transcript

Speaker 1:
[00:00] Do you want to hear a funny story?

Speaker 2:
[00:02] Yeah.

Speaker 1:
[00:03] So ever since my wife and I got married, I told her that I was the salutatorian of my class, because I thought I was a salutatorian. But it turns out I wasn't even the salutatorian.

Speaker 2:
[00:16] You just told her that to impress her?

Speaker 1:
[00:18] So I've been lying for 25 years about my graduation class. And so I don't know if I like, I don't know what happened. I don't know if I consciously did this, huh?

Speaker 2:
[00:31] You imagined it happened?

Speaker 1:
[00:32] I don't know. But it was just like in the last, I don't know, six or eight months that we found out that I wasn't the salutatorian. I don't even remember how we found out. And my wife has not let me live it down since then.

Speaker 2:
[00:43] As would I.

Speaker 1:
[00:45] I'll be in a casket. And my wife will be in tears talking about our lives together. And she will definitively mention that I was not the salutatorian of my high school class. Hello, and welcome to Hoosier Health Matters for Friday, April 24th, 2026, brought to you by The Good Trouble Coalition. I'm Gabriel Bosslet, pulmonary and critical care physician and former and founding president of Good Trouble. I'm joined, as always, by Tracey Wilkinson, pediatrician, health services researcher and Good Trouble board member to talk about all things public health in Indiana. Hi, Tracey.

Speaker 2:
[01:25] Hi, Gabe. How are you? Are you enjoying the seventh spring that we're having?

Speaker 1:
[01:29] Yes, I think we are past the average first frost date. So we should be good.

Speaker 2:
[01:35] Okay. This is my favorite time in Indiana is spring when things start like exploding in the garden and when all the checkered flags start coming out because it's getting closer to race season.

Speaker 1:
[01:47] So what happens now, though, is first summer.

Speaker 2:
[01:52] Right.

Speaker 1:
[01:53] That is right. So it will be 97 degrees in like a week. And we'll both be complaining about that. Tracey, we should say briefly before we start the episode that The Good Trouble Coalition is hiring an executive director. This is a big step for The Good Trouble Coalition. I think that this is a big deal for any nonprofit to get to the point where they can hire someone to sort of do the day to day. This is probably a 25% position, so it's not a full-time position. But if you get our emails and you should look in your inbox, it will have details on how to apply. So if you're interested, if you know someone who's interested, you have the requisite skills, this is a paid position, that would be awesome.

Speaker 2:
[02:34] Yeah, we're so excited for this next phase of leadership.

Speaker 1:
[02:37] All right. Should we do the news?

Speaker 2:
[02:39] Yeah, we should. We got a lot to cover, as always. But I did want to highlight a story that I want to give props to Governor Braun for. They announced that they were going to propose moving $200 million to the Child Care Development Fund, which is important because there are over 35,000 children right now on the wait list to get vouchers for daycare access. And so this will help kids come off that list. And so kudos to Governor Braun for doing something that's really needed in a timely fashion and not waiting until the next time the budget is opened.

Speaker 1:
[03:22] Yeah, I don't know. Yes, kudos. This is good. Kids are going to get to go to daycare, and that's important. At the same time, this is a little bit similar to the Rural Health Transformation Grant, where, oh, great, we got a $207 million grant. That's great. This comes right after a $1 billion cut from the federal government in sort of all this stuff. So yeah, it's good, but it comes right after you took much more of that away. So I don't know, man. I'm agnostic.

Speaker 2:
[03:58] I agree with you. It is infuriating because I think, one, the budget was happening, and people were freezing these child care vouchers. People said this was going to be bad. And so I guess I'm just like giving them props for acknowledging that it wasn't going well and making somewhat of a course correction. Not a complete course, but partial course corrections. Okay, let's talk about vaccines. We learned that the CDC is delaying a report that is showing benefits of the COVID-19 vaccines. And the report's important because it talked about benefits to the vaccines beyond just preventing the disease. And obviously, this is yet another example where people are worried that there is not a separation of politics and science over at the CDC and that there are powers that are blocking this report from being released.

Speaker 1:
[04:50] Yeah, this was supposed to be published in the Morbidity and Mortality Weekly Report, which we've talked about before on this podcast, which is a scientific publication put out by the federal government every week for decades until it wasn't after the Trump Administration came in. Last year, and now is published again. But apparently, through multiple people from the CDC, they've wanted this to go out and they are not going to publish it for a while for ideological reasons, I think.

