The Power of Speaking to 20,000 People About PBMs | Benjamin Jolley, PharmD  Apex Pharmacy Consulting

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Mike Koelzer: Benjamin, introduce yourself to our listeners.

Benjamin Jolley: Benjamin Jolly third generation pharmacist, senior fellow, healthcare policy at the American Economic Liberties Project, founder and consultant at, apex Pharmacy Consulting. I saw that you spoke to 20,000 people a little bit ago. That

Mike Koelzer: kind of interesting. I gotta tell you though, you gotta come up with more info for us here today because it's longer than you spoke for and we're not, I. Saving room for the applause and the booze whenever you bring up the PBMs and things like that.

So 20,000 people. I know you've spoken to, like maybe some of us have a hundred or 300 at a convention or something like that. does it twist you around a little bit for 20,000 or is it just like, yeah, you're up on the podium and you do your same

thing?​

Benjamin Jolley: It's a totally different experience. speaking in front of a friendly crowd of pharmacists at a CE is, good, you know,

Speaking in front of a friendly crowd of 20,000 Bernie fans is a totally different experience. The energy from 20,000 people in a stadium setting that has just been amped up by a couple of bands that are loud, is a very, very different experience.

if you ever want to feel a sense of. Power control and hubris, just go speak in front of 20,000 people, 

Mike Koelzer: Power you

Benjamin Jolley: oh yeah, no, it, it's absolutely a power trip to, to, it's absolutely a power trip to say I work at the oldest pharmacy in Salt Lake City. Jolly's, compounding pharmacy.

Yeah. Jolly's. And there's this other company called CVS.

people boo and cheer at the right times.

Mike Koelzer: thinking nerves, but that soon flipped over. Kind of seeing your face here, it soon flipped over to say, wait. That's energy that you're getting from this group.

Benjamin Jolley: Oh yeah. I mean there's definitely both, right? Like when I got up on the stage it was kind of like, holy crap, what is happening?

like, also my neighbor had just introduced me and everyone was cheering as I went on the stage. It's a friendly crowd, right? If everyone was booing when I went on the stage, that would've been also, again, a very different experience . 

Mike Koelzer: There you go. 

Benjamin Jolley: But yeah, it was awesome.

Mike Koelzer: I won't dignify the name, but let's say you have a leader of a country and you're not fond of them. I'm talking back in history, you're not fond of what they came up with. And a lot of people blame the leader and probably rightfully so, but what people can't forget is that this leader is up there and they can say sentences.

They can go this way with a sentence and that way with a sentence. Well, if this one gets a cheer, now all of a sudden, hey, that's the direction the crowd wants to go. And then if they say this and it gets a boo, probably not a boo, but probably just a, you know, not much going, they're like, Hmm, I'm going to talk more about this other thing.

Well, you multiply that by, you know, hundreds of rallies and pretty soon you've got the crowd going, but that's because they've sort of told you what they want to hear.

​

Benjamin Jolley: Yes. I mean, absolutely. Yes. I've heard some politicians, contemporarily and also like, you know, Hitler for example, described, um, as like.

Mike Koelzer: wanna say it. I was talking about Hitler. I'll right

Benjamin Jolley: Okay.

Mike Koelzer: You, you dragged him outta me.

Benjamin Jolley: Okay, fine. I've heard the process of Hitler developing his ideas is not dissimilar from how chat GPT works, which is Chad GBT, just intakes the entire contents of the internet, what everyone says, and then spits out.

Like you, you, you say something, then it spits out a plausible response based on what it has seen on the internet related to that issue. and then it goes through a process of, what's called reinforcement learning with human feedback, where you basically have it talk to human employees and have them say, this is a good thing, this is a bad thing.

The humans in the context of chat, GBT are trying to produce a relatively docile, helpful, harmless, persona. Right. And so they are downgrading Nazi propaganda. They're downgrading, racist slurs. , And they're trying to 

Reinforce behavior where you have a helpful persona and so forth. That's exactly what, speaking in front of a crowd and hearing the booze and cheers is And so if you're Hitler, you go in, in front of a crowd and you say things, 

you just, you know, say all sorts of things and then the ones that people cheer at you say more of,

I definitely had the sense of like, why people really become politicians and become the kind of person that wants to just do this all the time. get it after having spoken in front of that crowd, it's like, oh, this can be a real power span.

