Meet AMCP Foundation Steven G. Avey Award Winner Mark McClellan, MD, PhD

Gregg Masters  00:05 

This is a live edition of the AMCP Podcast Series powered by PopHealth Week on HealthcareNOW Radio. I'm Gregg Masters, managing director of Health Innovation Media and the producer co-host of the show. Joining me in the virtual studio is co-founder and principal co-host Fred Goldstein, president of Accountable Health, LLC, PopHealth Week engages industry leadership and stakeholder voices spanning payer, provider, patient, vendor, and regulatory communities and population health best practices and strategies. Connect with us via www.popupstudio.productions or follow and direct message me on Twitter @GreggMastersmph and that's Gregg with two G’s on today's live edition. Our special guests are Mark McClellan, MD, PhD, and Paula J. Eichenbrenner, the executive director at the Academy of Managed Care Pharmacy AMCP Foundation. And with that rather understated introduction, Fred, over to you. 

Fred Goldstein  01:07 

Thanks so much, Gregg and Paula and Dr. McClellan. Welcome. 

Mark McClellan  01:10 

Well, Fred, it's great to be with you and your colleagues at AMCP. I really have enjoyed working with all of you over the years around prevention, around treating diseases more effectively. So great to be back today. 

Fred Goldstein  01:22 

Great pleasure to have you and Paula, why don't you introduce yourself? 

Paula Eichenbrenner  01:26 

Thanks, Fred. It's terrific to be here. AMCP Foundation invests in future leaders, and we advanced critical insights about the practice of managed care pharmacies. So, I'm really thrilled to be joining to chat about AMCP Foundation. As Executive Director, I work closely with our board to implement initiatives that support AMCP's primary objective helping patients get the medicines they need at a cost they can afford. For example, AMCP Foundation offers a robust internship program for student pharmacists this summer alone, we've placed more than a dozen bright young leaders at health plans across the country. We also maintain a research agenda for managed care pharmacy, but really Fred, I'm here today to talk with you about the selection of AMCP Foundation's annual Steve G. Avey award. 

Fred Goldstein  02:13 

Talk a little bit about what the award is.  

Paula Eichenbrenner  02:15 

Let's talk about who the award recipients are, if you don't mind, Fred. When I think about the Steven G Avey award, I think about visionaries truly and how patient care is being defined and redefined. In America today. I think about innovators and how they're creatively elevating the practice of population health management. I think about advocates affecting change through public policy. Those are the types of individuals and the types of leaders that AMCP Foundation recognizes with our prestigious Steven G. Avey Award, which is of course managed care's highest honor. Through this award, AMCP and AMCP Foundation together point to the future of healthcare, and we inspire the next generation of managed care pharmacy professionals. 

Fred Goldstein  02:59 

So, this year’s awardee, obviously, somebody very well known nationally. Why don't you talk about Dr. McClellan and his selection? 

Paula Eichenbrenner  03:07 

It is my distinct pleasure to do that, Fred, thanks. Today's guest features our 2022 recipient of the AMCP Foundation, Steven G Avey award physician and economist Mark McClellan. Dr. McClellan is the Robert J. Margolis, professor of business, medicine, and policy, and founding director of the Duke Margolis Center for Health Policy at Duke University. Mark served the U.S. government and top posts as a former Administrator of the Centers for Medicare and Medicaid Services, or CMS, of course, and as a past commissioner of the U.S. Food and Drug Administration. Now, Fred, you may know that while leading CMS Mark played a key role, in fact, was the architect in developing and implementing the Medicare prescription drug benefit, what we now know as the highly popular and very successful Part D program. But did you know that AMCP leaders were vital partners in that effort, including prior AMCP Foundation Avey awardees, like Kim Caldwell, and Babette Edgar? And did you know that after Part D was established, AMCP created the guide to pharmaceutical payment methods, the sound medication therapy management programs, and numerous research publications? So, I think that the ways in which Dr. McClellan has left a legacy, through his distinguished record of public service is also an example for all of us in collaboration and pulling together partners to affect change. 

Fred Goldstein  04:33 

Quite the accomplishment. I want to thank you, Mark. Why don't you tell us a little bit about your experience and how you see managed care and pharmacy, and some of the things you've done in that area? 