Speaker 2:
[05:23] Yeah. Well, and speaking of the CDC, we did hear news that they have found a nominee for the head of the CDC, which is exciting. It's a little late. They're turning in their homework late. However, Erica Schwartz is an impeccable physician who has an MPH and a JD, which by the way, is my dream additional degree. She was a deputy surgeon general previously, and so they're tapping her to lead the CDC.

Speaker 1:
[05:57] Yeah. Most of the public health community actually thinks that she's a very good choice.

Speaker 2:
[06:01] Yeah, which makes me think she's not going to last very long.

Speaker 1:
[06:05] Well, what's interesting is that, and I think we're going to talk about this, but RFK, Jr. has been on the hill in front of committees in Congress, and it was asked over the last couple of days if she's elected, whether he would allow her to set vaccine policy, and he has said that he is not going to commit to any answers to that at this point. So, who knows?

Speaker 2:
[06:31] Adorable. So speaking of RFK, Jr., he has been not happy with what's going on at the ACIP committee. For those of you that listen regularly, you know that the ACIP committee is the advisory committee on immunization practices. Recently, a federal court case was filed that basically made everybody on the committee not eligible for membership. And so RFK, Jr. is responding to this by just rewriting the rules of who gets to be on the committee by revising the charter aims as to eligibility and expertise criteria.

Speaker 1:
[07:12] Not surprising. And he's actually increasing the list of liaison organizations to include batshit crazy organizations like the Association of American Physicians and Surgeons, the Independent Medical Alliance, the Medical Academy of Pediatrics and Special Needs, the Physicians for Informal Consent. These are basically very fringe groups that are not reputable at all and should be not even allowed in the building where ACIP committee meetings are being held and are now going to be given liaison organization status, I think, partly because the AAP and several other organizations who had non-voting positions on the committee have stepped away because of how crazy ACIP has become, I think this is kind of a thumb in the eye to them. And so, I don't know, it's the next step in sort of just a long line of leadership malpractice issues here.

Speaker 2:
[08:12] Yep. Yeah. And RFK Jr. has done all of this work while also being really busy because he has been called to seven committee hearings on Capitol Hill to present and talk about the fiscal year 27 president's budget request and to kind of answer questions about this. However, what's ended up happening is because he's testifying, you know, senators and congresspeople are taking the opportunity to ask him some other questions while they have him under oath about some of his other kind of approaches and feelings about other things going on. So I just wanted to highlight a couple of the things that like did and did not happen. So first of all, he defended the confirmation of Casey Means to be the Surgeon General. He changed his messaging about vaccines and actually admitted that the measles vaccine is safe and effective for quote most people and agreed that the measles vaccine was safe and effective quote for most people, and that it was safer than getting the measles. And he just talked about things like the United States Preventative Services Task Force and mentioned that he plans to replace all the task force members pretty similarly to what he did to the ACIP committee.

Speaker 1:
[09:27] Yeah, I mean, I think, you know, there was reporting that there was a memo that went around that instructed people to stop talking about vaccines because of the midterms that are coming up and because vaccines are massively popular among the American public. And I think that's what most people think is going on here.

Speaker 2:
[09:44] Yeah, he's trying to be like less inflammatory.

Speaker 1:
[09:48] Yeah, and then the midterms were happening and he'll do crazy shit again.

Speaker 2:
[09:52] Yeah, speaking of federal funding stuff, I did want to highlight that, you know, we have talked a lot about indirects and research and the battle that was happening between the Trump Administration and various academic centers in terms of indirect rates. And we learned that the Trump Administration has dropped the court fight about that. So that is basically ending the controversy for now about indirect payments on grants from the NIH.

Speaker 1:
[10:23] That's a big deal. You know, this was a huge deal for academic medical centers and academic institutions, I don't know, how long ago. It seems like a decade ago now. And now it's pretty much just resolved. And this is, you know, I think their bark is worse than their bite is a, is a generally a pretty reasonable mantra for the way HHS has functioned. They love to yell things that are terrible and watch people's go crazy and then back off. And that's what's happened here. You know, if the indirect payment system that currently is in place was changed the way they talked about doing it, it would basically crumble the American scientific enterprise, period, full stop. So this is good.

