May 20, 2025 • 30 mins
Understanding Trump's Executive Order on Drug Pricing | ShiftShapers
In this episode of ShiftShapers, host David A. Saltzman welcomes Tiffany Ryder, emergency medicine PA, host of Healthcare Liberty Lab, and writer at Red Flag Hero on Substack. Tiffany breaks down President Trump’s executive order on drug pricing and what it could mean for patients, providers, and pharmaceutical companies.
She explores key issues like most favored nation pricing, transparency in drug costs, and the role of PBMs and middlemen. Drawing from her frontline experience and policy knowledge, Tiffany explains how these changes may impact everything from consumer behavior to research and development in the pharmaceutical world.
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🔑 Key Takeaways from This Episode
📌 Trump’s Executive Order Is Not What It Seems
Initial reactions framed it as a price control, but deeper analysis reveals an effort to create competitive pricing similar to standard market structures—challenging the global imbalance of U.S. drug costs.
📌 The U.S. Pays More—And It’s Unsustainable
Americans make up only 4% of the world’s population but generate 75% of pharma’s profits. Tiffany explores how this executive order could shift the burden globally rather than stifling innovation.
📌 Transparency Could Empower Consumers
One of the most promising aspects of the order is a potential direct-to-consumer model and increased pricing transparency. It may spark a shift in consumer behavior, giving patients tools to understand what drugs should actually cost.
📌 PBMs and Middlemen Drive Up Costs
Tiffany highlights how pharmacy benefit managers (PBMs) and other intermediaries inflate costs, create confusion, and block consumers from accessing the best value for their medication.
📌 Generational Shift in Patient Trust Is Happening
Today’s younger patients are skeptical of the healthcare system but often feel powerless. Tiffany argues that consumer apathy is a major barrier—but rising costs could force change from the ground up.
📌 Clinicians and Patients Both Hold the Key
Tiffany believes change can start with both groups opting out of the broken system. Asking more questions, rejecting rushed visits, and demanding accountability are small acts that can fuel major reform.
⏱️ In This Episode
00:00 – Introduction to Trump's Executive Order on Drug Pricing
01:08 – Meet Tiffany Ryder: From Rural Louisiana to Healthcare Advocate
03:55 – Key Takeaways from the Executive Order
06:40 – Impact of Most Favored Nation Pricing
09:56 – Challenges and Potential Outcomes
15:23 – The Role of Transparency in Healthcare
24:36 – Generational Shifts in Patient Attitudes
27:06 – Future of Healthcare: Incremental Changes or a Major Overhaul?
29:45 – Conclusion and Farewell
Mark as Played
Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:00):
President Trump's recent executive order on drug
pricing tried to answer somequestions a lot of us have been
asking for a long time, but italso raised a bunch of new
questions.
So what does it all mean?
We'll find out on this episodeof Shift Shapers.
Speaker 2 (00:17):
Change either energizes or paralyzes.
The choice is yours.
Paralyzes the choice is yours.
This is the Shift Shaperspodcast, bringing the employee
benefits industry interviewswith individuals and companies
who are shaping the industry'sshifts.
And now here's your host, davidSaltzman.
Speaker 1 (00:39):
And to help us discuss the executive order and
the issue of drug prices, we'veinvited our friend and emergency
medicine physician assistant,tiffany Ryder, who also hosts
the awesome Healthcare LibertyLab podcast and writes long form
on Substack at Red Flag Hero.
Welcome, tiffany, how are youtoday?
Speaker 3 (00:56):
Hey, I'm great.
How are you?
Speaker 1 (00:59):
I am awesome.
I'm better now having you onthe podcast.
Speaker 3 (01:01):
I'm so excited to be here.
Speaker 1 (01:04):
We're going to have fun and we're going to try to
bring some sense to all of thiscraziness.
But first we typically askguests a little bit about your
background, because yourbackground is more unique than
pretty much anybody.
I know from how you got to whatyou were doing and what you're
doing today.
Give us a quick summary of yourbackground and how you came to
be doing what you're doing.
Speaker 3 (01:23):
Sure, yeah, I used to be a little embarrassed of my
nonlinear path and now it's, Ithink, one of the greatest gifts
that I've had the pleasure ofhaving.