Mark McClellan  04:41 

Well, I'm happy to talk about that. But first, I just want to say thanks to you all to the rest of the AMCP Foundation. As Paula mentioned, this is a very special award. It's particularly meaningful for me since pharmacists have been absolute, pharmacists, especially willing to think outside the box and focus on population health and reimagining how our health care and health insurance could work. Those pharmacists have been critical for me at every single step of my career. You mentioned some of the work at Medicare Part D, where before that program began, you know, pharmacists were not a thing at CMS and people like Babbette Edgar and Kim Caldwell changed that. The pharmacist community, which had its hands full period, starting a new drug benefit, engage, and your leaders engaged around building that infrastructure around the drug benefit for things like immediate determination of eligibility and checking and benefit features and building quality into the program with the start of the pharmacy Quality Alliance. You know, people like Laura Cranston involved in that. And since then, we've done a lot of work in my program at Duke Margolis. Yes, about what I've been up to lately that Duke Margolis Center for Health Policy is a university wide program at Duke is, as you just heard from Paula, but one that very much engages pharmacy and pharmacists in improving quality of care. So, we've been very involved in building out some of the programs that started actually with that Medicare Modernization Act, you know, close to believe it or not 20 years ago, around population health programs, the forerunners of accountable care organizations. And today, there are hardly any of those programs I can think of that don't involve pharmacists in some significant way. So much of the future of healthcare is about identifying patients who could benefit from drugs and other biomedical interventions early where pharmacists have a huge frontline role to play, and then getting them appropriately into treatment where pharmacists are playing an increasing role. Over the last couple of years, we've spent a lot of time working with pharmacists in frontline settings and managed care organizations and health systems on responding to the COVID 19 pandemic, where again, pharmacists were just central. And that's still the case today, in getting vaccination and booster rates up in screening for people who have developed COVID-19. And for getting them into effective treatments, if we could just clone the programs that work that pharmacists are involved in, in identifying patients at risk, and then engaging them and getting them to treatment for their diseases. Whether it's COVID, or diabetes, or heart disease, or the list goes on and on. We'd have a far, far more healthy and far, far more prevention-oriented health system. So, the work’s not done. But boy, I sure have appreciated the partnerships. 

Fred Goldstein  08:02 

It's really amazing to think about, you know, what, what's been accomplished. And you think back to the day and how pharmacists’ roles were in the past and then bring managed care and pharmacy and begin to implement some of those programs. We've talked about medication therapy management; do you see the pharmacist getting out from behind the counter? And then all of this stuff about how do we integrate this into a value-based care model? And more recently, obviously, the COVID work where pharmacists can now prescribe for COVID. So, what do you see Dr. McClellan is sort of the future. What are some of the other things you think we need to be looking at for pharmacists within this realm? 

Mark McClellan  08:34 

Well, the good thing about health care, I guess, the good and the bad is that our technologies keep evolving. So, whether it's around data and infrastructure support or around earlier, more accurate diagnostic tests, including rapid tests that can be done in pharmacies or with pharmacists help and that at home, and then more and more interventions to to change the course of illnesses early on, whether it's, you know, COVID, and every other major respiratory condition where we have not, we have rapid diagnostic tests. We have therapies that work. We have vaccines that work, but we haven't yet made them figured out how to get them widely available or chronic diseases like diabetes, prediabetes, people with cardiovascular risk factors. There's a common feature in all of these models of reaching people where they are out in the community, coordinating the use of the above the treatments in a way that makes for a viable, personalized clinical care pathway and helping patients along with those decisions where I think the future for pharmacy is really bright. But we do have some work to get there and two areas Fred that maybe we could follow up a bit on one is the way that we have set up our drug coverage and drug benefits. So, you know, Medicare Part D was was terrific at the time, I can't tell you, it was great to get to know pharmacists around the country. But you know, seniors who would just get up and hug me, thank you, I can afford my medications now, nothing like that experience. But I think the benefits kind of fallen behind, we've got a lot of people with high medication costs that really weren't what Part D was designed to address. And we've learned a lot more about how to manage patient populations in a drug benefit that remember, the drug only coverage hadn't even existed before the Medicare Modernization Act, so it's time to modernize the benefit. And then, as I said, we still got a ways to go on really getting person focused prevention oriented, comprehensive care, to individuals, and pharmacists have a critical role to play in that as well. So, both are great topics for, I think, further work and hopefully for further leadership from pharmacists. 