Speaker 2:
[11:09] Yeah, this is good. And then I want to round out the news with a couple of stories from Indiana. So we learned this week that, sadly, Marion County is among 20 counties nationally that has failed every single pollution test in the American Lung Association's annual State of the Air report. And the only other county in Indiana that also was on the list was Lake County. And this just made me really sad today.

Speaker 1:
[11:41] So wait, we had two counties on the list?

Speaker 2:
[11:43] Yeah, which actually makes me wonder if like two out of 20.

Speaker 1:
[11:48] That's 10 percent.

Speaker 2:
[11:49] Yeah, it's from Indiana.

Speaker 1:
[11:51] Yeah. Oh, that's not good. The ALA, the American Lung Association, is a really good association. As a pulmonologist, this is like one of my sort of, this is a philanthropic organization that has done a lot for lung health in the history of the United States. It's a very reputable organization that's really well run. And so yeah, this is not good. I mean, this is, we've talked about this with Gabe Filippelli when he was on about air pollution. And so yeah, maybe we should have him back on to talk about it.

Speaker 2:
[12:21] I know, the other Gabe.

Speaker 1:
[12:23] Yeah, the other Gabe.

Speaker 2:
[12:25] Yeah, yeah. Okay, and then the last new story I want to talk about is just kind of the like slow boiling that's happening around abortion access. So we learned that the Indiana Supreme Court has announced that the challenge to the state abortion ban will skip the appellate court and go straight to the state Supreme Court in terms of the next legal decision on our abortion ban happening.

Speaker 1:
[12:56] I'm not surprised. They did this before. It's fine. It was going to go to the Supreme Court anyways. It is what it is.

Speaker 2:
[13:03] Yeah. So they're just kind of speeding up the process this way. And just as a reminder, that was a case that was challenging our abortion ban based on religious objections to the law. Okay. Nationally, I wanted to flag that there is a case coming out of the state of Louisiana challenging the FDA approval for Mifepristone, which is the medication abortion drug. That case was basically put on pause when the judge said, let's let the FDA continue their review of the approval of this medication. And a lot of people think this has got to do with the midterms coming up and they're not wanting to be like any big shifts in terms of medication abortion access before the midterms. However, the plaintiffs in that case have now appealed and asked the Fifth Circuit Court of Appeals to immediately impose a nationwide dispensing requirement for Mifepristone, which would in essence mean that you have to be in person and telehealth provision of Mifepristone will not be permitted nationally. That would impact states that also have more permissive abortion access laws.

Speaker 1:
[14:17] But that hasn't happened, right? They've just asked that judge to do that.

Speaker 2:
[14:21] Correct. But the Fifth Circuit Court of Appeals is not necessarily very friendly to reproductive rights. There's obviously a tension happening here with the legal process to impact access to medication abortion.

Speaker 1:
[14:36] Interesting.

Speaker 2:
[14:37] But that's not the only route that they're taking. They're also enlisting the Environmental Protection Agency. So we learned that in the month of April, the Environmental Protection Agency released a list of quote human health benchmarks for water contaminants. And it actually contained a lot of pharmaceutical drugs, actually 374 pharmaceutical drugs. And tucked into this list happen to be drugs that are used for abortion. So including mesoprostol, methotrexate, and mifepristone, as well as drugs that are used in oral contraception. And so I just wanted to flag this to our listeners that this is another way that abortion access is attacked by using like wonky administrative rules to lock down access.

Speaker 1:
[15:23] So I have mixed feelings about this. And that is the fact that if you're gonna release a list of human health benchmarks for pharmaceuticals, it seems reasonable that these would be on there. There's a lot of drugs on the 374 drugs, including anti-hypertensive drugs, etc. So it does not seem more reasonable that these drugs would be on there, because these are endocrine medications, etc. I don't know. But to sort of have that happen by an EPA that has simultaneously reduced or rescinded limits on PFAS chemicals, so forever chemicals, mercury, which both of these are like known bad chemicals. And an EPA that has now decided to ignore the endangerment finding of greenhouse gases does seem odd, Tracey. So I do, you know, I have mixed feelings about this, but this EPA is at best inconsistent and more likely just ideologically hypocritical.

