Name: Former Pharma Rep on Health Insurance Corruption and Pharmacies
Uploaded: 2023-12-27T18:06:52.000Z
Description: Watch the stand-up comedy video 'Former Pharma Rep on Health Insurance Corruption and Pharmacies' from PowerfulJRE on Comedy Buff. Published 2023-12-27. Transcript available.

Watch the stand-up comedy video 'Former Pharma Rep on Health Insurance Corruption and Pharmacies' from PowerfulJRE on Comedy Buff. Published 2023-12-27. Transcript available.

the Joe Rogan experience Huberman gets into all that academia there's tons of
studies on this so and all I think the main reason it's not adopted more often
is they're just in the insurance model right they they use the tool that's in
their tool belt and if that's not a tool in my tool belt that I'm not going to
talk about it and I don't have time to do it and and that's where I see large
language models and an evolving market allowing patients to get that education
on their own they don't have to wait to talk to a doctor right I will have a
team of academics right there at your fingertips proactively analyzing
everything about you and I would tell you another I talked about predictive
proactive personalized all that another one would be private private you do not
want this data in the hands of insurance companies listen to what Gary Brekka
was
telling you he worked for the big insurance companies he worked to assess
your all-cause mortality risk and the risk profile to the insurance company
right and
so if you if let's just say in a in a miracle world all the sudden blue cross
blue shield rolls out a large language model to streamline your experience and
they want to tie into your wearables the last person you want digging through
your
underwear drawer is the insurance company because they're going to use it to
limit
your care to limit what they cover and to kick you off a plan right they're
going
to know when the chronic disease is coming and they're going to charge you when
they
know they can monetize you and then as soon as you reach a state where they can't
and
and that's the dangerous side of these large language models and that's the
dangerous side of
the tool and so a sword in the right hands is you know one thing and a sword in
the wrong hands is a whole
another thing jesus i wonder if they are trying to do that i wonder if these
insurance companies are
oh they're for sure going to roll that out yeah if they're not already and that's
the problem like when you have an insurance based model and that's where i
would tell you maintain the car outside of the system right and the insurance
based large language models are going to ensure that you stay on these
treatments because that's where they're profitable correct so there's the
insurance company and then we broke this down last time then there's the
pharmacy benefit manager pharmacy benefit
language models are going to ensure that you stay on these treatments because
that's where they're
profitable correct so there's the insurance company and then we broke this down
last time
then there's the pharmacy benefit manager pharmacy benefit managers are a
middleman between the
insurance companies and big pharma okay and they were put in place to negotiate
the price of
pharmaceutical drugs for the average american because so many drugs were coming
into the
marketplace the government couldn't get to and decipher what drugs make sense
what drugs don't
make sense what should we cover what should we not cover so they allowed
pharmacy benefit managers to
do that within a decade the big insurance companies went out and acquired
pharmacy benefit managers
within a decade from that date the pharmacy benefit managers began to negotiate
rebates to themselves
not discounts to the patient okay so yeah that's that's where i was trying to
go with this when i
talked about 244 million in fraud um in the state of ohio how where's the fraud
and and the answer is
the margins are made in the mystery the more confusing the insurance companies
can make it and
the more condiluted they can make it the more profits they can make they have
only a handful of
levers they can pull to make money so let's go over that they can raise your
copay they can raise your
deductible they can raise your out-of-pocket expense that's one lever they can
drive down the price of
a drug that they buy at a wholesale price point they can mark up the coverage
of your care for your
employer okay and then they tier price all the pharmacy benefit manager gives a
tier pricing that tier pricing
is not based on what drug is best for you it is based on what drug is best for
their financials and so they
prioritize drugs in a tier pricing under the misnomer to the american people
that a tier one drug is the
best drug and a tier four drug is not as good right but the truth is a tier
four drug is not as profitable
because there's a lesser rebate and so so let's say let's go back to the
insulin example the average
price of this insulin is 381 is what the senate finance committee found 381 on
i can't remember if
it's sanofi i think was their uh was their price out of that the pharmaceutical
company got less than 40