Fred Goldstein  11:06 

And when you think about the the idea of on both of those questions, actually, do you see potentially the move to these value-based care models? 

Mark McClellan  11:15 

Yeah, let me start with the pricing cost. Because I think if you talk to most Americans today, despite Medicare Part D, and, you know, all of the things that have worked in that program, the premium is has been close to flat, it's reaching many more people than than we expected, it's doing so at a lower-than-expected costs. But the medical technologies here kind of outgrown the benefit structure. So back then, in 2004, most drugs were for large populations, they were expensive by historical standards, in part because drugs were not even a major part of medicine, when Medicare itself was created, you know, it was really downstream care, you know, a lot of treatments in the hospital, and when people would develop medical complications, so Part D did help change that. But it didn't have a catastrophic benefit, because that's not where most drug expenditures were, it was pretty lenient, I'd say on the drug plans. And that, above that, at the high end, the government picked up 80% of the costs of drug coverage, which isn't, you think about like incentives to negotiate that probably isn't gonna lead to really aggressive negotiation if the federal government's picking up 80% of the tab. So those things need to change. And and there's been a lot of work over the past decade around what a modernized pharmacy benefit would look like. And right now, I got two things coming together with congressional interest in this exact topic. One is, there have been bipartisan proposals for how to modernize Part D. And that's actually largely incorporated in the legislative package that the Democrats in Congress are working on now. It would create catastrophic expenditure protection. So, beneficiaries past $2,000, don't have to pay anything. That's really important, because while you know, the rebates that we see are helpful and keeping premiums down are not necessarily helpful. For those out-of-pocket costs for people who have high drug needs. And the fact that there's no out of pocket limit in Part D is also a problem. So, this benefit would fix that it would also create stronger incentives for the drug plans and the manufacturers to negotiate lower prices for these high cost drugs, because it would shift the burden of those costs to the insurers where, frankly, I think it should be now that we've got like really good experience and understanding drug costs and understanding how to administer and update drug benefits. So that piece of legislation I think, is really helpful. I think the concern here is, Fred, that just fixing, just trying to get to lower prices by itself isn't the whole problem on what we've seen in a lot of areas of care. Take COVID for example, a treatment can be free Paxlovid,  vaccines, and that still doesn't reach many people who can benefit, we still have seen big disparities emerge in outcomes and access. And that gets to the other thing that needs to change, which is our whole care models for using the medications and you know increasingly good diagnostic tests and supporting data and analytics effectively to find patients where they are and really intervene early and effectively in that care pathway. So, it's not just a question of, okay, you've got coverage, you're not going to pay much. You know, when you're hospitalized with a COVID complication or the complication from your poorly controlled heart disease risk factors, but you're gonna get help and identifying if you're at risk and then having the the health care system meet you where you are. And pharmacists are just critical in doing that and helping to inform the kinds of care models that we should be implementing in being out there on the front lines, interacting with patients spending time with them. You know whether it's their pharmacist in their community or pharmacist member of a coordinated care team, they they understand the medications that are just so important in managing so many conditions today and more so coming in the future, that they have the ability to be the glue, that puts a lot of these new care pathways together. And while we've made progress in implementing those models, there's still more to do. And that's why this is also a very high priority for CMS and many Medicare Advantage plans. Medicaid plans are finding that, you know, just negotiating a low price for a drug doesn't solve the problem. It's necessary, but it's not sufficient. We've got a match that with with payments to health care providers that support and sustain these kinds of care teams where pharmacists are playing an increasingly central role. 

Fred Goldstein  16:10 

Yeah, and I think one of the areas you're sort of touching on to, and I know AMCP is very involved in this whole area of health equity. 

Gregg Masters  16:17 

And if you're just tuning in, you're listening to a live edition of the AMCP Podcast Series powered by PopHealth Week Our guests are Dr. Mark McClellan, the director and Robert J. Margolis, MD Professor of Business medicine and policy at the Margolis Center for Health Policy at Duke University. And Paula Eichenbrenner, the executive director of the Academy of managed care pharmacy AMCP Foundation.  

Mark McClellan  16:41 

Paula, I know this is a really high priority for AMCP. 