Speaker 2:
[16:31] Yeah. And given the report that just came out about our air quality, I would much rather the EPA be paying attention to getting air quality in all places to a better space that we're not bailing tests on pollution. And we can raise our kids in an environment that is not so polluted that we fail every single test and not worrying about this politicalization of adding certain medications to a list that needs to be tested and tracked.

Speaker 1:
[17:01] Agreed.

Speaker 2:
[17:02] So that's all the news I've got for you, Gabe.

Speaker 1:
[17:06] So Tracey, that's not a lot and not terrible. And I'm going to be honest with you, I think as we go through the summer and approach the midterms, you and I are going to have less and less to talk about.

Speaker 2:
[17:16] That is true. But I do want to flag that you cross out like half the news I bring to you.

Speaker 1:
[17:23] That's because this is supposed to be a commute-length podcast. Not like a reading of War and Peace every week. Should we move to the interview?

Speaker 2:
[17:38] Yeah, let's talk to our guest.

Speaker 1:
[17:40] Okay.

Speaker 2:
[17:42] So if you've ever stood at a pharmacy counter and wondered why your life-saving medication suddenly costs $300 more than it did last month, or why your insurance is forcing you to switch to a drug that doesn't work as well, today's episode is for you. We're pulling back the curtain on pharmacy benefit managers or PBMs. These are the powerful middlemen of medicine, companies that sit between drug makers, insurers, and your local pharmacy. They were designed to lower costs, but many argue they've become a black box that drives prices up while squeezing our local independent pharmacies out of business. To help us untangle this web, we're thrilled to welcome back a friend of the podcast, Dr. Veronica Vernon. Veronica is a pharmacist, a professor at Butler University, and a board member of the Good Trouble Coalition. She's been on the front lines of health policy in Indiana, and she's here to explain why PBM reform is one of the most critical healthcare fights in the state house right now. Veronica, welcome back to Hoosier Health Matters.

Speaker 3:
[18:41] Thank you. I'm delighted to be back.

Speaker 2:
[18:43] Veronica, to level set for our listeners. Most people listening know their doctor, their pharmacist, but they've never met their PBM. In the simplest terms, what is a pharmacy benefit manager, and at what point in the process do they enter the room between a doctor writing a prescription and a patient picking it up?

Speaker 3:
[19:01] That's an excellent question, Tracey, and it's actually pretty complex to answer of what a PBM actually does. PBMs, think of them as being intermediaries or the middlemen between pharmacies, planned sponsors, which would be your health plans, your insurance companies, the employers, if you have a self-funded health plan, pharmaceutical manufacturers, and drug wholesalers. They are touching multiple different parts of the drug supply chain, and they're also touching practitioners because they're in charge of things like prior authorizations for medications and formularies, what is going to be covered and not covered. And so they have control over a large part of how a drug gets from the manufacturer all the way to a patient.

Speaker 1:
[19:47] So can you color that in a little bit more? I mean, so great, they're in there. They interface with all of them, but what do they do?

Speaker 3:
[19:58] So in the 1970s, PBMs were just there to process claims. Actually, if we start back in 1958, the first pharmacy benefit manager was actually created by pharmacists, which is interesting, because now we see more of an adversarial relationship between pharmacies and PBMs. So PBMs were initially made just to pay pharmacies for drug claims. That's all that they were supposed to do. And what we saw in the 80s and 90s, there was the rise of PBMs because health plans wanted to offer prescription coverage. Back in the 80s and 90s, if any of our listeners remember what it was like to go to a pharmacy then, you paid cash for most of your prescriptions. We started to see more prescription drug coverage in the 90s, early 2000s. And that's where we flipped our model from 90% cash, 10% insurance to the other way around. Now we're all mainly insurance-based in the pharmacy setting. And that was because PBMs. PBMs said, we can process your claims to health plans. They contracted with health plans. Then they started to really grow, and especially after the passage of the Affordable Care Act. PBMs started to set formularies, and they would make formularies for plan sponsors, whether it's a health plan or an employer, and say, this is what we will cover, and this is how we will keep drug costs down. Then they started to say, well, we will do some additional benefits for you in managing your drug cost. And PBMs started to add in additional fees to provide some of these services. All it used to be was they processed prescription claims at a pharmacy, and they made sure the pharmacy got paid. And we've grown to something much, much bigger than that now.

Speaker 1:
[21:40] Why doesn't the insurance company just do that?

