Improving Prescribing Decisions | Carm Huntress, CEO, RxRevu

Transcript Disclaimer: This transcript is generated using speech-to-text technology and may contain errors or inaccuracies.

Mike Koelzer, Host: [00:00:00] for those who haven't come across you online, introduce yourself and let our listeners know what we're talking about today. 

Carm Huntress: Carm Huntress, I'm the CEO and co-founder of RxRevu, which is helping providers make more informed decisions with cost and benefit data. At the point of care, I've never worked for a big company.

I've always been a startup guy, uh, love, you know, kind of bringing new technology to market, to really help, uh, people in new ways and have been doing that a lot of different industries, but RX review is the first, uh, that I've done in healthcare. And so, uh, it's been a, uh, kind of crazy learning curve for most of us who are coming in and spending a lot of time with kind of industry experts, understanding the value chain, especially in our core business, which is in pharmacy, which is very, very complex.

It's probably one of the most complex value chains I've ever had to kind of study and understand. And I'm still learning, you know, eight years later, there's still, still new things. What 

Mike Koelzer, Host: Does that mean by value chain? Describe that a little 

Carm Huntress: bit. Well, look, you know, in typical markets you have, um, you know, supply and demand, right?

It's, uh, it's usually these sort of, two-sided simple markets to understand like a consumer market, you know, you sell a product to the consumer and a consumer buys that product, um, that is just wholeheartedly, not true in healthcare and, and, uh, definitively not true in, in the pharmaceutical world. If you think about it, you know, I go back in history early on when I was starting, I was in an incubator and like by myself at a desk and I would spend days almost the first year when I started the company.

I just read constantly for almost a year straight. I was pouring, you know, I remember I had a filing cabinet that was just. Piles and piles of paper, trying to understand the complexity of the value chain on the pharmaceutical side. And it's much more, you know, it starts all the way back with the manufacturer and then you have all these complex pieces of the value chain that the drug has to either move through.

And as well as payment has to move through. Tell eventually there's this thing called the beneficiary, which is us. That means the consumer, right. That eventually gets the drug. So you've got, you know, wholesalers, GPO posts, um, pharmacies, PBMs, um, payers, providers that are all part of this ecosystem of value chain.

And they're exchanging the drug and, um, you know, the, uh, the dollars in different ways to, to rationalize how it comes to market. And you have to be a good student of history. Um, that was really what unlocked it for me to understand the history of why these things came to be. Why do we have pharmacy benefit managers and why did they evolve?

You know, now 30, 40 years ago. Um, and why did it start to make sense to have. I understand 

Mike Koelzer, Host: the word chain. I just don't know what the word value means. Is that a fancy term to say chain or do we say value because you're actually trying to find the value in 

Carm Huntress: it? Well, I think the vernacular is, " value chain is a term used in many industries.

Right? I could talk about the, um, the high-end audio value chain, right. In that, I could just use that as an example. So it is a common term. I think it's interesting in healthcare cause we hang a lot of, um, meaning on the word value. And in this case it just only speaks to the connected entities that make up, you know, the pharmaceutical, uh, delivery of drugs to patients.

Mike Koelzer, Host: It's kind of a pleasant name. Pretty much. Nobody wants to think that they're part of the chain and not adding any value. Right. 

Carm Huntress: I think this is the whole crux of healthcare today, 

Mike Koelzer, Host: right? Because there's arguments saying that opaque, PBMs, aren't adding very much 

Carm Huntress: value kind of thing. Right. Well, and I think that's a really astute observation.

I think that today you can sit there and say, gosh, you know, there's a lot of entities here. Uh, CB insights had a wonderful article on the breakdown of the value chain. And, and what's extraordinary, right? When you think about middlemen, right? Which a lot of these, these wholesalers, PBMs pharmacies, et cetera, et cetera, right.

Payers they're middlemen right. To between the consumer and really the manufacturer who makes the drug. Yeah. Um, T to get value. Now, what CB insights said is, look, if you look at every single pharmaceutical dollar, 41 cents of every single dollar goes to the middleman yeah. And that's kind of extraordinary.

Uh, no, no sort of supply demand relationship typically has middlemen with that type of margin. Like, you know, if I'm an Amazon, you know, I, you know, Amazon gets single digit margins, um, as a middle, if you want to call them a middleman, if you warehouse and, you know, do Amazon fulfillment, right? Most, most are [00:05:00] single digits.

Maybe, maybe some double digit, low digital digital, but it's very rare for that to happen. I think this is driving a lot of the questions in industry today or are these entities really bringing value. And you're seeing a lot of disruption, right? If you look on the startup side, um, just in pharmacy delivery, right?

So you think about the pill packs, the hymns, the Herms, the Romans, the Altos, um, the capsules of the world. You're talking about a 1.6 billion to try to come in and disrupt the, the, the, the middlemen that exists today and that's happening. Um, you're also seeing a lot of the big look at how, you know, Cigna and express scripts have come together.

Aetna and CVS, CVS health have come together or Caremark. And, and so we're, you know, they're all coupling together to try to hold onto their territory. And there's clearly. This I think, and, and, and, and payers and employers are really waking up, you know, to the high cost of drugs, to the need, to create a more rational value chain and really make a lot more value, make the value in there, right in there.

And that's not, that's, you know, in a lot of ways not happening. And, and it's still true, if you think about a company like Express Scripts, they're making a hundred billion dollars a year. It's very hard to understand, you know, how much of that is actually just drug costs and passing through rebates and volume now. It's very hard to understand a lot of these companies and now they're living inside Cigna.

Right. You know, it's even more kind of complicated. And so it is very complicated. Um, world and, um, it's, it's really hard to rationally rationalize and that's part of the reason why, you know, why we exist at RX review. Cause we're trying to bring, you know, cost transparency much more, uh, to the forefront of medicine and really to the point of care when a provider's making a decision and we can talk more about that.

Mike Koelzer, Host: You were in the audio business, so your high end audio stuff. And now I know you come from a electronics background, you're a electronic engineer, 

Carm Huntress: electrical engineer, electrical engineering was yeah. What I did at Northeastern, you came from that 

Mike Koelzer, Host: in your role at the audio company, were you in management or were you still in design?

Carm Huntress: No. I was in management. I came in really as a technology partner, a sort of a CEO CTO there. Um, and with my background. So I've always been in, you know, technology and early stage companies. I don't really use my electrical engineering background at all anymore, but, you know, that was really a classic turnaround.

That was a company that had about 13 years old technology. They. Really didn't even have a database when I showed up and we sort of went through a two and a half year, pretty grueling period of, um, re you know, rethinking everything from the organizational, uh, uh, uh, design of the company, the people, the, the, the, the competencies and the technology ultimately, and sort of set that company on a much better path to grow, because they had a lot of growth potential, but they were kind of capped out because their technology was pretty outdated.

I 

Mike Koelzer, Host: checked it out in line there kind of a retail, or they looking online, audio thing, 

Carm Huntress: or easiest way to think about that. That company was, uh, thinking about them as eBay for high-end audio. It's about selling, buying, and training. 

Mike Koelzer, Host: Oh trading even. So individuals going back and 

Carm Huntress: forth. Yep. Audio Quip. Oh, I got ya.

Yeah. It's really an exchange. I mean, that's ultimately what it is in high-end audio. What you have is these audio files who really like to upgrade and they're constantly sort of changing out their system with this endeavor to kind of recreate sound. Right. Um, and the natural sound you would hear when I see you have a guitar in the background when someone is playing guitar and that's the goal of audio being an audio file.

And so you're constantly kind of upgraded trading, buying, selling, you know, every little piece of equipment. It's fascinating, um, uh, fascinating. 

Mike Koelzer, Host: I'm on some of the DAW digital audio workspace. So for the listeners at home, it's like the old mixer boards in a studio, but you're doing it online, you know?

And if you just told an audio file, if you said, all right, here's the answer, here's the best piece of equipment. All your plugins work, all the sound is perfect. They'd say, no, let's start over. That's part of the dream is to keep reading about it and learning it. And that's part of the puzzle. It's like their golf game, basically.

