Reducing Rx Costs with Point-of-Prescribing Tech w/ Arrive Health CEO Kyle Kiser

Nearly all insured Americans have prescription medication benefits.

So why are so many Americans struggling to afford those prescriptions?

Shouldn't these benefits cover the cost?

 In this episode of CareTalk, David Williams speaks with Kyle Kiser, CEO of Arrive Health, to explore the factors driving the disconnect between consumer needs and prescription pricing, and how point-of-prescribing technology can serve as a patient-centered solution.

This episode is brought to you by BetterHelp. Give online therapy a try at https://betterhelp.com/caretalk and get on your way to being your best self.

As a BetterHelp affiliate, we may receive compensation from BetterHelp if you purchase products or services through the links provided.

TOPICS
(0:17) Sponsorship
(2:01) Why Is Medication Access an Issue?
(4:23) What Happened to Affordable Medicine?
(5:14) The State of Prior Authorization
(7:08) Why Hasn't Electronic Prescribing Solved Consumer Constraints?
(8:58) What Is Patient-Centered, Provider-Friendly Tech?
(13:18) The Issues with Preferred Pharmacies
(15:34) How Have Pharma Support Programs Evolved?
(18:12) The Role of Biosimilars in Reducing Prices
(19:38) What Should a Patient Know When Dealing with Prescription Costs?

🎙️⚕️ABOUT CARETALK
CareTalk is a weekly podcast that provides an incisive, no B.S. view of the US healthcare industry. Join co-hosts John Driscoll (President U.S. Healthcare and EVP, Walgreens Boots Alliance) and David Williams (President, Health Business Group) as they debate the latest in US healthcare news, business and policy.

🎙️⚕️ABOUT KYLE KISER
Kyle Kiser became CEO of Arrive Health in 2021, having previously served as its President and Chief Strategy Officer for over four years. Under his leadership, Arrive Health has built a network of top health systems, health plans, PBMs, and IT vendors to enhance patient access, affordability, and outcomes while minimizing administrative burdens. Before joining Arrive Health, Kyle held senior roles at Welltok, Catapult Health, and Principal Wellness Company.

🎙️⚕️ABOUT ARRIVE HEALTH
Arrive Health is dedicated to improving patient affordability and access to care, and this new brand exemplifies its ambitions and purpose in a more unique way. They are wholly focused on integrating accurate data—encompassing pharmacy, medical benefits, and more—into provider and care team workflows, ensuring that patients receive the highest quality care at the most affordable price.