Speaker 3:
[21:43] The insurance company didn't know how to do it. The insurance plans were built to cover medical billing and cover medical claims. Prescription claims were completely different. And what we see now is a lot of PBMs own or are owned by a health plan. So we're starting to see what we call vertical integration, which it's a great business practice, right? If you own a pharmacy, a health plan, the pharmacy benefit manager, you can control so much of the drug supply chain. And we're also seeing these PBM, vertically integrated companies also own medical offices too and medical practices. So they're controlling the prescribing all the way down to how it gets to a patient. And that's why this is getting so complex and gaining a lot of attention, especially from entities like the Federal Trade Commission.

Speaker 2:
[22:32] So talking about vertical integration, Veronica, in 2025, our state house passed Senate Enrollment Act 140, which really targeted vertical integration. Can you explain how that actually changes what happens at the checkout counter for Hoosiers?

Speaker 3:
[22:47] To be honest, it doesn't change much, to be quite honest. I think if we're talking about vertical integration, what other states have been doing, I think is interesting. I think it's really complex. Arkansas passed a law recently that prevents PBMs from owning pharmacies. This was an attempt to curb that vertical integration because, although there is supposed to be a firewall in between what the PBM practices do and what the pharmacy does, and those two are never to cross. We know that there has to be something else going on behind the scenes that we're not able to see. Because in other states like Florida, what a PBM audit found from the state is that, one PBM in particular was paying its pharmacies more that it owned than other pharmacies in the state. So Arkansas said, if you own a PBM, you cannot own a pharmacy, and they got that bill to pass. And I think this is something we're going to start to see more of in how do we control this vertical integration. Because if you own everything, and it lines right up vertically, it's really easy to be able to set the price and to control what you're paid as the pharmacy benefit manager or the insurance company or whoever is the parent company. And it's really easy to squeeze out other competition. And so we're seeing this with independent pharmacies and chain pharmacies that are owned by PBMs closing. So one of the issues we see is that the PBM pays the pharmacy for the drug. They process the claim. And the PBM could pay their own pharmacy more than what they pay an independent pharmacy. The patient may see no difference if both pharmacies are part of the PBMs pharmacy network, but the PBM is the architect of this network. They will say the health plan is, which to an extent, yes, but the PBM comes up with the network and proposes it to the contract holder, whoever is telling the PBM, please work for us and manage our pharmacy benefit management system. But the PBM can pay their own pharmacy more than what they pay the independent pharmacy or the other chain pharmacy down the street. And that leads to issues where pharmacies can't stay in business. We've seen 30% of pharmacies, of all pharmacies over the last 10 years, have closed. And the number one reason is due to reimbursement practices from PBMs.

Speaker 1:
[25:02] I go to a pharmacy to fill my drug. The pharmacist says it's $30. What vertical integration does is if they own the pharmacy, they may pay the pharmacy $25 and keep five. If they don't own the pharmacy, they may pay the pharmacy $15 and keep 15. Correct.

Speaker 3:
[25:23] And the cost of that medication could be $35 to the pharmacy, but then they're paying the pharmacy less than the cost of the drug. I think a great example of this recently has been our glucagon-like peptide agonists like ozempic, semaglutide, where it's a brand-name drug. The PBM is paying the pharmacy less than that pharmacy's acquisition cost, the cost of buying the drug from their wholesaler. And that's the issue we're seeing and why pharmacies are starting to say, do I even want to keep these drugs in stock? Because I lose money every time somebody walks out the door with it.

Speaker 2:
[25:59] This is fascinating.

Speaker 1:
[26:01] So Veronica, you talked about pharmacies closing. Have we seen a lot of independent pharmacies close in Indiana?

Speaker 3:
[26:08] Oh, absolutely. We used to have a much larger number of independent pharmacies 10, 15 years ago than what we have now. To paint a picture of what this looks like for community access to pharmacies and medications, there were two pharmacy locations in southern Indiana, DeVille Pharmacies. One of the locations in Dillsboro, Indiana had served their community for over 40 years. The independent pharmacy was the only pharmacy in the entire county, and they had a very large Medicaid population that they served. So people that really needed access to medications, and a lot of their patients also had transportation issues. They closed after many years of being in business. This had been a family owned business. It was a small business. And the reason that they cited was due to PBM reimbursements declining. They were getting paid less for most prescriptions that they were sending out to patients than what it actually costs to buy the drug and keep it on their shelves in the pharmacy. I want to draw the attention to independents because they are small, they are not independently owned, they are part of our communities, these people live here and some of these pharmacies in our state have been here for over a hundred years. And we're seeing them at risk of closure, which is really unfortunate.