so that remaining 200 something dollars stayed at the pharmacy benefit manager
okay pharmacy benefit managers are making billions upon billions of dollars a
year they decide what
gets covered what goes on your insurance plan what your copay is what your
deductible is and they can
move any lever at any time so examples let's go back to glp ones right the uh
the weight loss diabetes
medications those are showing up on insurance plans as tier four with a really
high price tag well you
look at that and you go man wouldn't insurance companies want to get rid of
that because it's
cost them a lot no because they're showing that the price of a glp one is
thirteen hundred dollars
they never paid thirteen hundred dollars they paid a fraction of that but then
they go to the patient
and they say hey this is a tier four drug you have a 50 copay on this drug 500
okay so they made their
money there they made their money off the rebate from big pharma then they come
patient pays more than
they actually are paying for the drug correct that is what happens on most
drugs and that is why i built a
compounding pharmacy and that's but even if they don't let's say it's a drug
that you think is covered
okay maybe they maybe the the pharmacy benefit manager got it wrong a drug
entered the market they
didn't know it was going to be a blockbuster they miss miss miscalculated how
this was going to play out
they have lever after lever they can pull okay high margin drugs they've gone
out and bought pharmacies
so they own mail order pharmacies and they so what they'll do like when i owned
a pharmacy blue cross
blue shield they literally said they owed me over a million dollars for one
month of shipping out drugs
i'd already shipped all the drugs to their patient i'd already done everything
they come in and say yeah
we're not going to pay you we don't think you collected the co-pays or deductibles
okay we did here's
all the records i can show you how soon can you get an auditor out we want to
cooperate like we're a small
company we need this money uh it's three months before we can get to you okay
and then they begin
to make it so hard for you to survive in their insurance model and then you'll
be sitting there
and a couple months later knock on the door hey man hurt is tough out there for
these small pharmacies
you know we're looking to acquire pharmacies just like you right they've gobbled
up the lifeblood of
america they've put all these small pharmacies out of business they now own
most of these big
juggernaut pharmacies so even if cvs says we only made ten dollars of that
prescription what did the
pharmacy benefit manager make okay or what is the pharmacy your mail order
pharmacy making lever after
lever after lever then the last part of it is my buddy who has ms he his his ms
treatment i think is
fourteen thousand dollars a month we just met i have 260 something employees
across both organizations
we met with the insurance company they're raising our rates because they claim
they paid fourteen
thousand dollars a month for his drug right he had a huge out-of-pocket burden
on that drug
but was happy because he thought well hey man it was going to be 14 and i only
had to pay x
and then they never paid the 14 because they negotiated a rebate on the back
end and then they
turn around and they mark up my insurance plan for all my employees every year
year after year
it is a profit driven system not a patient outcome driven system and so that's
that's all i'm trying to
hammer home with patients when you say why don't you take insurance because
insurance is the crux of the
problem you cannot operate in that ecosystem and provide quality care you can't
everything's controlled
everything's dictated it's it's it's terrible and most people have no
understanding or awareness of this
so there's no real push to fix this system there's no real push to regulate and
analyze
all these problems and what's the downstream effect of these problems yeah and
i even hear clinicians
talk a lot of clinicians don't know like a lot of clinicians don't even know
about pharmacy benefit
managers the the only reason i know is because i've been in every aspect of
this business and i've and
then i would get into it and i go oh oh god that's why that was happening okay
now i get it now i get
the magic trick i understand what you're doing here how you're moving and
shifting profits and monetizing
disease states so think about this if i can monetize your diabetes why would i
cure or prevent your
diabetes right and and i know if i'm a big wig at united or cigna that you're
going to switch jobs
in three years and by the time that diabetes leads to metabolic disease and a
cascade effect that puts you
in a hospital that costs me more money you're somebody else's problem or if i
can stall it long enough
you're the federal government's problem and so every aspect of health care is
focused on that quarter
on that day on on that time frame um another terrible example of surgery and
this is honest to god i talked
to my buddy who's a president at an orthopedic company he told me he was
sitting down with a surgery center