Mike Koelzer: Absolutely. There's uh, psychiatrist. I'm thinking that I listen to him a little bit and he says that. He says, the audience will give you feedback. You're like, well, what do you mean feedback? And it's like he says he knows when he is really onto something.

We've been talking about cheering and so on. He knows he's really onto something. When the crowd goes quiet, when the crowd goes quiet, that's also feedback. my grandma, God rest her soul.

She's not fumbling in her purse for her lutens cough drop. And you know, people are not fidgeting and things like that. They're just dead still. And that's when you've hit on something too. 

Benjamin Jolley: Right. I mean, I had that experience when I was describing, I. My experience filling a prescription, building the Caremark.

I said, and this is an absolutely true story. we built it, I think it was actually a Lamotrigine actually. We built a 90 day supply of Lamotrigine for a patient. And the total allowed amount and reimbursement from the PBM was 35 cents.

They charge a transmission fee of 30 cents a claim. So our total payment is 5 cents. Like that's, that's it. and when I said that, the crowd went silent and was like riveted on me, I could tell.

 and then as I, like, like I'm not used to speaking, so I should have turned that into like a boo line or a cheer line, but like they were, they, they got it.

They understood what I was getting at. And so that was a, A really satisfying experience from that perspective.

Speaking in front of 20,000 people is a really cool experience. And what I was speaking about was that it really shouldn't be okay for CVS Caremark to be the same company as CVS pharmacy.

Right. Like that's just, it's just screwed up, right? Like, why is it that 30% of the prescriptions I dispense, I am paid by my largest competitor? In what context is it okay for that to be a thing? And that, that's taking it from my perspective, 

It's still really screwed up. It's like. Okay. I am JP Morgan Chase. I'm going to hire CVS Caremark as my PBM, and I'm going to trust them to reduce drug prices for me. They're also a pharmacy that wants to be paid as much as possible for drugs,

and JP Morgan is actually currently being sued by some of their employees for, Letting CVS basically screw their plan. They specifically cite a case of an MS drug called abiraterone, where CVS pays CVS specialty pharmacy. $6,229 for a month's supply of this medicine, if I remember the numbers right.

And that drug is apparently available from Rite Aid Pharmacy for $32 and 19 cents. and so it's like, why are you wasting our money in this way? To me, the concept that I'm paid. 5 cents net for a prescription and they pay themselves 6,000 for a prescription above cost is, it's the same issue,

Basically if I am a PBM and I'm a pharmacy, my strategy to. Extract money from people is going to be, I'm going to push down the price on commonly prescribed drugs, and then push up the price of rarely prescribed drugs, and then make sure that I fill all of the rarely prescribed drugs at my own pharmacy.

And thereby I can say I'm lowering prices overall for the plan because I've pushed the commonly prescribed drug so far down that it offsets the amount that I'm. Charging over cost. And so the trend will look good, but I am basically driving all of my competitors out of business and extracting an enormous, toll from that employee health plan,

like six grand a month for one drug.

that should cost 30. That's a lot right?

Mike Koelzer: Benjamin, we had spoken before and, you are saying, alright, it's one thing if the world knows about. Pharmacy monopolies and so on, rather than the PBM monopolies. But to really make this thing stick in DC we gotta talk about chicken monopolies and monopolies on this and maybe monopolies even on monopoly games, whatever, you know, I mean, it's,

Benjamin Jolley: Sure.

Mike Koelzer: across the board.

 When you are at a crowd like this, I know it was in Utah, I know, you know Bernie Sanders was there. I'm, I'm thinking it was more than just pharmacy, more than just monopolies.

Benjamin Jolley: Yeah.

Mike Koelzer: When you bring up pharmacy, do people know what the hell you're talking about, number one and number two is that a popular point as far as monopolies go? Or do people know A, B, C, and D, all these popular monopolies. Let's say in the past it was the phone company and all that, and all of a sudden you throw in PBMs and they're like, whoa, what?

or is PBM kind of the poster child when there's these monopoly talks going on?