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Transcript

0:00

Almost everyone has a drug benefit these days, but many patients still struggle to pay for their prescriptions. Is there a solution to that problem? And how can point to prescribing technology help? you Masks are visible to everyone in October, but many of us have an invisible mask that we wear all year long, at work, in social interactions, basically everywhere. But therapy can help you rediscover your true self so you no longer feel the need to hide behind a mask of any kind. Masks are fun for Halloween, but we really shouldn't have to keep our emotions buried. That's where BetterHelp steps in. BetterHelp provides online therapy tailored to your life. convenient, flexible, and made to fit your individual needs. With just a few questions, you'll be matched with a licensed therapist who aligns with your preferences. And if you ever feel the need for a change, switching therapists is easy and comes at no extra cost. So whether you're managing stress, dealing with anxiety, or simply seeking personal growth, BetterHelp connects you with a professional who can guide you on your path to self-discovery and healing. Let BetterHelp help you take off that mask. visit betterhelp.com slash care talk to get 10 % off your first month. That's betterhelp, H-E-L-P dot com slash care talk. Welcome to Care Talk, America's home for incisive debate about healthcare business and policy. I'm David Williams, president of Health Business Group. I'm looking forward to delving into these topics with today's guest, Arrive Health CEO, Kyle Kaiser. Kyle Kaiser, welcome to Care Talk. Glad to be here. I think I'd say a long time listener, first time caller if this was a radio show. Yeah, that sounds good. I think that's about right. And then they'd say, yeah, can you turn your radio down in the background so we don't hear it? know you're impressed with being on Sports Talk or whatever we're doing, but no, it's great. Well, we're to talk broadly about medication access. And as I mentioned in the intro, everybody has health insurance, and that health insurance generally includes prescription drug benefit, not just generally, and that's almost universally. Why is medication access even an issue? I what are we talking about here? Yeah, I mean, it really comes down to patient out-of-pocket costs. So to your point, drug benefits are nearly ubiquitous. We've done a great job of sort of access to insurance, I guess, as a problem to solve. But in doing so, deductibles used to be hundreds of dollars. They're now thousands of dollars. Out-of-pocket cost for copays and coinsurance used to be fives and tens of dollars. And now it's hundreds and thousands of dollars. And in that context, almost everybody then is effectively a cash payer. And so, you know, that's, that's primarily why I think we feel a strain is there is absolutely this sort of confluence of that happening at the same time as the unit cost of meds going up because there's new meds and new technology, new brands. But I think we were talking about it more and feeling it more acutely because ultimately the way patients are paying for medications has changed. the burden is shifted to their shoulders more acutely. Got it. So it used to be you'd go in and you have like a $1 or $3 or maybe 10 or maybe $50 if something's out, you know, out of off the formula or whatever. But now even though you've got some of these drugs that are very expensive and the insurance company is paying a lot from the consumer standpoint, it's still comparable to like a car payment or a monthly rent. And even in the less expensive cases that you're mentioning, the complexity has just gone way up, right? It's just in a... in an effort to control their own cost of goods, health insurance companies negotiate specific deals based on specific types of meds in a category. And it ends up with a dynamic where something will be, know, a category of drugs might be generic and assumed to be nearly zero or zero. But the out-of-pocket cost ends up being surprisingly high because the doc didn't know to pick, you know, this specific form rather than this other specific form. And that's not a function of you know, overall cost of meds being higher. It's just a function of the complexity that's in front of that doc having to make that decision being kind of untenable or invisible to them in lot of cases. Yeah, yeah, yeah. Well, so feel I'm lucky I don't really take any medications, but back in the olden days, as you're saying, it's like, okay, that's a generic drug, so that's basically free. And then there might be like a branded one that's advertised and that may be expensive. Then there's something that maybe it's like pseudo cosmetic or they don't necessarily want you to have it and that's more, but it's gotten to the point where even if that still generally carries the day because of the way the deal making is done. I could have something that should be free that actually ends up being pricey is what you're saying. Yeah, yeah. did a study of our data recently and found that almost half the time a doc prescribed something that was more than $50 out of pocket with the patient, what a $0 option was available. That's just an information availability problem. It's just not getting the right option in front of the right decision in that case. So that's not an overall function of drug prices going up. It's just complexity. So one of the things that's been used for a while, but I think it's used even more now, is prior authorization. And so my understanding is that you've got coverage, then in order to keep costs under control and make sure people are using the proper product, there's prior authorization, which serves that function, but it also puts a lot of friction in the system. What's the state of prior authorization these days? I would say that its utilization is higher. Right? Like that the actual experience of prior authorization