about joints and there's a new joint that they have and it's more expensive but
the efficacy data of the
long-term benefits on it astronomically outperform the other joint that this
hospital system was using
he sat down with the ceo of the hospital and he said here's the data uh five
years out here's what
we're seeing da da da da the ceo said i don't give a what happens five years
out swear to god he's this
is a call i had yesterday he said he looked me in the eye brigham and he said
if you told me that this joint
will last at least 90 days and it's cheaper that's all i care about oh my god
because all of their
data and records and accountability are only on the first 90 days once you're
out of that 90 day and
you've done your your little review and all that you're off again and you're no
longer a monetizable patient
and so too when we talk about primary cares and what's happened the same thing
with pharmacies where
they've been gobbled up by insurance companies if they're in the insurance
model is the same thing
that happened with primary care practices the day of a primary care being
independent and a free thinker
is over they're employed by hospital systems major conglomerates have gone out
and bought up the
primary care practice why because now they have the patient population if i can
get you at the primary
care level then i can control the referral of where that primary care sends you
as we profiteer off
your disease state okay so you go to a primary care let's say let's just walk
through the same example
i gave earlier a methylfolate test they never run that test right there's
genetics the methylfolate test
tells me my genetics but there's epigenetics the choices i make every day
impact which genes turn on
and which genes turn off if nobody ever has a conversation with me in my 30s
about my hormone
levels about getting into the sun about eating right and you push me towards
chronic disease because you
wrote me a prescription to treat a symptom and now i go through this system and
i get cancer
that primary care is going to refer me to an oncologist and that oncologist is
part of that
same system right and most people don't know this 65 percent of an oncologist's
income comes from
chemotherapy from the markup they're making off your chemotherapy 65 and i
attached that link jamie too
where it talks about this so all i'm getting at is russell brand said this and
he was spot on another
guy who's not a clinician but understood what's going on here if we make things
about profits and
quarterly earnings and big business and not patient outcomes don't be shocked
when we get phenomenal
quarterly earnings and piss poor patient outcomes 65 65 and i attached the link
just so we'd have it so
they have a financial incentive so this is an article where they were trying to
in uh the insurance
companies were trying to incentivize them to use a generic in this instance
because this is one of
those issues where there's no rebate in no way for the insurance company to
monetize it but it breaks
down how much money these guys 65 of an oncologist's income comes from that wow
this is incredible um
and and so i i say all this again because i don't think that a clinician's to
blame i don't think that
they're just operating in the system that they're given they're playing with
the playing field that's
been set before them and the rules of the game that have been set before them

Former Pharma Rep on Health Insurance Corruption and Pharmacies

the Joe Rogan experience Huberman gets into all that academia there's tons of
studies on this so and all I think the main reason it's not adopted more often
is they're just in the insurance model right they they use the tool that's in
their tool belt and if that's not a tool in my tool belt that I'm not going to
talk about it and I don't have time to do it and and that's where I see large
language models and an evolving market allowing patients to get that education
on their own they don't have to wait to talk to a doctor right I will have a
team of academics right there at your fingertips proactively analyzing
everything about you and I would tell you another I talked about predictive
proactive personalized all that another one would be private private you do not
want this data in the hands of insurance companies listen to what Gary Brekka
was
telling you he worked for the big insurance companies he worked to assess
your all-cause mortality risk and the risk profile to the insurance company
right and
so if you if let's just say in a in a miracle world all the sudden blue cross
blue shield rolls out a large language model to streamline your experience and
they want to tie into your wearables the last person you want digging through
your
underwear drawer is the insurance company because they're going to use it to
limit
your care to limit what they cover and to kick you off a plan right they're
going
to know when the chronic disease is coming and they're going to charge you when
they
know they can monetize you and then as soon as you reach a state where they can't
and
and that's the dangerous side of these large language models and that's the
dangerous side of