Paula Eichenbrenner  16:44 

Well, I was just going to jump in here and say that in fact, addressing health disparities and ensuring more pharmaco-equity is a key priority for AMCP and the AMCP Foundation. Earlier this summer, we hosted a summit on health disparities, and I'm tracking with great interest some of the case studies that were showcased there, and some of the other great work that I'm aware of this summer AMCP Foundation has been involved in a study with a health plan, looking to have its prescriber base, adopt more usage of the Z codes in the ICD 10 system. And so, we're really looking at ways like that, that can help us to refine and move towards the more preventive model of care that Dr. McClellan has pointed to, I think that, you know, we all agree that there are disparities in care, right, and we agree about eliminating them. But let's acknowledge that there's a business case to do that, too. When we make health health care more equitable, we're typically making it more affordable for all stakeholders. So absolutely a key priority for our organizations. 

Mark McClellan  17:46 

Yeah, this is a great way to, or the right way should say to get health care costs down, not not restricting access to valuable innovative treatments, or not updating our benefits to reflect what really matters, I think the challenge that we're finding and implementing these reforms is that the scope of activities or interventions that matter for a particular patient varies. And as we get more tools available, you know, digital apps are great for interacting with some patients, not others. Some people, as you're saying, with the Z codes, those are intended to help capture some of these social factors that are such important barriers for people who are having, you know, issues with transportation or worried about where they're sleeping tonight or getting enough food for their families that are not going to be worried about complying with their adhering to their medications. So, we have to have effective ways of addressing those challenges. But they have to be personalized, so that we have a sustainable and affordable system. And that's putting more pressure on all of us and health care systems to develop new capabilities to be able to move as, as Fred mentioned, in some of these new payment models with CMS. Advancing models like accountable care organizations and the new ACO REACH program that have explicit goals around improving outcomes, reducing inequities reducing total cost of care, and with that the health care providers get more flexibility, but that's tough because you know, you're accountable not for just Okay, did the patient did I prescribe that drug? Or did the patient pick up their prescription? But, you know, did they actually get on the right medication? Is it actually are they adhering to it? Is it actually having an impact on their outcomes? And, you know, the first reaction understandably, for many health care providers is well look, my job's hard enough, and especially after a couple years of trying to deal with all the challenges of COVID staffing and response and so forth. This it seems like more work on top, but that's where I think some of the AMCP work and more we've seen like, like pharmacists are playing increasingly critical roles and helping these teams stay together and work well together. One of these ACO supporting organizations, company called Upstream actually relies on embedding their main intervention, Fred is embedding a pharmacist in a primary care practice to fill in these gaps to be able to put together data and maybe spend more time with individual patients where it's needed to understand why their adherence issues and you know, help the whole kind of team work together. It's not easy to do. But the good news is a lot of support from CMS from moving in this direction. And thanks to AMCP AMCP foundation work and others, more evidence, more case studies, more examples of how to succeed. 

Fred Goldstein  20:49 

So, you've been inside the rooms for all these meetings, you know, high level government meetings, obviously policy work, medical work, etc. Do you think we're at an inflection point now to begin to see some sort of major shifts in the health care system that will allow for these newer models to flourish and ultimately root and grow? 

Mark McClellan  21:07 

I think so. And partly, that's driven by progress and biomedical technology. So, you know, this pandemic, for all of the preventable deaths, and so forth, we're just talking about all the inequities, it really has been incredible to see the speed with which, you know, we now have very rapid, pretty not perfect, but pretty reliable tests for diagnosis that can be used by pharmacists and others out in the community by people directly. Over the counter set of tests, we've got treatments, we've got vaccines that need to be updated. Yeah, we can do better. But it really is, I think, a model for what the future is going to look more like. And if you think about cancer, well, there are tests in development now actually started being used that can help with earlier diagnosis, through blood samples not just of the big ones that we've been able to screen for, to some extent before breast cancer, colorectal, etc., but many others, pancreatic cancer, thyroid, liver, etc. Where we haven't had been able to intervene as earlier, effectively, the treatments are getting better. And I think that's going to push Fred more create more pressure for moving to these models that that help put people back at the center. So, they're not just feeling like they've got to coordinate across social issues and, and different kinds of specialties and so forth. But they really can get access, they can be part of a health system built around them that really is a health system that is designed and can help keep them well. To make that work, we do need to make further progress on payment reform. So that's why I'd like to accompany some of the steps like we're seeing right now that's interested in Medicare Part D to make the benefit more comprehensive and to create more pressure for price negotiation by the drug plans to complement that with other steps like more movement towards this whole person accountability, including accountability for reducing inequities. That's challenging for health care providers. But again, it can be done. 