But basically, you know, Iactually grew up in rural
Louisiana in a poor community nohealth care, no health
(01:43):
insurance or access to thosesorts of things, and that was
just sort of part of thebackground.
When I was first starting outas an adult, I moved to Maryland
and found myself in a positionwhere, as a young mother in
college you know, just trying tofigure out life was looking for
something big and ended upbecoming a professional dancer
(02:07):
and really having all of thisexposure to these big people in
DC doing cool stuff, especiallyin the health care space.
And so when I finally retiredfrom dance, I was living in the
EU and decided it was time tosort of go back to my roots and
figure out how to have an impacton people who were growing up
(02:30):
in similar situations to the waythat I had been, was enrolled
in medical school, movedoverseas, finished up here and
found myself in rural ERs as aPA, and that I thought thought
was my path to fixing thehealthcare system and really
having the impact that I dreamedabout and really it was all.
(02:52):
It was all a nice fantasy butwas not playing out.
So I started getting involved.
I read Marty McCary's book nowthe FDA commissioner.
He was a surgeon at Hopkinswhen I read the book and really
changed the way that I thoughtabout healthcare and that I
understood some of the healthpolicy and business aspects, and
(03:16):
so I've spent a little timehelping out in compliance and
marketing and all of thesedifferent spaces.
But where I see myself now ismoving the message forward,
trying to use some of thoseskills of being plain spoken,
from Louisiana and and alsobeing in the emergency
(03:36):
department, you know, sittingwith people with varying degrees
of health literacy and beingable to take more complex
messaging and actually helppeople understand it, because I
think that's where we all needto be looking to in health care
in general.
Speaker 1 (03:53):
And that's a great jumping off point.
So let's talk about this.
What were your key takeawaysfrom the executive order?
Speaker 3 (04:00):
Yeah.
So you know it was a littlescary at first because I, you
know, initially read the initialheadlines that came out and the
big talking points that werejust quickly thrown out into the
universe and it sort of lookedlike price controls to me, just
(04:27):
because in my experience, in myreading and experience in life,
you see price controls come upand immediately you think of
things like shortages and reallythe cessation of development of
new ideas and new solutions.
And in healthcare that isabsolutely a devastating concept
.
Right, it's got a huge impact.
But the more that I have lookedinto it, to be fair, there
(04:58):
aren't a ton of details onexactly how the nuts and bolts
of all of this are envisioned towork.
But through watching the pressconferences that again Marty
McCary has given and PresidentTrump gave officially the day he
signed the order, and readingthrough the White House
information that they've put out, it looks a lot less like price
controls and a lot more likealmost like we see things
playing out in the normalmarketplace.
(05:20):
My husband owns a just starteda coffee company of all things.
It's a product-based companyand when I look at the
distributors that he buys fromor the stores that he sells to,
every bit of pricing works withthis sort of understanding and
(05:43):
formula that the larger theorder is, the more favorable the
pricing is.
And given that Americansrepresent only 4 percent of the
global population but we areactually providing 75 percent of
pharma profits, I think thatdoes speak somewhat to the fact
(06:04):
that we're sort of not operatingin the same way that every
other industry is operating, andthis executive order seems to
be an attempt to rectify andsort, of course, correct some of
that.
Speaker 1 (06:17):
Yeah, I mean, even if you make the argument that
there might be a drag ondevelopment of new drugs and
whatnot, the question is, whywould you require one country to
subsidize all of the otherstuff?
Why wouldn't you spread yourdevelopment costs over your
entire marketplace rather thanjust one?
I mean, it's kind of arhetorical question, but then
(06:38):
again it's not.
So I digress the bill.
The bill, the executive order,seeks to set up what they call
most favored nation pricing.
What does that mean and what doyou think the impact might be
on us mere mortals here in theUnited States?
Speaker 3 (06:54):
Yeah, there's a spectrum to look at impact and
you know I've attempted toreally find diverging viewpoints
on this and basically thespectrum at the moment, from
what I've seen, runs from youknow, it's actually not going to
(07:15):
do much.
It's a big nothing burger.
It's a PR stunt which, as faras worst case scenarios go, that
is not the worst one I couldimagine.
Right To this, could you knowif it works?
(07:50):
The way that talks aboutcreating a direct-to-consumer
path.
It's not clear what that is.