Speaker 1:
[27:22] So are the chains CVS, Walgreens, are they associated with specific PBMs?

Speaker 3:
[27:28] CVS is. CVS is affiliated with CVS Caremark, which is one of the three largest PBMs in the entire country. So our three largest PBMs, they all own some sort of pharmacy. It may be a mail order pharmacy. It might be a brick and mortar pharmacy. In the case of CVS, it's both. But Walgreens does not have a PBM, which I think is important. Why Walgreens has been in the news recently because they were bought by private equity and they were closing a lot of their stores around the nation. And it was because of, yeah, PBM practices.

Speaker 2:
[28:02] Yeah, like all of them have closed in Indianapolis. Like they're all gone.

Speaker 3:
[28:06] Yeah. I will tell you, I used to work at Walgreens and every store that, except one that used to be my home store, has closed because of the declining reimbursements. And most of the stores that we see are in communities that are medically underserved.

Speaker 2:
[28:20] So, Veronica, I just want to go back to like, why PBMs existed in the first place because they sold themselves as being able to negotiate better prices and save patients money. So what is actually happening today? Because it sounds like that's not happening.

Speaker 3:
[28:36] Oh, initially PBMs said, we will save you, buddy. And they did. And I will say to this day, there are some very transparent PBMs out there that do save money. And they have some really, really great practices. There's even some locally owned PBMs here in the state of Indiana. The issue is when you have three PBMs that control over 80% of the market, it is very challenging to have transparent practices. It's like the black box. You don't know what's inside the black box. There are all these transactions that occur and these fees that PBMs write into their contracts with pharmacies and with employers, and nobody knows what they mean. And PBMs said, we will save money because we will put less expensive drugs on the formulary. We will work to reduce your costs. But what we're seeing, the price of prescription drug insurance to employers has exponentially increased and it is not slowing down.

Speaker 1:
[29:28] There are a lot of discussions of the fact that PBMs get rebates from drug manufacturers. So are these getting to patients or no?

Speaker 3:
[29:37] No, not always. So PBMs negotiate rebates with drug manufacturers and it's a way to get the drug manufacturers medication on their formulary. These are going to be brand name medications. And so if you may be thinking, wow, I think it's really strange that my patient's insurance or my insurance covers a lot of brand name medications. I wonder why that is. It's because your PBM has negotiated with the drug manufacturer to get a rebate. The PBM will take part of that rebate and then pass on the rest of it to whoever owns the contract with them, whether it's the employer or the health plan. But rebates are tricky because what rebates do is they can inflate the list price of the drug. Because if you are a drug manufacturer giving a rebate to the PBM, you may want to increase the list price of the drug because you're giving somebody else a discount. Well, if you're insured, you benefit, which is great. But if you are underinsured or uninsured, that's a real challenge because now your drug is more expensive at a cash price than what it is for somebody who's insured. And I think that's where this is really, really frustrating with rebates. And I really question why we have rebates anymore.

Speaker 1:
[30:50] Veronica, can we switch to selfishly, like as a physician, are PBMs tied to the scourge of prior authorizations that we have to go through now? And for our listeners, like when I, you know, if you come to see me in the office and I write a prescription for you, I would say probably 30% of the time now, I have to get what's called a prior authorization, which means I have to get permission from the insurance company to even write that prescription, even though the medicine is on their formulary. It means that I have to sometimes talk to a physician in order to write a, I've had to do a prior authorization for albuterol multiple times. So is this a PBM issue?

Speaker 3:
[31:38] Yes, it absolutely is. Prior authorizations are a way to manage, initially to manage costs, right? We saw prior authorizations for more expensive medications, maybe new brand medications, when there's a therapeutic alternative on the market. But we're seeing more and more prior authorizations. And when I think of our prescribers listening, that adds to your administrative burden significantly. You add up all the hours that you have spent on the phone. I married a physician, so I hear a lot of the peer-to-peer conversations that he has had to do. Pharmacists are frustrated with prior authorizations too. It takes up a lot of our time. And I think it's really hard when patients come to the pharmacy and they are understandably upset when their medication is not ready because of prior authorizations required and our hands are completely tied.