Benjamin Jolley: to start with, almost every person in America, Goes to a pharmacy at least once a year. It's something like 90% of the country has a prescription filled at least once a year. Something like half of people are on chronic medicine. and so the issue of the pharmacy benefit manager vertically integrated monopoly is something that.

Every single person in the country has at least some degree of interaction with. The people who are most affected by this are the people who are taking those rare drugs that get crazy marked up, or people who have a pharmacy that succumbed to the low reimbursements.

But every single person has interaction with this at least some time in their life. and probably at least once a year. I think that it's a relatively popular monopoly too. Get to because people do have interaction with it in their life.

 It's not nearly as obvious as Google, which everybody interacts with every single day, basically. if you go on the internet and you see an ad, you've seen Google, that's how big they are. Or Facebook. meta

is also like, those are both suits that are. Ongoing. Right now meta is being used.

Google has lost twice, monopolization cases, and they're currently debating what to do about it. Apple has lost a monopolization case. so like the big tech people have mostly been targeted, which makes sense because they are. Platforms that affect everybody in the whole country.

But healthcare, I think, is probably the next big priority area because it does affect almost everybody, not as intimately as I do. If you're a Joe Schmo, you don't see thousands of transactions that, and, and you can't see the pattern, but 

You see the effect of small businesses in your community closing. I mean, you see Rite Aid closing, they're going bankrupt and selling 60% of their pharmacies to CVS.

Mike Koelzer: And I always say the problem with, well, there's a couple things. The problems with the reimbursement, and most of our listeners will know this, but, with, with the PBMs, because of this monopoly and, I've been beating some of the listeners to the punch of, why don't you just get outta these contracts?

Well, for most people, this is 30% of your income with each of these big PBMs, and there's contractual language where you gotta. Take everything and so on. So, you look at our pharmacy, we're down to, I got rid of the brand name. We're just doing generics. My staff is like razor thin. I don't even answer the phone anymore.

It's on this messaging system where the customers leave a message and all this stuff. I'm working with like, one to two employees sometimes, and it's heaven. Compared to the past where I once had 40 people running around and in, in the DIRs you were, you were losing money on this. If the world sees 40 employees at our pharmacy and you're managing 40 employees, everybody thinks it's successful and you don't have any time to look and say this can't be successful. on the customer side, they're getting pretty good service and there's a million people there And. Pharmacists have a big heart, so they continue to do things even though they're not getting paid for it, partly because they have to, partly because of their big heart. But then all of a sudden, the next day, the store's not there anymore. And, and people think, well, that's probably mismanagement by old Kelzer, but now the RiteAid aren't there, and now some of the other ones aren't there.

And so that's the problem with these pharmacy deserts is people don't see it coming. it just drops off a cliff because of big hearts and PBMs setting it up. So nobody can really pay attention to this until it's too late.

Benjamin Jolley: Absolutely, I definitely did not see it coming. the closure of Intermountain retail pharmacies in Salt Lake throughout Utah. That was 25 pharmacies gone

in like a month.

and that was a big deal. they sold their records to CVS, of course, 'cause they're a buyer, which is like a whole other layer to this.

The thing to me is like, that happened five, six years ago now. It's been a while. and Intermountain hasn't done anything with the space where the pharmacy used to be. So there's just this empty husk, like you can see the pharmacy shelving still sitting there,

Mike Koelzer: I heard you mention that in your talk. 

Benjamin Jolley: 

Every time I walk into an Intermountain clinic, which I get a good fraction of my healthcare from Intermountain because they're a couple blocks from my house, but every time I walk into the clinic, it's like, oh. That's sad 'cause the pharmacy was located right at the front of the business so that you would get there as you're walking outta the building or as you're walking in.

but it's just really sad to see that there's still nothing done with that space. Instead, 

Mike Koelzer: And Benjamin here, here's what gets me, I'm gonna go back to talking about meta and Google and that. But all this happens. And then you get the brokers coming and talking to the local businesses of, you know, three or 400 employees, and it's like, well, we had nothing to do with that.

