be kind of in this insurance realm or PBM realm. So don’t discredit that and know that you will have such a great effect. You might not be talking to patients on the daily basis, but you are working to help many, many people.

 

HB: Thank you, Greg. I think that is such great advice, and I think that with such a focus on drug prices right now, I think that’s such an opportunity for pharmacists as the drug and medication experts to step up and show our expertise and, you know, help to make those good decisions on what are the best medications and what are the most cost-effective medications. So I think that we really have an opportunity as a profession here to step up and help not only guide patients when they’re coming into your retail pharmacy and, I mean, I’ve had many instances where I’ve had patients on brand Norvasc or something, and you just have those one-on-one conversations and, you know, get to know them on a personal level. And you can make an impact and, you know, oh, were you aware that the generic is less than $10? And their kind of eyes light up, and they’re like, hmm.

 

GS: I’ve been on this for 20 years now or whatever it might be.

 

HB: Yes.

 

GS: Advair, Advair, I think I saw you posted Advair is now generic, and that can be a significant savings for people when that drug’s being marketed.

 

HB: Absolutely. Yep. Well, thanks so much, Greg. It was a pleasure to have you as a guest on the Talk to Your Pharmacist podcast.

 

GS: Oh, thank you so much, Hillary. I really appreciate it. This was great fun to be here this morning.

Host

Hillary Blackburn

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