Carm Huntress: Yeah. And it was a great learning experience for me. You know, I went, I grew up a lot as an executive and learned a lot of tough lessons during that, that I had to kind of take an RX review about, you know, teams and communities and technology, and, um, really thinking about, um, I spent too much time earlier in my career, focused on the technologist.

Cause my background, I am a technologist and the transition I really have had to make coming into RX review is that it's not just, you know, technology it's about it's about enterprise value and really how you were taking capital from outside sources and using that most efficiently to maximize the value of, of what you can create.

And I think we've done [00:10:00] really successfully. It's taken a long time of eight years of kind of, um, really fundamental work in the space to figure out the value equation of how to bring, you know, real-time individual patient cost to the point of care. Uh, that's what the technology does, but the value is tremendous, you know, in terms of what we're doing to help patients and payers better rationalize drug costs.

Mike Koelzer, Host: Could you have said as a 25 year old, like I'm going to do less of. Electrical stuff. Now I'm going to think more about management. I mean, it wasn't that your age, or would you truly have done something differently earlier knowing what you know now 

Carm Huntress: I think I do two things differently and I think this is where a lot of people miss in their career.

I think focus, I think having earlier kinds of immersive experiences in your twenties is incredibly important. That sort of immersion, um, in, and, uh, doing really hard work and sort of grinding stuff out is a really, um, important thing you gotta do in your twenties. I was pretty diversified in my focus. I was a little bit all over the place and I think that didn't serve me well, but how did you know what to focus on?

Well, you know, it's, it's, it's hindsight is 2020, right? We have to be 

Mike Koelzer, Host: easy on us as we get older, right. 

Carm Huntress: Especially after this past year. And it's a little bit unique to me, I'm a very curious person. So I kind of can get all over the place. Sure. One of the first things I did, and this is sort of, my second point is having great people around you.

Hmm, and getting mentors early in your career that you can rely on. I now have a wonderful group of board members outside advisers, business coaches, you know, around me that are really helping. And there's this kind of thing where, you know, This idea that you're supposed to know it. All right. You're just supposed to be this kind of incredible executive day.

One is sort of a terrible fall, you know, sort of false hood. Um, even like the really good entrepreneurs. I know they have great people around them. Um, you know, they have mentors and people that are bouncing ideas off of constantly, and that never goes away. It's not like you reach some sort of pinnacle.

And then you're like, oh, you know, I'm, I'm done talking to other people that is just a sign of a really experienced operator. Who's. Taking advice and guidance from a lot of people and synthesizing that to help us make smart decisions. And that's been a really big transition for me to get to this next level as a leader now.

And you know, we're a 60 something person company now. And, um, you have to act in really different ways and going through the, you know, scaling a company from where we've been to, where we are now, you know, you have to have the ability to make those transitions and you need a lot of support along the way to do that well, because you're, you know, humans only scale linear, literally not exponentially.

So when your company is going exponentially, you kind of wait a minute. I'm a human, I don't do these things. I go nice and linear and slow. And, as a founder, you don't have that privilege. And so the only real way to leverage that as people, right, you have to get people around you to help you move in sort of exponential ways and learn an exponent.

Mike Koelzer, Host: Now there, again, to be easy on our former cells, I would argue, I would say calm, you were younger than you didn't have the access to the mentors you weren't as successful. And so you didn't have people that maybe wanted to rub up against you. And so on. Would that be true or could you have done something differently, younger to gain more mentors and so on?

Well, 

Carm Huntress: I do look back and I said, I had some moments where I could have engaged more directly with people that were around me and asked more thoughtful questions. I think my. You know, my ego got in the way too much of thinking that I knew what I knew more than I actually did. Um, and it wasn't until kind of going honestly, arcs reviews been just a wonderful experience for me to kind of right-side my thinking because I came into it and I said, Hey, you know, my twenties were fun and you know, I did some stuff, but I hadn't felt like I had a measured amount of success and I sort of questioned that.

And I said, wow, it's really because I'm not, I don't think I've learned the right skills and abilities to be. What I really want to be, which is a really great CEO. You know, I want to be a great leader. I want to inspire people. I want to be on a mission. I want to, you know, change, uh, change healthcare or change industries, you know, leave this world a little bit better than I found it.

So I think that we all go through those phases. So my twenties were phenomenal. I mean, you know, I had, I had a job. I had, you know, a lot of fun. I had great friends. I lived in a few different parts of the country. Uh, you know, those twenties were wonderful fundamental times for me. And I did learn a lot.

Um, I didn't create a lot of financial success for myself, but I did learn a lot, which is some in some ways, the more important, um, uh, 

endeavor, 

Mike Koelzer, Host: what allowed you to hunker down for a year and learn it because most people would say, all right, calm had some success at the audio. He's going to leave this.

He's got this great idea. He knows what he's going to do. And that's why he's taken the jump to say, he's going to [00:15:00] start this business. When you said you were learning it for the first year, should I be thinking that you knew enough to say this was going to be a hot business, or did you take some time to see what you wanted to do with it?

Carm Huntress: Yeah. So I, um, met a guy named Dr. Kevin O'Brien, who's also a co-founder of this business and he's a pulmonologist, and he's the one who really introduced me to this concept of saving money on your drugs. And he has this great, great story of, uh, you know, we met over breakfast and he told me about, you know, Hey, I, this all kind of started.

I just, his, his mom's name was Lucy. And, uh, he, uh, one, she was on a fixed income and she was on a bunch of meds, like seven different medications. And over a weekend, he helped just optimize for meds. He just figured out, you know, here's some better options for you and ended up saving her about $400. And he said, geez, you know, if I can do this for me.

You know, there's gotta be a lot of other people that need this help, um, and could save money on their prescriptions. And so he started cataloging over about a three-year period, almost as an academic exercise, about 110 different conditions in every single drug ranked by costs that you can take for that condition.

And he showed me this, he turned it into a book. He was going to publish it on Amazon. Why did he meet with you? Why. I, I had moved to Denver and I didn't have a job and I was looking for something new. I wanted to be in a startup. Um, we got connected and really, and I just started a great dialogue. You know, it was kind of, uh, uh, you know, we over breakfast, we just kinda hit it off.

And he showed me this book and it was an incredible piece of work. You know, it was like he put three years of work into it. Wow. And he, you know, not being a doctor and an academic, he wanted to publish it online. You know, he was like, opt-in, I was just self published. And I, I looked at this and I said, oh my gosh, you know, this needs to be a technology.

This is a platform. Um, because prices have changed all the time, new drugs come on the market. Right. You're not, you don't want it to be a static book or a reference tool. Right. And so I said to him, let's turn this into a company and that really kicked it off. But, you know, I think hindsight's 2020. If I had known what I know now of how hard.

And this market is complex. I wonder if I have this, you know, thoughts sometimes, like what I've really done this. Right. You know, they talk about this kind of founder ignorance, right? Like you, you don't know any better. And so you just, you just, you, you, you rationally know what the world should look like, and you have a, you know, you sort of, sort of, oh, well, you know, all doctors and all patients should have access to what their drugs cost and what their alternatives are.

Right. That. Yeah, that's just going to happen someday. Um, it turns out, you know, that's not the case and there's a ton of both technical business, uh, and, and other challenges to bringing, you know, this, this reality to, um, where it needed to be or where we are today. You know, I'm happy to say that we spent a lot of rough years early on there kind of figuring out our way in the world.

But eventually these things like real-time benefit check, which is, which is the technology we rely on to, to these real-time pricing events for doctors came to fruition, and we got involved in that and started to work with a lot of the national payers and PBMs to bring this data to the point of care where, you know, where doctors can really benefit from it and make more rational cost-effective decisions for patients.

And, you know, we're now working with over 200,000 doctors. So, um, we've grown tremendously. Um, uh, just in the last couple of years, what found you 

Mike Koelzer, Host: leaving your audience? And being in Denver, looking for something, is that a great story or is that a bitter story? 

Carm Huntress: No, no, it's not. I mean, literally, um, my now ex wife and I, uh, we moved here to Denver and we just kind of made a decision.