probably feels like more friction than ever before. And I think if you wanted to hear this description from an insurance company or a PBM perspective, I think they would describe that as a quality program. The goal being reviewing decisions that are being made to ensure that the right patients are getting the right meds and the wrong patients aren't getting those meds too. Cause there's a function of, you know, auditing that decision-making behavior to some degree. That's probably an indelicate way to describe that, you get the point. And, and I think that that what's been challenging is, it faced with that barrier for the most part, providers just submit everything and see what happens. Yeah. And, and so, you know, what I think creates an opportunity is, is to really start to apply new types of technologies to turn decision support. capabilities into more real time prior off decisions for capabilities, which some of the things we're working on. Because there's, it's, it's got to kind of turn into a guidance system, not just a, a no machine, which is kind of how it functions today. Right. Instead of submitting everything, seeing what you get notes for then tackling appeals or making a different choice. Can we get to the decision right the first time? And that's largely what we spent time on is how do you. How do you guide around formula decision-making? How do you guide around prior authorization and get the right patient on the right med the first time rather than having you rework everything multiple times, which is often the case these days. So, you know, when you've got a process that used to be the physician or other prescriber, usually physician would write out the prescription on a pad, you bring it to the drug store, they'd fill it. And sometimes they'd have to call the doctor because they say, hey, this is expensive or we don't have it or whatever. And that was the process. And that was kind of slow because you wouldn't necessarily get the physician, the pharmacist is busy, you're not taking everything into account. And you'd think in a way that electronic prescribing that's tied in with the electronic medical record, and also that's the same system that the offices was using for billing, like it should all just sort of tie together in a straightforward way. like, it sounds like there's more electronics where if I go to Amazon, I can just do one click and there's a lot of complexity in the background. you know, relating to payments and pricing and logistics, that all seems to happen. And, but it seems like it's gone the other way when we deal with prescribing. I think you're right. This is in my view, the only time in my knowledge of our economy where we adopted an electronic process and consumer choice was constrained. You know, you had a paper script. If you felt so inclined, you could go shop that anywhere you wanted at the corner pharmacy. And we adopted ePrescribing in the early 2000s. And what changed is that script got routed directly from EMR to directly to pharmacy. And then, you know, someone else made a purchasing decision on your behalf and neither of you knew what it cost until you're asked to show up and pay for it. And so our mission for many years now has been how do you reintroduce consumer choice into that clinical decision-making process and throughout the patient experience to then start to do exactly what you just described. How do we make... I really like that selection process and that purchasing process feel a lot more like the other ways that we experience purchasing in our economy rather than it being this great mystery that you sort of have to figure out along the way. Now, I think based on this discussion, it's starting to come into focus now. You use a term on your website on Arrive Health that talks about patient-centered provider-friendly technology. Just unpack that for me a little bit. What does it mean to be patient-centered and why provider-friendly? Yeah, absolutely. I think patient centered, I would almost be more specific than that. Part of what changed when we moved from generic formulating benefit data to what's now real-time benefit data is that it's patient specified. It's not that the prior auth is required generically for that plan. It's that this prior auth is required specifically for this patient, that they haven't satisfied it already, that it's not pending. There's a sort of patient specified insight in what we do. you know, what we're doing millions of times a month now. So that's one aspect of patient centered. It's also taken into account pharmacy selection in a really specific way. as I know, you know, the prices at pharmacies vary widely. And that's very widely from minute to minute or day to day, or even location to location, right? But, you know, the Rite Aid and the pharmacy across the street may have very different prices depending on your formulary and their negotiation. And so being able to provide a really specific insight into that pharmacy selection process is also quite patient centered. And those things are taking into account benefit design and, you know, specific patient benefit design, not generically group and plan level design. So that's sort of patient centered. We'll set aside. Provider friendly is, you know, we've, we've really not done a great job as an industry of designing things that are with provider user experience in mind. We've had the benefit of being incubated inside of the Care Innovation Center at UC Health in Colorado. And that gave us this provider-centric view on how we design solutions and how do we make things that are easier, not harder, and it's fewer clicks, not more clicks, that's right, reliably, and something that providers can trust and rely on to make decisions. And that led us down this path where we took... What was a new transaction emerging in the form of real-time benefit, which is real-time patient specific moment in time, specific price insight into the