Fred Goldstein  23:14 

Yeah, and as you pointed out earlier, it's really about bringing together a team to solve that kind of a problem, because you need the pharmacists in there may need some behavioral health specialists in their community Resource Coordinators, etc. Working with the patient. So, I really want to thank you for in the work you've done has just been fascinating over the years, and obviously, a well-deserved award. So just congratulations on that effort. 

Mark McClellan  23:37 

Well, thanks. And hopefully, Fred, none of none of us are done, we still got a lot, a lot of things to look back on. Again, I want to thank all my colleagues in pharmacy who have made these important steps possible and so much a part of my life and my career. And just a reminder that the good news is our technologies, our drugs, biologics, other therapies keep getting better. They keep enabling us to move care more out into the community with early diagnosis and targeted interventions to patients and we need pharmacists now more than ever to help manage all of that. 

Paula Eichenbrenner  24:13 

I just want to comment briefly on the award's namesake. Steven G Avey, himself a beloved Past President of AMCP, and a past Executive Director of AMCP Foundation for his entire career, he has reflected the values of integrity and volunteerism and collaboration. I'd love to hear any reflection from you Dr. McClellan about leadership and the role it's played in your career and words of encouragement for the young leaders on the line who may be joining us.  

Mark McClellan  24:41 

Thanks, and that's that's a great point to end on. I mean, one reason this was such a special honor is not just because of my long ties with AMCP and everything you stand for but Steve's leadership as well. The work that AMCP is doing to improve access to high-quality cost-effective medications and medications is now a very broad term with a lot of diverse interventions where pharmacists can play a role, you know, not sugarcoat it. You know, I know, it's been a tough couple of years for pharmacists, and everybody else who's been on the front line. But I think looking ahead, especially from AMCP's perspective, some of the most important health care leaders for the future are going to be pharmacists, it's not going to be the traditional way of, you know, sitting behind a counter and just filling the prescriptions accurately, as important as that is, it's going to be using data, it's going to be engaging with patients. It's right. So, it's gonna be engaging with care teams. Pharmacists, pharmacy training is very efficient to begin with, in terms of getting up to speed with the mechanisms behind diseases and the practical steps that we can take to address them. But it's gonna be even more important for the future as we have more of these interventions possible. So, you know, what I tell some of my students is, you know, when you're thinking about going into career in health care and health reform, don't just think about the job there now that you'd like to do think about what the future can be with these more effective diagnostics, more effective interventions, if we can target them effectively and efficiently and equitably to the right people. And think about what that job would be like. And I see AMCP playing a critical role in making all of those jobs happen for the future of medicine. 

Fred Goldstein  26:32 

Well, thanks so much, Mark, for ending with those thoughts. And Paula, it's been fantastic. Thanks for getting you both on 

Mark McClellan  26:38 

Fred. Paula AMCP. Thanks very much. 

Paula Eichenbrenner  26:42 

A pleasure for us as well. Thanks, Fred. Mark, congratulations again. 

Fred Goldstein  26:45 

And back to you, Gregg. 

Gregg Masters  26:47 

And that is the last word on today's broadcast. I want to thank Dr. Mark McClellan, the director and Robert J. Margolis, MD Professor of Business medicine policy at the Margolis Center for Health Policy at Duke University and Paula J. Eichenbrenner, Executive Director of the Academy of Managed Care Pharmacy AMCP Foundation for their time and insights today, do follow Dr. McClellan's work via www.healthpolicy.duke.edu and on Twitter via @DukeMargolis. And Paula Eichenbrenner  via www.amcp.org or on Twitter via @AMCP O R G or the hashtag AMCPFDF. We stream live on HealthcareNow radio weekdays 5:30am, 1:30pm, and 9:30pm eastern. And for you westcoasters 2:30am, 10:30am, and 6:30pm pacific. For the AMCP Podcast Series Powered by PopHealth Week, my co-host Fred Goldstein. This is Gregg Masters saying please stay safe everyone. Bye now.