She actually is a doctor and she had gone through residency. I had kind of this run with audio gone for two and a half years. And it was, I think for me it was really a discussion about. Um, wanting to do something a little bit more mission driven in my life. Um, you know, bringing high-end audio to people is nice, but I think there was this sort of double thing.

One, I really felt like it was time for me to really focus on something, have a career, and try to make a difference in the world. Like all these things, you know, I was in my early thirties and starting to think more about sort of career and legacy and all those things. And I think that led me to say whatever I do next, I want it to be a really big thing.

Um, that's very mission driven and really makes an impact on people's lives. And so when I met Kevin, it was just obvious. It was like, oh my gosh, you know, like if we can do this, the effect we can have on people's lives is tremendous. Actually, there was just an article last week that said that if you increase the cost of a patient's drug by 10%, that group of patients has a 33% higher mortality.

They basically. Wow, isn't it. I mean, I read that and I saw, oh wow, just the effect of a $10 increase. And you know, we've seen $500 in increases on generics, um, over the last few years. And [00:20:00] so this study was pretty compelling in that basically if you're low income or you're on a fixed income, um, you know, that 10 bucks, you just abandoned, you just say, Hey, I'm going to stop taking it right now.

What was interesting about the researcher? Sort of saying, wow, people are not putting a lot of value on their life. Um, if they're trading $10 in potentially dying, but I sit here and I say, wow, what a. Uh, impactful, amazing effect we can have on people's lives just by rationalizing the cost of their drugs and trying to help them save money.

And I'm happy to say when we can find a lower cost option on average patients are saving 260 bucks a month. So yeah, so we know we're, you know, I don't want to pound my chest too hard and say we're saving lives, but directionally we're definitely probably improving people's lives, making it easier to take their medications and hopefully.

You know, reducing their mortality, um, which, which is, uh, you know, I couldn't be happier in terms of having a mission, um, and, and a real value. And it's something, we talk a lot with the, our, our, our employees about our team, about, about sort of the fundamental impact that you can have, you know, working at a company like ours.

I know you 

Mike Koelzer, Host: talked about this in another podcast, but you lost both of your parents when you were a mid teenager. And you said that had a little bit of a pull maybe on your life's goals and things like that. 

Carm Huntress: Yeah, it definitely, uh, drove a lot of my entrepreneurial sort of drive that comes from that is, uh, you know, just, I think all the things that, you know, I think I'm starting to see.

I mean, some of my friends now are at that age where their parents are getting older. They're not, you know, I think they're doing okay overall, but some have lost some parents and. Uh, you know, it forced me at a very young age to kind of have to, by the time I was 15, you know, I'm sitting here thinking about like, what's the meaning, you know, I've lost both parents.

I'm like 15, you know, you sort of have to have these introspective moments of like, and it compounded, it wasn't one parent was both. And it was like, okay, what's the meaning of life here? Right. It got into this very esoteric, um, viewpoint of like, where do I, you know, what does this all mean? And I think I kind of came to conclusions that obviously serving and helping other people is kind of a fundamental part of life and something that you can really be impactful about.

Um, and, uh, you know, the, the sort of, what's your billboard of, of life going to, you know, if you had a billboard and could say one thing, I think it's about, you know, how have I impacted and made the lives of others better? And you know, that, that came very early to me as sort of, um, something that. Uh, uh, you know, I saw both of my parents, they were very service oriented in their community, but also just something of like losing, you know, these two incredible people in my life.

So early on really drove me to think about that more. And entrepreneurship seemed like the biggest driver to do that. I would also say as a young kid, it was like the best distraction ever after losing parents. It was like this thing I could really get involved in. I started the hosting company with one of my best friends and we got into, you know, really, um, uh, into technology in the late nineties.

So it was a very cool time to be in kind of early internet stuff. Um, so it wasn't very engaging, but it was shaping in that, you know, How do, how do I support service my community? How do I serve others? How do I make a difference in this world? And I think you, you know, you ha I just had those questions come a lot earlier, which really drove my entrepreneurial trajectory and desire to do this.

And I would say, too, you really need those things. You know, I know a lot of other entrepreneurs and almost all of them have kind of this fundamental, something happened in their life that was, um, gave them the wherewithal and the capacity and the want to go do these things. Um, and I think, I think those things really do, um, shape you in positive ways to, you know, some good can come out of it and then you get, get these drives and you need that drive to have the wherewithal to go do these things, frankly.

And the resiliency 

Mike Koelzer, Host: That's cool that you didn't say that. Health was necessarily a lot better than darting up websites or helping people with sound. In other words, there's a lot of different ways we can serve and make the world a better place. And for you that came through your entrepreneurship, not necessarily saying I'm going to help someone's health, because that's more important than A or B.

You're not necessarily saying that it's really serving in any place that you feel a goal to serve or a way to serve. I suppose, just 

Carm Huntress: making a difference in people's lives. Like we spend, I mean, you know, think about today's social environment, how much time people are spending, bashing each other and being really quite mean.

Yeah. You know, I don't want to spend my time doing that. I want to make a positive difference in other people's lives. Right. And we all should, no matter what that is, I don't care. You know, you name it, you [00:25:00] go, whether that's, you know, making a coffee for somebody or doing high-end audio or whatever, you know, it's, it, it, it, um, uh, that that's the key and it doesn't really matter.

And I think number two is, for me, it was the intersection of, of, of helping other people in technology. I mean, you start to see what technology, you know, we, we, we pick it apart and say, it's, it's, you know, it's got a lot of bad parts of it, but overall technology. If you think about technology and capitalism and what that has done for the world, it's extraordinary.

And look at India, you know, 2 billion people have been taken out of poverty because of capitalism and, and a lot of that had to do with technology as well. And so, um, you know, I just look at that intersection and that's where I want to spend my career. I love this intersection of bringing great technology and products to market that are, you know, really helping people's lives.

Yeah. Um, and that's where I wanna, you know, I'm 40 now. I've got, I'm halfway through my career, essentially. Uh, you know, I want to spend the rest of my career doing that stuff. That's the stuff that gets me up every day and is super fun. And we've got a lot of big problems. We've got healthcare, huge healthcare problems.

We've got huge climate issues. We've got education issues. We've got, you know, really big, I think, fundamental things that we need to fix in this country and worldwide, um, that I can be part of it. I'm super, you know, that's what gets me up every day to be really excited about it, whether that's RX review or, or, you know, um, other stuff happening out there.

Mike Koelzer, Host: Karma. I am glad that I was not at that breakfast with you guys, because here's what 

Carm Huntress: I would have said. Yeah. What would he say? See, you're the, you're my hindsight. You're, you're the guy who knows too much at that breakfast. Oh, they 

Mike Koelzer, Host: always say in these management books, they say, be careful not to say, well, we've done that.

And we'd tried that before, you know? Well, I'm that guy, but I can now in my mature age, I can say some of that stuff, but you're lucky I wasn't there because I would've put a damper on a good business because here's what I would have said years ago in pharmacy. They always say the great thing about having.

All of this stuff on the computer, you know, and back then it was Newton, you know, and that kind of stuff. But the great thing about having this is the doctors would be able to make real time choices. Okay. So instead of just scribbling something out, they can make a realtime choice of drug choice and, you know, levels and preferred drugs and all that kind of stuff.

And this is even before the PBM was messing around with the reality of telling doctors to dispense something that has a generic and it's five times as much with a brand name, you know, before all that stuff, these were true decisions that people were making and we would always then get something in the pharmacy.

And it would be for some like a far out long acting version of a drug, which no one has seen in 10 years. In my mind. I always knew what happened. The doctor didn't want to take the time to do anything on Newton, you know? And so they would give it to, you know, Molly and Molly was their 16 year old friend of their daughter who they just hired that day.

And they put her in the front office and here Molly is punching in the drugs that in theory the doctor was going to do on his handheld, but the doctor was an old fart. Didn't know how to figure it out. And so he'd have Molly do it and she'd send this crazy thing to the pharmacy. So if we were sitting there that morning, karma would say, Carm, here's your challenge.

The doctors aren't very good at this. If they can't do it with a pencil and paper, you know, they're just going to hand it off to say 20 years ago. Now they're just going to hand it off to Molly and you're fighting the wrong fight here. You'd say, what is the fight, Mike? And I would say. Oh, I don't know.