Speaker 1:
[32:27] We actually have a person employed in my clinic that just her entire job is to deal with prior authorizations, her entire job.

Speaker 3:
[32:37] Health systems and clinics have hired whole teams to do this.

Speaker 1:
[32:41] It's crazy. It's crazy.

Speaker 2:
[32:43] So, Veronica, if you could wave a magic wand and pass one reform, what would it be?

Speaker 3:
[32:48] It's a great question. As a pharmacist, I will say that I would love to see fair reimbursement for pharmacies. We passed something last year in Indiana. It was part of our PBM reform that PBMs would have to pay the acquisition cost of the drug plus what we call a dispensing fee. If you were watching the news legislative session 2025, you may have seen some inflammatory language that called this a prescription tax. It's not a prescription tax. It's the cost of dispensing your medication. It's the cost of the bottle. It's the cost of the label. It's the cost to keep the lights on. It's how we pay our staff. Because if I just get paid for the ingredient, the actual medication I'm giving you, all the other stuff that I do in my pharmacy isn't going to get paid for. My computers, the lights, electricity, the building. It's not a lot. The cost of dispensing a drug in the United States is about $12 on average across all pharmacies. But I would like to see all pharmacies in our state get paid that dispensing fee. Because right now, it only relates to certain plans that are required to do that. Our managed care entities were carved out of that for Medicaid. And I think it's really important because our pharmacies are hurting in the state. And I don't want to see any more pharmacies closed from an access perspective in Indiana.

Speaker 1:
[34:10] Let me ask a follow-up question to that, Veronica. Why can't we just say, no more PBMs?

Speaker 3:
[34:16] I think that's a great question. The state of West Virginia said, no more PBMs. The PBM is only there to actually process the claims. They don't do formulary design. They don't do any of that. The state of West Virginia contracted with their West Virginia pharmacy school, the University of West Virginia, to do some of that for them. I believe the initial estimate was $54 million were saved to the state the first year that they did this.

Speaker 1:
[34:45] When did they do that?

Speaker 3:
[34:46] They carved out everything from Medicaid in 2017. So they moved to a single PBM. Kentucky did this too. And pharmacies in Kentucky already saw an improvement in reimbursements when they did this. Ohio has also done a carve out model. So the states closest to us are looking at this.

Speaker 1:
[35:04] Well, I've just learned so much, Veronica. Thank you so much for joining us today. This was really terrific. And we look forward to having you back on the program, I'm sure, in the future.

Speaker 3:
[35:13] Thank you.

Speaker 1:
[35:14] So Tracey, now's the time when we talk about things you can do this week to help affect change or good vibes. What are you going to pick?

Speaker 2:
[35:21] I'm going to remind everybody to vote in their primary elections. By the time our next episode happens, the primary will be over.

Speaker 1:
[35:29] Oh, yeah. I'm going to say the same. Everyone who listens to this show should vote in the primary. If you...

Speaker 2:
[35:35] And tell everybody in your life to vote in the primary.

Speaker 1:
[35:37] Agreed. If you listen to this show, you understand the importance of elections. And so I have no doubt that everyone listening will have voted in the primary by the time our next episode airs.

Speaker 2:
[35:50] Yeah. And there are a lot of contested races this year, especially at the statehouse level. And so it's really important that everybody's voting, and we do not allow these primaries to decide our candidates with just, like, 10% of the population voting.

Speaker 1:
[36:05] Agreed.

Speaker 2:
[36:06] If you enjoyed this episode, please subscribe, rate, and review us wherever you get your podcasts. Also, email us your thoughts and issues you think we should be covering at goodtrouble at goodtroubleindiana.org. If you aren't already a GTC member, please become one by visiting our website. It's free and easy, and we promise to not overwhelm you with emails. Also, consider becoming a donor. Even $20 a month is help to support and grow this work. You can find the links to join and or donate in the show notes. You can also follow us on social media on Bluesky, Facebook, and Instagram. Look for our next episode two weeks from now on May 8th, where we will continue to discuss health policy happenings at the State House and all other things public health. Thanks again for joining us. Until next time, be safe and be kind.