the tool and so a sword in the right hands is you know one thing and a sword in
the wrong hands is a whole
another thing jesus i wonder if they are trying to do that i wonder if these
insurance companies are
oh they're for sure going to roll that out yeah if they're not already and that's
the problem like when you have an insurance based model and that's where i
would tell you maintain the car outside of the system right and the insurance
based large language models are going to ensure that you stay on these
treatments because that's where they're profitable correct so there's the
insurance company and then we broke this down last time then there's the
pharmacy benefit manager pharmacy benefit
language models are going to ensure that you stay on these treatments because
that's where they're
profitable correct so there's the insurance company and then we broke this down
last time
then there's the pharmacy benefit manager pharmacy benefit managers are a
middleman between the
insurance companies and big pharma okay and they were put in place to negotiate
the price of
pharmaceutical drugs for the average american because so many drugs were coming
into the
marketplace the government couldn't get to and decipher what drugs make sense
what drugs don't
make sense what should we cover what should we not cover so they allowed
pharmacy benefit managers to
do that within a decade the big insurance companies went out and acquired
pharmacy benefit managers
within a decade from that date the pharmacy benefit managers began to negotiate
rebates to themselves
not discounts to the patient okay so yeah that's that's where i was trying to
go with this when i
talked about 244 million in fraud um in the state of ohio how where's the fraud
and and the answer is
the margins are made in the mystery the more confusing the insurance companies
can make it and
the more condiluted they can make it the more profits they can make they have
only a handful of
levers they can pull to make money so let's go over that they can raise your
copay they can raise your
deductible they can raise your out-of-pocket expense that's one lever they can
drive down the price of
a drug that they buy at a wholesale price point they can mark up the coverage
of your care for your
employer okay and then they tier price all the pharmacy benefit manager gives a
tier pricing that tier pricing
is not based on what drug is best for you it is based on what drug is best for
their financials and so they
prioritize drugs in a tier pricing under the misnomer to the american people
that a tier one drug is the
best drug and a tier four drug is not as good right but the truth is a tier
four drug is not as profitable
because there's a lesser rebate and so so let's say let's go back to the
insulin example the average
price of this insulin is 381 is what the senate finance committee found 381 on
i can't remember if
it's sanofi i think was their uh was their price out of that the pharmaceutical
company got less than 40
so that remaining 200 something dollars stayed at the pharmacy benefit manager
okay pharmacy benefit managers are making billions upon billions of dollars a
year they decide what
gets covered what goes on your insurance plan what your copay is what your
deductible is and they can
move any lever at any time so examples let's go back to glp ones right the uh
the weight loss diabetes
medications those are showing up on insurance plans as tier four with a really
high price tag well you
look at that and you go man wouldn't insurance companies want to get rid of
that because it's
cost them a lot no because they're showing that the price of a glp one is
thirteen hundred dollars
they never paid thirteen hundred dollars they paid a fraction of that but then
they go to the patient
and they say hey this is a tier four drug you have a 50 copay on this drug 500
okay so they made their
money there they made their money off the rebate from big pharma then they come
patient pays more than
they actually are paying for the drug correct that is what happens on most
drugs and that is why i built a
compounding pharmacy and that's but even if they don't let's say it's a drug
that you think is covered
okay maybe they maybe the the pharmacy benefit manager got it wrong a drug
entered the market they
didn't know it was going to be a blockbuster they miss miss miscalculated how
this was going to play out
they have lever after lever they can pull okay high margin drugs they've gone
out and bought pharmacies
so they own mail order pharmacies and they so what they'll do like when i owned
a pharmacy blue cross
blue shield they literally said they owed me over a million dollars for one
month of shipping out drugs
i'd already shipped all the drugs to their patient i'd already done everything
they come in and say yeah
we're not going to pay you we don't think you collected the co-pays or deductibles
okay we did here's
all the records i can show you how soon can you get an auditor out we want to
cooperate like we're a small
company we need this money uh it's three months before we can get to you okay
and then they begin