I'm just a negative guy here at this breakfast. My point is a big part of it is the real time doctor's decision. Is that wrong or is that right? Yes. It's really 

Carm Huntress: about informed decision-making with the providers at the point of care. And what we're doing is, we're bringing that real-time benefit cost and coverage data around the drug to that point of decision-making.

Gotcha. It took me a while to see this right. But you have to really start with first principles on this one because, you know, the pharmaceutical industry is so complex and there's, you know, to your point, you just walked through like, you know, kind of the status quo of where pharmacy is today in a lot of ways.

But you know, if you look at it from first principles, like I say this to investors and our employees, like some day, all doctors, when they prescribe. We'll understand the cost and, you know, uh, of a cost and benefit and coverage of, of, of that drug in real time. Yes or no. It's obvious that 

Mike Koelzer, Host: will, everything is moving 

Carm Huntress: towards that.

Okay. So then we're just arguing over timing. And so that's the key thing that I try to instill in, you know, our employees and I, you know, when I talk to the external world that is going to happen, it has to happen. If we're ever going to do value in the United States, you can see the tailwinds on the regulatory side, doctors are [00:30:00] going to have to have, you know, have this data to make better decisions.

And I always love the, you know, if you know what tool Gawande has, this thing, like the most expensive, you know, as quotas, the most expensive medical devices, the provider's pen, right? Because, you know, he ends that quote. A lot of people ended up there. The end of that quote is providers, doctors order all the.

Of healthcare. And, and so if you look at that, right, what we've spent all this time, the last decade, I'd say I'd argue pretty heavily. We spent all this time trying to engage consumers and their employers and, you know, to, with all these tools and apps and, you know, I think they, the, we just broke 10,000 healthcare apps that were built in the last decade.

We've in rest vested. I know 40, 60, $70 billion. And nobody's sitting here saying, wow, we've had a complete rewrite of healthcare in this country. No, gee, you know, it's still, you know, GDP wise, it's still going up on a percentage basis. Right. And, and I would argue the reason for that is that, you know, providers today.

Are still making really bad decisions and all, and because they're the ones making the decisions, they're ordering all the money of healthcare and we have to do a better draw. And it's not like they're doing it on purpose. This is the other part that really it's such a fallacy. It's like, no doctor is sitting there saying I want to be cost effective.

And I want to know, you know, cause my patients to go bankrupt, which is now the third leading cause of bankruptcy in this country. Um, they just don't have the right information. Right. And that's what RX reviews really set out to do is to say, look, if, if we could imagine a world and now we're doing this, really not even imagining it for 200,000 doctors, if we could, in real time show the provider.

When at that point of decision, not in some portal, they have to log into, not in, you know, some sort of third party app inside the EHR at that point of ordering when they're thinking about it. Okay. My patient's got hypertension. I need to order a drug for that. We show them the cost. Is it, you know, what it costs at that patient's preferred farm?

Is it covered or not? Right? Can, is it, if it's not covered the patient's going to have to pay full cash. Um, and are there any restrictions, is there a prior auth or a quantity limit or step therapy, right. And, and patient specific, have they already done the prior auth? Right. This isn't sort of generalized, there was a prior auth on this drug it's is this patient had done a prior auth or not, and then of course, alternatives to that.

Here's a drug that doesn't have a prior auth. Here's a drug that is covered. Here's the drug that will save them a lot of money. Um, because this is, you went from a not preferred to preferred drug on their benefit. Um, and you know, that is the rationalization of healthcare that is ultimately not only for pharmacy, um, we're, we're now moving into medical specialty drugs as well as medical services across the board.

Um, we're, we're, we're really opening up the doors to say, Hey, well, if you, Hey, payer, if you've got data that would help in the decision-making of providers at the point of care to rationalize, uh, You know, uh, patient's drugs, uh, and, and make, make it more cost-effective for them. And a more efficient, you know, takes friction out of the process of them getting to those drugs.

Uh, let's do that. And, and, you know, it's so exciting is, you know, two, three years ago we only had a couple thousand doctors in our network. We now have 200,000 and growing rapidly with 150 million insured lives. We can price drugs for today. We're in over 2000 hospitals. Um, uh, and we're running millions of these transactions a month now as a company.

And so I'm so excited about the work we've done, how we've enabled doctors to get this information, and they really are using it, this, this whole stigma that providers don't want it. And you know, they're not, um, they hate technology. Um, it turns out really good technology and information delivered at the right moment at the right time.

They do love for sure. Right. And, and we, we survey doctors a lot and they absolutely know we're 90 plus percent on surveys and stuff in terms of positivity. This is super helpful for me in my day to help me make better prescribing decisions 

Mike Koelzer, Host: back to our breakfast that we didn't have, uh, you know, 10 years ago together, the doctors are actually deciding that right at that time.

So as soon as they like their stylists or fingers or whatever hits the button that's already happened. And so they're choosing the correct drug, whatever, right at that time, 

Carm Huntress: Yeah, the way the technology works is, you know, there, they have an ordering screen inside their electronic health record. And so they say, Hey, I want to order, let's say Humira.

A lot of people know that drug, and that can be what karma is handheld. No, it's not a computer. You know, they're sitting in an exam room with a patient or after a visit, you know, putting in their orders and they say, Hey, I want to order Humira. Um, we would go ahead and price that in real time. And, um, we, we know at that point we know, oh, this patient has this insurance.

We send that off to the PBM, the [00:35:00] pharmacy benefit manager, they come back and give us that real-time price, um, for that patient at their preferred pharmacy, on that specific day. So it takes into account deductibles and accumulators. It's literally like a lot of people say, well, is it the real price?

And it's like, it is literally like the patient is standing at the pharmacy counter saying, you know, how much should I pay you? Um, that's what our, that's what our network does. And, um, uh, it's, it's some technical term, it's essentially a trial. You know, if you want to look at it from, from a, uh, a billing perspective.

And so then we show that right in workflow to the provider, they can look at alternatives, they can look at the cost, they can have that discussion with the patient if they're still in the exam room. And, uh, it's just, it's wonderful to just rationalize that all in real time. And then what's great with, uh, with our network is we bring back alternatives, lower cost, alternatives, and options to sort of help them improve that decision.

If there is, um, you know, maybe it's not Humira it's Embrel, I don't know, you know, what's covered and, and they just rationalize that right upfront. And so, um, and there's lots of ways what's so exciting is like a third of the time. There's some, there's, there's a bit, sometimes almost 40% of the time.

There's a better, better, possible decision, right. That the provider could make if they had this information in real time and the cost. Right. You know, if you look at the effect, um, it's about 20 hours off. Of per doctor, per se, for staff time per week, dealing with pharmacy issues. Now, you know, it's like a part-time job.

At most clinics managing prior authorizations, pharmacy callback, cost issues, refills, you know, the list just goes on and on and issues, and we're just rationalizing all that upfront. And so we're really alleviating a lot of this administrative headache and back and forth with the doctor to sort of figure out this stuff.

Um, you know, th th even say on an individual doctor basis, pharmacy issues on an annual Lise basis is about $15,000 worth of costs just on pharmacy callbacks, right where the pharmacy is calling, Hey, the drug's not covered. I need you to switch the script. Right? All those types of issues are incredibly Frick.

You know, burdensome on the provider creates a lot of friction for the doctor during their day, leading to patients, either delaying therapy or just giving them. Right about a third of abandonment issues are due to cost. Um, and so we're really trying to just rationalize that all upfront at the point of decision making and then not all of this, none of this happens, right.

We just live in a world where it's very seamless and streamlined and all makes sense, um, to the patient. And, you know, we think if you look at the 400 billion we spend on drugs each year, you know, most studies are saying about a third of that is waste. And a lot of that is just due to not rationalizing the cost and benefit, um, for those patients in real time.

Um, and, and we really think we can deliver that value to them. Let's say a 

Mike Koelzer, Host: Doctor fails this for some reason, is that their attitude is that of their comfort. If a doctor fails this, why are they failing 

Carm Huntress: still? The main thing is just sort of being, um, kinda stuck in their ways. And, but I would say we were starting to really see a change.