We're not associated with that. And so things are closing and the brokers have a big smile on their faces and they're still. Shoving stuff down the company's throats, unbeknownst to them. And then here's the one I don't like my grandma, well, like this is my other grandma.

I think I already bought my first grandma. This is my second grandma. But she used to say, whenever she sees something bad on tv, she said, you know what? They ought to string them up by their toes and let everybody take a whack at 'em. You know, I mean, that's pretty good stuff there.

 My point is that no one gives a rat's ass until somebody ends up in jail. In my mind, I mean, what is Google Care or Facebook care about? They have a monopoly. Then they get, you know, not shut down, but moved around and pressed around.

So now you've got these stores closing down. The brokers are smiling their way to the bank saying, Hey, you know, this isn't us. It's, you know. 80 companies removed, and then you got no one going to jail on the other side. And so they can do all the shenanigans they want to. Michigan had all these PBM laws, but no one's got the guts, in my opinion, to shut down one of these PBMs overnight because they're not following the rules. So while we're not gonna do that, but we'll find them, well that's back to my first problem about who cares if these companies are fine.

So it's kind of like that. Stringing 'em up by their toes and everybody taking a whack at 'em. That's the only solution I have to this Benjamin.

Benjamin Jolley: there's an old saying that, a fine is a price,

and so when you find someone, you're basically just saying that the government needs to be cut in on your scam

The fine is high enough that it's threatening to the business's continued existence.

Um, otherwise it's just saying, Hey, cut me in on your, on your scam. 

Mike Koelzer: It's the price of business. I

Benjamin Jolley: exactly,

Mike Koelzer: My dad years ago, I was probably 25 and this lady owed us 200 bucks. You know, I said, dad, I'm going down to her doorstep and I'm gonna pound on her door and give her what for that.

She owes us this and this and that. He's like, well, Mike, you can do that, but there's better things to focus on. It's a cost of business. It's part of your rent, it's part of your bill, it's, it's part of your electric bill, it's part of your, you know, trash bill, that kind of thing. So it's a cost of business to them. 

Benjamin Jolley: Oh, sure. I mean, on your topic, there's another fascinating saying that is, the optimal level of fraud is almost certainly not zero.

which is basically what your dad was saying, right? you extend people credit in an accounts receivable because you wanna drive sales, not because you fully expect to be paid. and so if you try to implement a system where, you have zero fraud. You're never going to extend Mrs. Jones credit and have her owe you $200.

You want to be a little loose, look away a little bit, give a little bit of freedom to people. 'cause if you clenched it down too hard, you wouldn't have any sales unless you had cash right there. Or You gotta get rid of all the credit card scans. You gotta get rid of everything but then your sales drop 90% because it's too hard to do business with you,

right, which is, a fascinating, 

I

Mike Koelzer: Saying and making you think a lot, which that, that it's from a blog that I read called Bits About Money. What finally forces a company, I suppose, know, the FTC breaking up something. I mean, how do you go about it? Making these laws work when people are afraid to enforce them. The companies don't care because the fine is the cost of business and the brokers are smiling and not really explaining what's happening and why. the stores around you are closing and things like that. You can do all this work on the front side, but if there's no power on the backside. Where does blank finally hit the fan?

Benjamin Jolley: when I was giving my speech, I gave another example of being paid a low amount by A PBM and the PBM in question was OptumRx which is a division of United Healthcare and. That was one of the moments where I started to be scared of large crowds. don't say United Healthcare in front of large crowds unless you want them to be very angry.

Mike Koelzer: At UnitedHealthcare.

Benjamin Jolley: yes. Um, but, um, the, uh. When I said the PBM division of UnitedHealthcare, the crowd started flipping double birds, started yelling free Luigi, and started yelling a variety of other things. so unfortunately if justice isn't served, by fines and by. Breakups. And by behavioral modification, sometimes people take things into their own hands.

That is one potential thing. And so I think like from a, I don't want to live in a world where we have a hundred Luigi Mangione running around.

is a frightening world to me.The guy had a point, I don't think that his actions were the right choices, but he, he was expressing an anger that apparently from the, you know, response from people yelling that, apparently is broadly held that, the actions of UnitedHealthcare are not acceptable actions in the public.