to make it so hard for you to survive in their insurance model and then you'll
be sitting there
and a couple months later knock on the door hey man hurt is tough out there for
these small pharmacies
you know we're looking to acquire pharmacies just like you right they've gobbled
up the lifeblood of
america they've put all these small pharmacies out of business they now own
most of these big
juggernaut pharmacies so even if cvs says we only made ten dollars of that
prescription what did the
pharmacy benefit manager make okay or what is the pharmacy your mail order
pharmacy making lever after
lever after lever then the last part of it is my buddy who has ms he his his ms
treatment i think is
fourteen thousand dollars a month we just met i have 260 something employees
across both organizations
we met with the insurance company they're raising our rates because they claim
they paid fourteen
thousand dollars a month for his drug right he had a huge out-of-pocket burden
on that drug
but was happy because he thought well hey man it was going to be 14 and i only
had to pay x
and then they never paid the 14 because they negotiated a rebate on the back
end and then they
turn around and they mark up my insurance plan for all my employees every year
year after year
it is a profit driven system not a patient outcome driven system and so that's
that's all i'm trying to
hammer home with patients when you say why don't you take insurance because
insurance is the crux of the
problem you cannot operate in that ecosystem and provide quality care you can't
everything's controlled
everything's dictated it's it's it's terrible and most people have no
understanding or awareness of this
so there's no real push to fix this system there's no real push to regulate and
analyze
all these problems and what's the downstream effect of these problems yeah and
i even hear clinicians
talk a lot of clinicians don't know like a lot of clinicians don't even know
about pharmacy benefit
managers the the only reason i know is because i've been in every aspect of
this business and i've and
then i would get into it and i go oh oh god that's why that was happening okay
now i get it now i get
the magic trick i understand what you're doing here how you're moving and
shifting profits and monetizing
disease states so think about this if i can monetize your diabetes why would i
cure or prevent your
diabetes right and and i know if i'm a big wig at united or cigna that you're
going to switch jobs
in three years and by the time that diabetes leads to metabolic disease and a
cascade effect that puts you
in a hospital that costs me more money you're somebody else's problem or if i
can stall it long enough
you're the federal government's problem and so every aspect of health care is
focused on that quarter
on that day on on that time frame um another terrible example of surgery and
this is honest to god i talked
to my buddy who's a president at an orthopedic company he told me he was
sitting down with a surgery center
about joints and there's a new joint that they have and it's more expensive but
the efficacy data of the
long-term benefits on it astronomically outperform the other joint that this
hospital system was using
he sat down with the ceo of the hospital and he said here's the data uh five
years out here's what
we're seeing da da da da the ceo said i don't give a what happens five years
out swear to god he's this
is a call i had yesterday he said he looked me in the eye brigham and he said
if you told me that this joint
will last at least 90 days and it's cheaper that's all i care about oh my god
because all of their
data and records and accountability are only on the first 90 days once you're
out of that 90 day and
you've done your your little review and all that you're off again and you're no
longer a monetizable patient
and so too when we talk about primary cares and what's happened the same thing
with pharmacies where
they've been gobbled up by insurance companies if they're in the insurance
model is the same thing
that happened with primary care practices the day of a primary care being
independent and a free thinker
is over they're employed by hospital systems major conglomerates have gone out
and bought up the
primary care practice why because now they have the patient population if i can
get you at the primary
care level then i can control the referral of where that primary care sends you
as we profiteer off
your disease state okay so you go to a primary care let's say let's just walk
through the same example
i gave earlier a methylfolate test they never run that test right there's
genetics the methylfolate test
tells me my genetics but there's epigenetics the choices i make every day
impact which genes turn on
and which genes turn off if nobody ever has a conversation with me in my 30s
about my hormone
levels about getting into the sun about eating right and you push me towards
chronic disease because you
wrote me a prescription to treat a symptom and now i go through this system and
i get cancer
that primary care is going to refer me to an oncologist and that oncologist is
part of that
same system right and most people don't 