I think COVID accelerated a lot. These doctors kind of woke up and said, gosh, we gotta change the way we do things here. 

Mike Koelzer, Host: And maybe they've been on with their family on a zoom call or some Sunday night or something like that. 

Carm Huntress: Yeah. You know, I mean, they've had to make this huge shift to telemedicine and, and so.

You know, I, I, there's a study that I almost always referenced just to give a real fine point on, on sort of providers get kind of they're, they're trained right in rote memorization. Right. And they are very clear, they kind of go through a differential and they, you know, and they, they pick, uh, a drug and they're going to what they know because they think it's safe.

They've prescribed it a lot of times. Um, and what's, what's crazy is there was a study done that looked at at Medicare claims data and they were able to just looking at the claims data, tell the doctor what residency program they went to up to 30 years 

Mike Koelzer, Host: prior, just by following the flow of their decision.

They can tell who trained them and stuff 

Carm Huntress: because the patterns, right. We're so embedded during that residency, for sure. Um, and that's the way the medical MC community works today, right? We, we sort of like having these, but these, these that's part of the reason why it's so hard to get. You know, the clinical guidelines, it takes about a dozen years for clinical guidelines to get up to date because there's sort of this long delay and people sort of stick with what they learned in residency.

Rightly so, because they know it works. They were trained that way. They know it's safe for the patient, and this is really what we have to change, but I think we're starting to really see providers. We really start to think about this data. They're moving into value. They want to provide more value to patients.

They're tired of dealing with pharmacy issues. All these things are kind of starting to get them to sort of wake up. And we rarely, if ever, we used to hear it a lot more like, you know, I don't want to use this as just going to get in the [00:40:00] way we now tend to hear, wow, this is great. This is so helpful for my workflow.

This is super helpful for my patients. And a lot more systems now are focused on, you know, pharmacy issues right related to patients. It's a bigger thing. If you look at sort of the top three complaints of bad health care experience, it's usually one of the top three is pharmacy issues for patients.

And so it's a big deal in terms of patient experience and patient satisfaction. 

Mike Koelzer, Host: I'd imagine as a doctor, too, one of the questions that I would ask, and this is cliche or stereotypical, but I would say what's going to interrupt my golf. The least, because you mentioned things like going to give the patient the best care, it's going to do this, going to do that.

But I think a lot of doctors get into their habits because they say, if I would have maybe done something else, maybe this person would have had better outcomes. But I think sometimes they look at the negative and they say, which one's the safest one for me. Yeah. It gives the outcomes, but I'm not going to have all the phone calls from the pharmacy.

I'm also not going to have someone calling me when I'm on the first tee because of this and that happening. So what negatives am I avoiding by doing the tried and 

Carm Huntress: true? Yeah. And I think a lot of providers, uh, You know, think that way. I, I don't, I don't necessarily disagree with you that there, there, you know, sort of thinking about, Hey, the night, you know, I'm trying to avoid as much negative as I can.

We really try to educate doctors around, look, this is going to be, you know, top three things here, one, this is going to make you more efficient, less administrative headache. And that's probably the biggest thing, right? This is saving Utah at the same time. This is a better patient experience. Um, and, uh, ultimately this is going to get the patient on the drug, you know, more, more likely, uh, they'll, they'll take the drug and stay on it, which is a big deal when you think about outcomes.

Um, and, and, and, you know, that's the sea change we're starting to have. And I think we've got, we're still in the early stages. I mean, I think the biggest thing, uh, We've got to keep working on it. As industry is bringing more of these data and services to the point of care, helping doctors understand them.

Um, you know, we do have, I would say one of the interesting things we still sort of talk about is like, well, you know, our doctors really like personal shoppers for patients. Like, you know, is that really what they have to do? And the answer is kind of, yes. I think though we have this undue burden on doctors.

Um, there's an early study. We did where we took a patient, um, hyper hypertensive, high cholesterol type two diabetic patient. And we just looked at, well, how many comments, if you had to, you got to prescribe three drugs at that moment. If you're a doctor, how many options are you sitting in front of?

You're sitting in front of 1.2 trillion options. Wow. And so there's this undue burden of like, why on earth are we telling, you know, in saying to doctors, like you have to figure this out. Of course, they're going to go to what they know. You know, there's no way they can do what's best because it's not a human endeavor.

It's a computational endeavor, right? It's a computer that should be solving that. And I really see a future where. You know, we're kind of rationalizing the universe of options down to a few sets, a small set that the doctor can look at and think about the other issues, right? The social economic issues, the, the, the empathetic issues, right?

That, um, the computer can't rationalize the rational, the computer's really good at rationalizing clinical issues and rationalizing cost issues. And then give that small set of options. And, you know, it is informed autonomy, right. It's helping me, the provider, to get down to that small set of options.

And that's really the future I'm really excited about in terms of providers and computers kind of working together in harmony. Right. Um, and you can, can kind of imagine an AI type agent, right. Kind of going out and saying, Hey, Dr. So-and-so, we've kind of looked at 1.3 trillion options. Here's my best recommendations.

You kind of pick what you think is best. And I really like that view of the future in terms of. 

Mike Koelzer, Host: That's for sure. And I'm sure you guys are all over this because you just said it right now. But if I'm a doctor and I go on this program, I basically want to pull up Amazon's choice for me. Yeah. I think back to the day when I would order like a computer, you know, like a Dell computer.

Oh yeah. I remember those days it would take like three weeks and I'd have all this literature and all this crap, you know, and I would be finding the best and all this stuff. Now it's like 10 minutes, you go on Amazon. And all my pharmacy friends. Don't like when I talk about Amazon, but you know, you go on Amazon and you look up Amazon's choice and it's got four stars and it's got this many reviews.

Hmm. You say that I'll pick that one and then I can spend my time thinking about other issues. Well, when my wife liked this one and what will I do with this? You know, is it going to fit in my house and all that kind of stuff? And that's kind of what you're saying. It's like, let the computer do what the computer does.

Let the doctor hold the person's hand and say, you know, look them in the eye and say, is this really gonna work for you? [00:45:00] And is this gonna work for your family? That kind of stuff. Don't reinvent the Amazon's choice every time 

Carm Huntress: that's already been done. Yeah. And I, and I think that's the right future too, and to aspire to be right where you have, you know, the Amazon feature, I was one of the people like you who did really well on this Medicare.

Yeah, right. Like, I'd love to have that when we all love to have that engine to give us some confidence, you know. Sure. And, and you can think about that, especially as we think about genetics and some of these other personalized precision based medicine approaches of sort of, oh, I've looked at people with your same genetic profile and same, you know, renal, hepatic function and all this other stuff.

And here's the best option, right? For you as a patient. And that's a. That's kind of a dream. And then to your point, right, that getting the doctor back to sort of, the way I like to look at it is getting back to the reason they became a doctor in the first place, right. Is to help patients and make a difference and be that empathetic partner for what's going on for them opposed to today's world, which is, you know, I was, I love that cartoon where the doctor's sitting there spending more time treating the computer than treating the patient, right?

Like they haven't even looked, you know, over at the patient. They're just trying to treat the computer and sort of get through the, the, you know, the, the encounter. And we've got to get away from that. Right. We've got to put technology in the right place, in the right ways to really support them empathetically.

And, and, you know, we discovered early on it's, it's not about, you know, this whole sort of stigma of like doctors hate technology. It's when you show them really good, we give them really good data at the right time and you take clicks out of there, you know, you lower their cognitive load and take clicks out of their workflow.

Right. Right. They, they will, you know, they'll take that path of least resistance every single time. And if you're lowering the cognitive load on them, right. Because they're under this extreme cognitive stress and, um, you know, um, pressure during a single shift, you look at an ER doc 4,000 clicks per, per, per shift.

You actually 

Mike Koelzer, Host: mean clicks like 

Carm Huntress: on mouse, click per eight hour shifts. And the ER doc does, they've done studies on this 4,000 mouse clicks. Dang. I mean, that is just, it makes your head hurt. Right? Just think about, and you're saying, wait a minute. That means all that time is not spent treating patients. Um, and so they're under this kind of extreme cognitive load, sorting out patient issues, you know, and, and I've, I've shadowed, you know, there's a great article in CNBC with Dr.