This last week, there was a Senate Judiciary committee hearing about PBMs. And, it's a phenomenal watch. If you want to see several senators sing from the same hymn book as me. but, anyway, Cory Booker described the. Actions of PBMs. He said, my Republican colleagues call this a scam.

I say it's corporate violence against the American people. And I think that that is really cogent language. It's not just united, right? To be clear. United is an archetype. They are the most well known of the companies that operate vertically integrated, physician insurer, PBM pharmacy operations, but they're not the only one.

And I think that business model as a whole is just immoral and wrong. you should not be able to be on both sides of a transaction like that. If you are in charge of bringing down the prices paid to pharmacies, you should not be able to be a pharmacy. If you're in charge of managing people's money to pay physicians and hospitals, you shouldn't be allowed to be a hospital or a physician like that is.

To me, that is pretty basic. Uh, common law stuff. We don't allow real estate brokers to be seller's agents and buyer's agents.

In the limited circumstances where like that happens, everybody in the transaction has to know this is what's going on. You need to know and you may want to go get another broker.

Right.

Mike Koelzer: alluded to this psychiatrist earlier in, in a, one of his. thoughts if you stifle freedom of speech and what's left is violence freedom of speech is not just not being able to say what's on your mind. But it's also when you've said what's on your mind, you actually have judges agreeing with you and then that speech slash enforcement is stifled. you're leaving violence and then. again, you have to have the disclaimer that we're not for Luigi, you know? What was his name? Luigi. Luigi.

Luigi Mangione. Chuck Mani is my favorite, so I don't get, you know, Chuck Mani.

He's a jazz guy, but just phenomenal.

I gotta give my listeners a tip here. This is a public service announcement here, , Benjamin, about,, Chuck. Man. It's just

Benjamin Jolley: All right.

Mike Koelzer: or orchestrated, jazz. You don't find it anywhere. So to my listeners, check that

Benjamin Jolley: noted. 

Mike Koelzer: You get a guy or a gal whose 4-year-old just died because the insurance isn't responding to this and that.

I mean, that's no longer like violence for them. That's like, justice, you know, whatever. I'm not condoning that, of course, but it's on a different level when a company's responsible for letting your child live.

Benjamin Jolley: I mean, there's actually a whole, Cory Dau wrote a fictional piece about exactly what you're describing. I don't recall the name of it, but if you look up, Cory Dau and like F Cancer, I think,

 He describes this, the situation where this, A guy, his wife is diagnosed with cancer and to cope, he goes on this online message board, of men whose wives or children have had cancer.

And it, it's like the name of it is like this, crass, like F cancer basically. I don't remember the whole bit. But anyway, this group Will have these conversations of how to cope with this and so forth. But then, eventually and several times someone will bring up insurance executives denying care and will, describe what should be done.

They should be strung up or whatever. And then eventually in the context of this fictional story, they will radicalize the, the, the various members of this group will radicalize and go, like, blow themselves up in an insurance executives, like in an insurance building or something. and like this becomes just a string of terrorist attacks, in the context of this thing.

And eventually it becomes. The basis for a law, to prohibit the kind of behavior that really, really frustrates people when they deal with insurance.

but that's like the climax of the story. But the short version is like people, if you give them no other option,

the turn to violence eventually, which is, which is frightening.

I want to live in a world where we solve these problems through the political process.

I think that there are good ways to do that. Elizabeth Warren and Josh Hawley and Jake Cloths and Diana Harshbarger have introduced the pharma, patients before monopolies Act, PBM Act, which I think solves a big piece of this.

It just says, if you're a PBM, you can't own a pharmacy. If you're a pharmacy, you can't own a PBM. Which I think solves a lot of them, it doesn't solve all of it, right. But I think that a broader bill than just that is necessary. That's good for pharmacy, but I think that we need the same thing in the doctor space too.

Like you shouldn't be able to be Optum, the medical clinic being owned by UnitedHealth Group that owns United Healthcare, the largest insurer, that shouldn't be a thing 

Mike Koelzer: you

 thousands of doctors that are employed by them 

Benjamin Jolley: Right. And there's evidence that I've seen, at least allegations, that they pay their clinics substantially more than competitor clinics.