e-prescribing workflow. And what was required to make that reliable every time and provider friendly is that we had to take the intelligence of the pharmacist and embed it into the technology. had to make sure that, you know, if there's an NDC mismatch or there's a quantity unit mismatch, or if there's some, you know, some mishandling of that transaction programmatically that the system could fix it. so that it could be right more often because pharmacists were solving invisible problems at the point of sale that providers never saw. And if we don't sort of marry those two processes into one real-time process, then you don't create a user experience that providers can rely on, which I think a lot of providers had that experience sort of in the initial launch of real-time benefit with some of those early solutions. And where we, I think we've really built something that's market leading is that now we have a tool that you can rely on. consistently and it handles a lot of that complexity. And those things matter most in the more expensive meds. It's in self-administered meds and self-injectable pens and the creams and the inhalers and all the things that are in those more complicated units where that stuff matters the most. And that's where the highest value is for all stakeholders that are using our solutions. know, one of the things about the introduction of the electronic medical record is that on the one hand, it's great to have all the records in one place. On the other hand, it took the the physician's job and made sort of more of these administrative tasks that could have previously been done by someone without all that training and were less expensive and kind of put it onto the doctor. And what I think what you're suggesting here was the e-prescribing side of it. Also, the physician ended up doing some of the pharmacist tasks, things that they weren't necessarily aware of, or not just in the e-prescribing, but in the whole process that you're talking about. So I think certainly patients are familiar with the providers struggling. you know, with the computer while they're in front of them. So there's that part of it. So that's well understood now. And you've added an extra element there when you talk about the interaction with the pharmacy. I wanted to ask you a little bit more about the patient centered part of it. you said before, you know, I take my script and you used to go wherever I was, maybe if I was at work downtown, I'd take it to the pharmacy there. If I was near my home, I might do that. Or if it's a place like that, you go shopping for groceries. And now it's more or less, what's your preferred pharmacy? And they have that in there. Are you saying that that I shouldn't have a preferred pharmacy, but that I should vary it based on like what I'm specifically being prescribed? In some cases, yeah. That is, you know, the rooming process is always going to have that question of what's your preferred pharmacy, but it's so arbitrary at that point in the visit that there's no knowledge of what you're going to be prescribed or, you know, what access or affordability barriers might be ahead of you. And so, yeah, I think that one of the things that's valuable and inherent in real time benefit is that we're bringing back alternatives around pharmacy. So let's say you start with pharmacy A and it's at a network. We can then suggest in a network pharmacy that's the best cost in that case. Let's say you're being prescribed a branded med that may have some patient support programs associated with it. We might be able to provide some insight into the paths for you to take down a medication access path. And those things can happen at the point of care and connected into a patient message that's really tightly coordinated. with the point of care transaction, which, you know, driving up patient engagement, driving up sort of patients acceptance of this information and hopefully adherence. And our goal is to help people manage their conditions more effectively because of those things. Let's talk about the pharma support here and how that plays in. You know, back in the olden days, it was, you some people didn't have insurance or they were, you know, low income. And then there were certain programs that you could essentially get free medication, you could get some help with it. But it was sort of the same way you think about, you know, being on food stamps or welfare, that's not for people above a certain, you know, the income, or if you have insurance, you certainly wouldn't be looking for free care and so on. But I think the world has evolved. And when you talk about, you know, people having hundreds or thousands of dollars in co-pays, then that affects, you know, everybody, at least 90 % probably of patients there. How have the pharma support programs evolved? Are they just for low income people these days? What does the environment look like and how does it play into what you do? Yeah, it is a team sport for sure in this case. I think we think about patient support mostly in the context of access teams inside of health systems, just because of where we sit and who we work with more often. And so there are teams of dozens, sometimes hundreds of people inside of health systems that are doing nothing but trying to resolve prior off and then find affordability options for patients. And that's, that's largely because that problem we identified at the beginning of the conversation. It's just the, the thousands of dollars of out-of-pocket costs is just something that doesn't work for the vast majority of Americans. And so in response to that, copay assistance has come in a variety of forms. There's commercial copay programs that'll buy down the out-of-pocket costs. for the patient for some period of time. There's the more philanthropic aid type category that you were describing where maybe that's a free drug program or a disease-based, some disease-based association that's providing