Rich sane, who I shadowed at UC health. He's an amazing doctor. Um, he's the chief innovation officer and, uh, at, at university of Colorado health system and I shadowed him and, you know, He's got these, you know, it's like, I'd never seen, you know, uh, someone so rapid firefly, you know, have to keep moving through patient after patient, right.

Where they have just a row of exam rooms. And he goes in with his tech, they do a whole diagnosis. They come out and then he puts in all the orders and what they want to do. And then the next room, and he's doing. You know, just go through and then start over. And, and, and so you think about the cognitive load and the pressure put on providers today to perform at a very high level for many, many hours on end and it's kind of untenable.

And then you're saying, okay, well rationalize all this other stuff that just has to do with administrative and cost related things. And it's just, it doesn't make sense anymore. It just doesn't. And so we've got to create relatable technology that they can engage with. That's really a guidance system for them and not this sort of abrasive, you know, 4,000 clicks, so a shift, uh, environment for them.

Um, and, and it's leading to F you know, I think we've seen this in the pandemic on top of everything else. I think it is a key part of why burnout is happening. So, um, so much in the, in, in healthcare with providers, Um, you know, I know people who've retired because there was an EHR 

Mike Koelzer, Host: upgrade. Yeah. Right. They talked about that in the pharmacy.

Carm Huntress: Yeah. You know, like, oh, there's, there's an upgrade coming on the EHR. Uh, this is a good moment for me to stop and to my career. Um, uh, it's that, it's that difficult and it's that hard to, to interact with these systems. So we've got a lot of work to do. Um, and I really encourage a lot of companies. I know there's been a big focus on consumer enablement and healthcare, and I love that, but I think there's a lot of work still to be done at the point of care with providers to help them make better decisions.

Mike Koelzer, Host: This weekend, I got a couple, uh, Google TV, remote controls, and it's just a cool remote because, and sometimes this can be overdone where it's not intuitive, but it's so cool. How after I hit forward on the remote. They know that my next step is going to be this. Why do I have to have a separate button for that?

You know what I mean? It's like, it's a one button, it'll take you forward 10 seconds and then it stops you. And then I forget what it does, but basically it's a one button thing. It's like, that's not really a choice that I have to [00:50:00] make, you know, and with the doctors, when you're talking about 4,000. That's not like 400 enter buttons where it's just going through the program.

Those are decisions and they probably don't have to be making all of those. 

Carm Huntress: It's really interesting. I just listened to an Elon Musk interview with Joe Rogan and he was talking about the Tesla cars. And I thought this, this viewpoint was really fascinating because in the new Tesla they've gotten rid of the park reverse neutral drive and the car just predicts if you want to go forwards or backwards.

And because it can see, you know, if it sees that there's a curb in front of you, you probably want to go, you definitely don't want to go up on the curb. Right. And so then you just hit your pedal and Joe Rogan and I'd me too. I was sitting there saying this is crazy. And Elan says the mentality of his engineers and the way they think about it is that any, any input is considered an error.

That's cool. And, and I said, whoa, like, boy could, if we could take that mentality to healthcare right. Where the systems were so predictive, they so anticipated what your needs were. And they just took all, you know, I don't want to say took care of it for you, but at least got you to a point where they're being predictive and sort of seeing what's most to your point.

Right. It knows, Hey, play the nice, next, most likely thing you're going to do here. I'm going to just tee this up. Right. Yeah, exactly. And, and I think that's, uh, uh, I think you could see a system in the future where it's like, well, Hey, if I'm going to order this procedure, boom, all this stuff just happens.

Right. You can see these predictive moments starting to come together. But the idea is to think that any form of input is an error and the machine should already know what you need next, or sort of predict that. Right. It's kind of a fascinating view to look at. Um, and you know, there's a lot of, I think, a sort of passive monitoring we can do.

To sort of figure out, Hey, this, oh, we're what we're seeing. This probably needs to happen next. Um, and, and in healthcare, we need a lot more of that type of mentality and thinking to sort of have this, I think more major technology revolution that needs to current healthcare to make it, you know, much more efficient, but obviously, uh, achieve the triple aim with patients and improve the quality of care.

Mike Koelzer, Host: I had a pharmacist on a few episodes ago and. She was saying that her dad got into a situation where two different doctors came in and both of them basically pressed a button and the form was filled out and none of them ever listened to the lungs, no one really took a good weight and things like that.

And so it's tempting to say, if they weren't listening to the podcast to say, no, we don't want to automate that stuff because the patient gets lost. It's like, no, if we do the predictive stuff that gives doctors really time to sit there and look at the patient and say, okay, wait a minute. You're not 300 pounds.

You're 170 pounds. And let me apply my warmth in my hands to your back and really listen to you. I mean, those are the things that open up when that predictive stuff. Can happen on its own. Yeah. 

Carm Huntress: And, and so much of it is it's not like we're rewriting the clinical side. It's really that there's so much work just to be done on the administrative side of healthcare does streamline, you know, the documentation and, and all the pieces doctors have to do outside of.

You know, patient care and, you know, the sad state of affairs today is, you know, doctors spending less and less time with really quality patient care and more time sort of stock doing administrative, um, uh, work and overhead. And that's where we are, that's where I think a ton of really good technology, um, can make a huge difference.

We're starting to do so, like for instance, we're looking a lot at, uh, electronic prior authorization. That is a huge burden today. Um, it's crazy. We've got to fill out all these forms and send them, fax them in, and there's still a lot of faxing going on in healthcare. There's a lot of opportunities. Again, I think there's a lot more companies that need to be built and developed to sort of tackle some of these big administrative, um, uh, challenges that, that really technology and most other industries has already kind of taken over.

And there's really no need, um, to do, uh, You know, to do some of this work at Toby, Toby Cosgrove, who's on my board. You know, he told me just in coding and billing, right. Um, they have over 2000 people working on coding and billing. I mean, you just sit there and you go like, really, like why isn't there technology that just figures all this stuff out.

Mike Koelzer, Host: I drive down the 

highway and I see these big buildings I say to my wife from like, what the hell do they do there? I mean, I don't break my back at work, but I actually sometimes will take a bottle of this and walk it down there or take a wheelchair and pull it over here, you know, whatever. That's just a big building of paper pushers, and it's just sad that you have these humongous buildings for pushing paper around.

Carm Huntress: Yeah. And, and the, the, you know, tens or hundreds of billions of dollars we could take out of healthcare. If we sort of come in and thoughtfully bring technology and [00:55:00] build it as more of a guidance and supportive a solution, I think we could just make tremendous strides and sort of rightsiding the cost of care in the U S and, and ultimately kind of fixing our GDP issues related to it because we're, we're in an untenable situation here.

If it keeps going up the way it is, you know, we're, we're, we're not only gonna, you know, it's gonna lead to a really bad economic situation in the U S but I really worried about our global position and us falling behind from a global perspective, because we just can't be as competitive because we're saying.

So much money on healthcare and we've got a really right side, the whole industry. And I think transparency, hopefully what we're doing is the first of a number of phases moving to value, right? Because we look at this and we say, Hey, if we can make it transparent, if we can help the doctors understand, and then we can measure right, what that cost and value is, we can then talk about improving it.

Um, and, and that's really, I think the trajectory we're really excited to be on is like, how can we prove, you know, improve the value of healthcare through helping providers make these better decisions. It's 

Mike Koelzer, Host: fun as an entrepreneur and a business owner to just get a lot of ideas. You know, it's just fun when ideas come at ya.

One thing I try to do with my ideas now is just so I make sure that I'm not running off with some idea on a Monday morning when I have a million other things I should be doing. Cause that's a fun one to track down. That idea is I'll put it into my. Dualist my computer list. And then I'll just, before I just jump on something, I tamed myself to say, well, wait a minute, where does this fit on a Monday morning?

You know, I just can't go off and have fun all the time. Here's my point on this Tesla. He was saying that I think it was he that was saying this. If I reverse in my driveway in a Tesla, I don't have one, but if I had one, if I drive down and let's say my car slides off six inches and hits the mailbox, you know, I didn't intend it.