Just like they pay their own pharmacies. I know this for a fact, substantially more than they pay my pharmacy.

and so it's like I. That's screwed up by itself. There was a great piece put out by, more Perfect Union recently about, Oregon Medical Clinic. That's this clinic in Oregon that got bought by Optum and Care plummeted.

They discharged thousands of people from the clinic, if I understood correctly. Anyway, that is just evidence to me that corporate practice of medicine laws need a rebirth, and need to prohibit the practice of basically UnitedHealth Group owning physician offices.

Mike Koelzer: Benjamin, what do you know about the Arkansas law that came down? Is that similar? Is I, I didn't

Benjamin Jolley: It is.

Mike Koelzer: through it, but it seems to be covering some of this stuff.

Benjamin Jolley: I feel like, at least in the week after I gave my speech, this was in April, I gave a speech on Sunday. On Monday after I gave my speech, 39 State Attorneys General sent a letter to Congress saying, please pass. The Patients Before Monopolies Act a bill that prohibits PBMs from owning pharmacies On Wednesday, governor Sarah Huckabee Sanders in Arkansas signed into Law House Bill 1150, which prohibits the State Board of Pharmacy from issuing pharmacy licenses to entities owned by PBMs.

It gives the state board till January to identify all such pharmacies and give them notice that their licenses will be rescinded, 90 days before the year ends. So that's September, the end of September. They have to give them notice. Those pharmacies then have to wind down operations and tell all their patients.

It does have A longer period of compliance for pharmacies that dispense drugs that would be otherwise orphaned. rarely dispensed. specifically for pharmacies that are the only pharmacy that dispenses a given drug,

they get one more year. to have a license, which makes sense because you don't want to pay people to not be able to get their drugs right.

I know people personally that take a rare drug called Xyrem, um, the date rape drug for narcolepsy. but it is currently only available from one pharmacy in the entire country called ACCredo Specialty Pharmacy owned by Express Scripts,

Would be locked out of being able to have a license

Arkansas.

so they get one more year, which really gives the manufacturer time to figure out how they're going to be able to supply that drug in the state. which means they have to figure out another pharmacy inside of Arkansas probably. 

Mike Koelzer: Benjamin what is your blog and. How exactly can listeners sign up for it

Benjamin Jolley: sure. I write a substack, it's benjamin jolly.substack.com. I write there occasionally, sometimes three times in a week, sometimes not for six months. If you go there, I have written extensively about the patient's Perform Monopolies Act. I've written about, 

Weird drug pricing stuff. the changes to the Medicare drug benefit under the inflation reduction act. Whole bunch of stuff. I call it the ramblings of a pharmacist because that's what I do, I ramble about things. I am pretty proud of my work there. I think that my work there has actually led to multiple interviews with you.

I wrote an article and you're like, Hey, let's,

Mike Koelzer: Ah, absolutely.

Benjamin Jolley: I recommend reading my blog. It's currently free. I may someday try to take it. people can always pledge and say, Hey. I think you're worth paying for. I've got a couple dozen people that have said, Hey, I'll, I'm willing to pay.

It doesn't take payments unless I turn on payments and say, yeah, I'm gonna start charging people for my blog. but anyway, that's my blog. happy to have anyone that's listening to this read it. but yeah, we need to pass the Patients Before Monopolies Act is the short version of this entire episode.

Mike Koelzer: That's a good sign. You got people paying. I don't, and in fact, I got some people that said they'd pay me just to shut things down. 

Benjamin Jolley: No one is paying me right now. 

Mike Koelzer: They're

Benjamin Jolley: They've said I'm willing to pay,

but no one's paying me right now.

Mike Koelzer: reminds me of, who was it? Louis CK said he was so proud of himself because he was sitting first class in a flight, and a service person got on and he thought about giving his seat up to this army gentleman.

He said, I didn't do it. I was just really proud of myself for thinking about it. Benjamin, can't thank you enough for joining us. I know you're busy as hell. I appreciate our listeners. Appreciate it. Great talking to you. Looking forward to next time.

Benjamin Jolley: Hey. Thanks Mike. Have a great day.