support for specific disease categories. And really the challenge exists now that it is the state of the art of where to find those things is usually 20 to 40 sticky notes over the monitor of somebody inside of a health system. And so we're trying to... rationalize some of that and, in tying that point of care encounter directly to a patient message that we can then sort of help move forward the appropriate enrollment based on what we know about that patient. it's there's a, there's definitely a much more coordinated dance between insurance benefits and other types of payment. and, even cash pay, I think just as importantly these days and probably at a higher volume from a transaction perspective, that cash pay is a real part of how people are paying for benefits. those, you know, the integrated cash coupon programs are just the way of the world. Now we work closely with several of the, you know, the payer, PBM type folks that are providing those programs. And that's, that just raises the level of complexity for doctors, right? Is that now in a clinical day, you may be see 30, 40 patients, those 30, 40 patients, you know, used to probably represent five to 15 different health plans and formularies. And I bet every one of them. And it's an impossible scenario for a provider to take on themselves. And it's where direct connectivity, interoperability, and automation can really be an important solution. We talk about a big driver of costs of medication being biologics, as you mentioned at the start of the show, a lot of new expensive medications being introduced. There's a countervailing effort, though, to introduce biosimilars. And I'm wondering how that plays in. broadly, is that helping to keep the cost of biologics down? And I assume it does something also with the complexity of your choice now that you're not just using the specific biologic. Yeah, it's certainly the answer to that question is different from payer to payer for sure. Everybody seems to be negotiating their own specific deals. And again, we come at it from this provider centric perspective, which means it's only a harder problem for the provider to solve. discerning, know, payer A and their preferences from payer B and their preferences becomes a challenge. And, and the only way that by some of those are going to have a real impact is adoption. If we can't get adoption because the decision rubric for the provider is too complicated, then that's going to limit impact. So our goal is how do you take that complexity, bring it to the point of care and make it easy to use for the provider so that So that patient one through 10 that have a different answer than patient 11 through 25 is easy for that provider to adopt and for their care team to administer and overcome the prior off and those sorts of things. It's bringing that into a decision support frame that I think is gonna ultimately make the impact. So this conversation we're having is actually fairly complicated and I can imagine a typical listener if they've made it this far is thinking, okay, I'm glad somebody else is dealing with that. But for the someone who's made it to the end here, and is more of like a patient or is responsible for the financial, let's say, of a dependent. I mean, what would be the takeaway of like, what should a patient know as they interact with the system these days? I I consider myself pretty well informed, but there's a lot that I learned even from this, but like, what are a couple takeaways for patients in this whole system? Let me answer the question with a little bit of a story. So one of our co-founders, guy named Kevin O'Brien, he's a doctor in Denver. And, and part of what inspired the beginning of this company is Kevin wanting to help his mom. His Kevin's mom approached him. She had a out of pocket cost. was a struggle. Kevin being a physician had the skills to do so. He looked at her beds, found ways to save, looked for options, that might've not been obvious to her or found, you know, a generic med that could be broken into its or a branded med that could be broken into the generic parts and cut her spin in half. And. So we still have a mantra around the company that that's Lucy up. And it's kind of our way to think about that problem and serving that one patient. It's because Kevin's mom's name is Lucy. And that to me is the, that's the, that's the opportunity for every patient is that there's likely something in your encounter with that physician where engaging in a different way could make a huge difference. And and I think that you provide providers desire this information. think that's the biggest thing that we've proven over the years is that, you know, the first thing we had to prove was do providers care. And I think definitively now we can say by the end of the year, we'll be doing north of 20 million of these transactions a month. And providers want to want this information. These are the problems they want to solve for patients because they want you to be able to take your medication. So I think. You know, the key takeaway, if I'm a patient without diving into the healthcare data and nerdery that we spent most of the time on is just that your provider wants to help. And in many cases, they now have the tools to do so. And that wasn't the case even a couple of years ago. So the adoption of these things has happened fast and there's an opportunity to really rely on that relationship. And to me, that's the biggest leverage point for change is that. patient-provider relationship, the trust that exists that's inherent in that relationship is the best opportunity we have systemically to make things better. Well, that's it for yet another episode of Care Talk. I'm David Williams, president of Health Business Group. I've been speaking with Kyle Kaiser, CEO of Arrive Health. Thank you, Kyle. Thanks, David. So if you like what you heard, or even if you didn't, please go ahead and subscribe on your favorite service.