I didn't really do it. It just happened well in the past, I gained that knowledge. And then maybe in 20 years, I can tell my kids. I can say, Hey son, be careful with a mailbox. You know, but with these cars, with this computer driving, it's like the next day 2 billion people. 8 billion. The whole world could understand that this car can slide into the mailbox.

So everybody has gained from my little car blunder the next day. The cool thing about the doctors is that if they can train themselves to do a lot of this stuff, kind of through the computer with a little bit of that process, just as I would do my tasks on a Monday morning, make sure I'm in line. Well with your system Carm, you can teach the medical world tomorrow that there's now an interaction between drug A and drug B that we never knew of before.

And the thought process just can't go that way anymore because. Interaction that no one thought of now the world understands, but if you jump over all that stuff is not going to work so much. But if the doctors almost use this as like a second brain and kind of walk through this, you can do a lot of change overnight from the experience that doctors pick up.

Carm Huntress: Yeah. I mean, we're starting to get to some of that sort of learning systems, right. Is that, um, we're, we're really starting to think about, you know, the behavior of the doctors. How can we improve that and continuously improve that right? From there, their decision, um, you know, our, our today we, we ask a lot of questions like, well, you know, if it's, if it's only $2 of savings to the patient, do we really want to show this to the doc, right?

As an alternative or something, we are really thinking about what features, um, do we want to show the dock? How do we want to influence their behavior? And, and I would even say like, We're really having some very interesting discussions about the personalization of the engine that we've built. It's sort of a three-way street.

It's kind of, Hey, what is the system learning from all the other doctors in their decisions, but what is the interaction between the computer, right. And this guidance system with again, Providers personal. Yeah. Right. And what are they, how did they approach this and how can we be helpful to them?

Um, and, and really building a personal, just like your Amazon experience, it's very personalized to your habits and your, your, your things. We don't tend to think about that in medicine, but I think that's something, um, worth noting because even workflow, right workflow from one doctor to another can, they, they might have the same outcome, same decisions at the end of the day, but the way they go about it is very different.

And I think we need to build systems that are cognizant of that and responsive to that, and really being sort of. Personalized agents right in, on behalf of the provider, we really look at, look at it from a cost, you know, um, uh, benefit perspective to the patient. And, um, I think we're going to get in the next year, probably, uh, to some level of personalization with [01:00:00] providers, not, not in a full sense, but in certain areas we might sort of say, Hey, let's make, make some recommendations, but I, um, that are more precision based to that doctor.

And then, you know, there's this really sort of interesting flywheel effect and learning system that starts to emerge over time as you start to improve those, that, that, um, way of approaching the provider and their decisions. It's 

Mike Koelzer, Host: like reading the Google news or something on your phone or apple news, they're showing you the world news and the U S news, but then they throw in something about whatever, you know, that's just kind of your taste, you know, that kind of keeps you coming back.

Carm Huntress: Yeah, absolutely. I, I really hope, you know, we can get to this. I, I think, you know, our, our, my concern over the last few years is sort of these companies coming out very aggressively about sort of AI and being, you know, kind of, um, this AI driven healthcare kind of concept. I think it's just a little bit of too much rhetoric and not enough sort of feet on the ground.

Reality, you know, good AI agents are built off really well. And the problem that I've had with where health, you know, health care is today is the data. Isn't very good. The understanding, you know, even understanding provider behavior, it's taken us years of really hard work to get to, um, understanding the data and having that data well structured, where you could build them, you know, an ML based model off of it.

And, um, I think too many companies kind of got a lot of value in just saying the words, AI without really sitting there and saying, okay, how do we really start to piece the data together? Um, you know, to, to make a model that's really going to be compelling and get providers to, um, uh, you know, uh, uh, adopt, um, and, and, you know, thinking about that too, as well as the value chain.

And how do you create value from, from creating a system like that? 

Mike Koelzer, Host: We've been talking about value, being the incentive for doctors. As they come across this, let's just pretend there's like an Amazon rating in there, you know, four, four or five star or something like that. Where do things like, you know, the sales rep just came in and kind of made their day or took them to lunch or whatever sales reps are allowed to do nowadays.

You know, I don't think they can go to baseball games anymore, things like that. But how do you disincentivize the incentives that may be. Popular years ago, is there a way to like force those 

Carm Huntress: incentives? I really would say like a lot of that stuff has gone away. You know, I think pharma reps and, you know, I think a lot of that is, is not a big of an issue.

Gotcha. I think what you're really pointing out, that's very hard, right. Is kind of this clinical versus V you know, cost discussion. Right. And the complexity of rationalizing that is very hard. Um, gotcha. You know, the, and I think we're still in the early stages. We had done a lot in the earlier years of the company.

We did a lot of clinical decision support solutions. We did work on antibiotics. Uh, we did work in congestive heart failure. We did work in actual pharmacogenomics in the mental health space and we experimented a little bit around a lot of things. It's a very hard thing to rationalize. I think doctors are actually a little bit more adamant in the clinic.

Piece, you know, in sort of their training and what they want to pick. Um, you know, when we moved into costs, it actually got a little bit easier. Cause the doctors less, Hey, I know these drugs, oh, this is the cheapest one. I'm okay with that. Right. Opposed to ones that are kind of okay with already. Yeah. And so there is this going to like have to be, um, I think a great rationalization, especially as we dig into the value between okay.

You know, here's the, you know, there could be something actually a lot more expensive, but that's a hell of a lot more beneficial to the patient, um, versus sort of the, the cheapest option in front of the patient. Um, and the doctor. And so, you know, these are things that I hope someday we get into sort of doing that sort of gross comparison of, okay, here's the measured clinical benefit and here's sort of the cost options.

How do we rationalize those two together today? We're really rooted in cost. And there's, you know, I think our challenges are so much, if you think about it, you know, we're running. Tens of millions of these transactions a year now, but you have to remember there's 6.3 billion or 6.5 billion, something like that.

Over 6 billion, uh, drugs prescribed each year to patients. We're not even in a, you know, we're on the tip of a very, very long iceberg in terms of, you know, my view, which is we've got to get this information everywhere at every point of prescription decision, helping doctors, helping pharmacists, um, helping everybody make better decisions.

Um, and we've got a long way to go just on the cost and creating that visibility. And then you can start to sort of say, okay, once I've got that, that footprint established and have that reach, then let's start to look at some of these other clinical things. And I think it's going to be interesting how that [01:05:00] will come about.

We've had discussions, for instance, just, um, a good example of. One way we might do this lightly in the future is just sort of look at, Hey, we know this patient's already taken this drug. Why are we going to show this as an, as an alternative to the doc? Let's just eliminate that because they've already, you know, they've already been on that drug and it didn't work or they, they switched.

So let's, let's not waste their time or the doctor's time around that. That's a light entry point into clinical decision support to guide better. Decision-making that kind of marries clinical and cost, but you get into much more complex things like, you know, recommending, um, you know, therapy for type two diabetics, much harder or congestive heart failure, where you need an ACE and ARB and beta blocker sort of combo package.

Uh, those are really hard clinical decisions, um, that take a lot of training to understand. Um, but I hope someday to rationalize it also points out why we shouldn't let doctors sort of do this wholeheartedly. If you look at like the type two diabetic guidelines, it's like 160 pages. It's insane to keep up to date on it, understand, and there's all these decision trees and it's super complex.

Um, asking a doctor. Did you do that? An endocrinologist is incredibly hard, but asking. Even teaching computers is really hard to do. That's a very, very hard endeavor. Um, and so, uh, I believe there's a future for that, but we're still going to a lot of iteration to get to that job security and future, I guess you could say that.

I mean, look, it's this, it's this whole thing that we've got to get to kind of what you said. And I think you're right. It's like the Amazon way of doing this, which would be, Hey, we've looked at all the options. Here's the best sort of. Right. Uh, both from a clinical and cost perspective. Now you have a rational discussion with the patient and be empathetic with the patient and find what the best treatment path is.

There's also this really big argument, right? That a drug might not be the right option. We're now seeing right. You know, express scripts just started this thing of a digital therapeutic right. It's an app, right? Is the bet that, you know, you're terrible at taking. Medications, you have bad side effects, maybe that's, you know, your drug of choice is an 

Mike Koelzer, Host: app.

It might say drug, a drug B app, and then four is starting apples instead of milkshakes or something like that. It's like, make sure you don't have that one for me. 

Carm Huntress: And it's going to be interesting. I mean, we're also getting into this world of curative. I mean, if you look at what's happening in gene editing and CRISPR and for sure, and that future, right, there's also this whole sort of future endeavor here where we're going to be in a more curative healthcare environment, a very expensive one, by the way.

I don't, I'm worried about the costs that are of some of these therapies, but, um, you know, that's also going to be a challenge coming up here in terms of rationalizing some of these curative, you know, look what we've, you know, Sovaldi was an incredible drug for Hep C it's, uh, it's literally eliminating.

You know, it's now gone, but it took a huge amount, you know, tens of billions, of dollars of, uh, cost on payers and patients to, to get that therapy out at scale and, and, and do it, but it was curative. And it's been incredible in terms of what it's done in terms of quality of life for those patients and not having to be sure.

Transplants. We're now seeing early work in sickle cell anemia. And that work with CRISPR is incredible and basically curing patients of sickle cell. And so I think it's going to be an interesting future, um, as these really amazing therapies continue to come to market 

Mike Koelzer, Host: to think that the doctors right now have to really think all this through in terms of ethics and medicine and all that, when a new thing comes out, I mean, that could take years, even if you had a sabbatical.

Yeah. You couldn't come up with all your own thoughts as a doctor of where you should be uncertain. I guess a lot of that has probably been taken away. You're not really always starting with a blank slate. I mean, part of it is what insurance are you on and what five drugs have they already done? You're making a choice now on maybe five things, not on maybe a hundred different things.

So you've already had some of that taken away from you as a company. 

Carm Huntress: Yeah, in a positive way. And that's really the, what we're trying to do right, is slowly sort of narrow this, this viewpoint down to what's, what's kind of reasonable and acceptable for the patient from a cost perspective. And then letting the providers sort of take that final step of choice.

And that was sort of that idea of informed autonomy that I was talking to, that we really have to get to. And, and I think to your point, like, look at medical information, it's now doubling like something like every 30 days, right? The amount of information and medical information, the acceleration that we're seeing is not, again, I think we're, we're doing a really unhealthy thing with providers instead of honoring the profession.

Like I think we should be in as much as we should because it's a very noble profession. Yeah, we're putting this undue pressure on doctors to be God's right. To know an incredible amount of information and continuously update against, you know, at least in the, you know, this last year of COVID and insane clinical schedule, which would never enable you the time to take a [01:10:00] sabbatical and do that learning and education.

And so, you know, again, this is where we need computers and technologies supporting that, um, helping, um, you know, helping inform the doctor and educate the doctor. And what's so interesting is I really think some of these, uh, the way to approach some of these things is. In the guidance, right? There's micro learning events that you can enable with a doctor to improve their cognitive understanding of why those things are being recommended and what are the latest guidelines, right?

And so you can create these, these, this is a band back to that personalization, right? Where not only am I helping guide the doctor to the right decision, I'm educating with micro learning events along the decision-making path to make them a better 

Mike Koelzer, Host: doctor. The little click of a, helped me a little clicker, just a sentence long, right?

Carm Huntress: Or a tool tip, right. Or they can go off and look at the study and, and that's happening in there. So now we've got a learning system, guiding their decisions, making them better. Doctor that's really approachable, great technology. And it's always there. If they want to look at it, they can, if they have an extra minute, they can have a look at it.

If they don't want to, they can, you know, ignore it for them. But, we're embedding that knowledge into the software itself and personalizing it to the doctor and knowing where the. Yeah. And that's really the future. I'm hoping for, you know, where we don't sort of have this expectation. Okay. You know, go home every night and weekend and read the latest journal, you know, it's just not a, and then you have to do all your documentation off hours and it's this endless, crazy, uh, you know, uh, really painful future.

You know, I think I'm hoping, you know, there was this big, uh, report that just came out that, you know, this year, this has been a record year for people applying for medical school and wanting to become doctors. And I think the pandemic has really woken up a lot of doctors to this, a lot of people to the profession of medicine.

I really wish for a future, you know, how cool it would be to, um, be a doctor with these AI agents, you know, and the, you know, EHR kind of working with you to support patients and do analysis and. Being a really helpful partner. Um, you know, I was just, um, uh, UC health is running a study right now in, in, in the GI clinic.

Uh, and it's incredible. The doctors over there have a, well, they're doing colonoscopies in real time. They can actually have an AI agent that's working with the doctor and they've fed millions of images of polyps to the AI agent. And it can in just by looking at the polyp, no, if it's non-cancerous or cancerous and what stage it's at, and, and the doctor has to commit.

Because the doctors build up the same mental model over years and years of doing this, where they can look at a polyp and have this determination, but now they have an AI agent. And I was, you know, talking to the doctor about this. And I said, well, what does this mean? And she said, well, you know, this could be a future where we actually don't take out the polyps because the, and there's no biopsies needed anymore.

And I just, my head said, you're going to get, you know, this AI agent now, just by looking at this thing can understand this. And it's not today. It's already like 95% accurate, it's got an incredible accuracy score. Um, just by looking at the physical, you know, the picture of it literally, and, you know, you think of a future with no biopsy, the results come faster.

They might change the standard of care from, you know, removing this stuff and just leaving the benigns ones. Cause it's less of a, um, an effect on your, your guts. Um, and, and it's just amazing when you start to think about some of this stuff and how it's going to be there alongside the doctor to support them.

And then. It's so fascinating. So I think there's just a lot of excitement and a lot of really good things coming, but we've got to do it in the right ways, right? This can't be burdensome. This can't be about a heavier cognitive load about the doctor. This can't be about more clicks and more time treating the computer versus the patient.

Mike Koelzer, Host: Really it's like, what can we bring down to almost make it like a simple app? You know, once it's that easy people can get the hang of. 

Carm Huntress: Yeah. And, and, and again, you know, that's the future that I think we all need to aspire to. Um, and, uh, we've got to get over these stigmas of doctors saying doctors hate technology, and that's just not true.

And I think we really can be much more thoughtful stewards of bringing them really phenomenally good technology that enables them. And I think a lot more, I'd love to see more startups working on this, especially provider facing tools and products. Um, but I also think it's real. Um, we were lucky as a company, we got sort of health system investors behind us, and we're very, um, uh, uh, closely partnered with them where, you know, I had my staff and my team members, including myself in shadowing doctors, because it takes a long time to understand how doctors work and what's their workflow and how they interact with [01:15:00] patients and how they think it's not conventional.

Right. It's not the way you and I would approach this stuff. It's just the way medicine has evolved. And I think we need more time really, that hands-on kind of in, in their day to day. And I think it's given us a unique, it's a strategic advantage in my mind for us as a company, to be able to have that engagement and being side-by-side with, with doctors, I'm excited to get back to it cause we've been taken away from it, uh, for, for over a year.

Now we're getting really close to getting back to it and I'm looking forward to that. Um, that future as a, as a, uh, company where we're back in clinics, really supporting doctors to make the best decisions. 

Mike Koelzer, Host: Well, Carl, thanks for your time. I wish that we had time to go through your whole business because it sounds fascinating, but we got stuck just on the problem that you're solving.

So maybe someday we'll be able to learn about what goes on behind the closed doors of your 60 member team. But anyways, karma, so fascinating. Keep up the great work and best wishes you're doing wonders with that transparency. And that's what our profession is as pharmacists we're really striving for and hoping for the simplicity and transparency to make up for the smoke and mirrors that the opaque PBMs have laid down.

So anything you guys do in that regard, we're big supporters. 

Carm Huntress: Yeah, well, I am, uh, so excited about the work we do every day at our extra view and bringing real-time costs and benefit data to the point of care and just the difference we're making in providers lives and ultimately patients lives.

So thanks so much for having me and look forward to being on again soon. All 

Mike Koelzer, Host: right, karma, keep it up. Talk to you soon. Bye.