The order provides for HHS, theDepartment of Health and Human
Services, to come up with somesort of structure for a
direct-to-consumer area.
(08:11):
It also alludes to some powerto source drugs from other
countries, which, for those ofus in this little corner of the
healthcare disruptors, we knowthat this is already happening.
But something that I think isparticularly interesting about
that as far as outcomes go is,you know, when you think about
(08:35):
other industries again, likemaybe a new parent who needs to
buy a car seat or a crib and hasnever done that before, you
have no idea sort of what thepricing is going to be for those
things.
Like what to expect, what'savailable in the marketplace.
You go to Amazon or whateveryou type in the search term and
then you get an idea.
In healthcare, if I have neverreally paid attention, I've
(08:59):
never had a chronic diseasebefore and my doctor prescribes
metformin I have really no ideawhat to expect.
Why is the CVS metformin adifferent price than maybe
Walgreens, than maybe myindependent pharmacy?
I have no way to shop and Ithink some of the unintended
(09:19):
consequences certainly might benot advantageous to different
stakeholders in the marketplace.
But one of the unintendedconsequences that I think could
result from this is really thatconsumers have a place where
they can go and start to informthemselves on what's possible
(09:41):
and what to expect in regards todrug pricing.
You don't have to buy itthrough this direct-to-consumer
area, but you at least start toget a transparent overview of
how healthcare works, and that'ssomething that I kind of love.
Speaker 1 (09:56):
Well, it's kind of hard to imagine that it won't
have a significant impact,assuming it gets implemented.
And there's a long way.
As everybody knows, there's along way between an executive
order and actual implementation,especially around things like
drugs where there's efficacy andsafety issues and all of that
kind of stuff.
But an example yesterday I wentto Walgreens.
I picked up a medicine afterMedicare, after my Part D
(10:20):
supplement, which is healthy.
It covers a lot.
My out-of-pocket was $144.
If I call up my buddy at theCanadian med store who's been
doing this importation stuffdirect from factories for years,
and I get the same drug, myprice is $140.
Which means that someplacebetween $140 and the retail, the
(10:42):
quoted retail price of the drug, which was $1,600, there's a
whole bunch of people making awhole lot of money.
And do you think that's part ofthe reason for trying to go
down this path?
Speaker 3 (10:54):
I mean, I absolutely think it is, and you know that's
not just speculation, that'ssomething that they certainly
brought up in the pressconference in a comedic way.
If I say so myself, it was alittle bit like I don't know.
We're not going to name all ofthese middlemen, but certainly
middlemen are involved in everystep of the process.
(11:14):
Pbms comes to mind, clearly.
But I want to go back tosomething that you said about
research and development,because I think that you know
bipartisan discussion andefforts and promises, quite
frankly, to reform and addressthe escalating cost of
(11:37):
prescription drugs have beengoing on for years and every
time you know this really comesup.
The one of the big argumentsagainst doing any sort of reform
is look, we believe in, youknow, capitalism to whatever
degree, we believe in freemarkets to whatever degree.
And if you take a, a companythat exists, pharma right,
(12:00):
whether it's Pfizer or whoeverit is, and you tell them, well,
we're going to take away yourability to make profit, then
obviously that has an impact onhow much they're willing to
invest, because the return oninvestment has now decreased.
What I thought was reallyinteresting about this approach
(12:22):
is that the goal of this orderand of the way that it's
structured isn't to decrease theprofits of pharma whatsoever,
right.
But if 75% of the profits areonly coming from 4% of the
population, then what ifeveryone just pays a little more
(12:44):
?
What if the deals are juststructured a little differently?
And you know, and it makes thisequalization effect.
And I love that right, becauseI feel like that argument and
that concern which, as aclinician, is concerning to me,
I, I want pharmaceuticalcompanies making, um, drugs that
(13:06):
are impacting lives.
Not a lot of those.
Those products don't have alarge effect, but some of them
do and, um, and, and I thinkthat this order does uh, is has
the potential to lower priceswithout having those negative
effects.
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And now back to ourconversation.
One of the things that you saida moment ago as the predicate
(15:10):
to your answer is in a freemarket.
Speaker 3 (15:13):
Yep.
Speaker 1 (15:14):
This is not a free market.
No, what we have today isprobably the furthest thing from
a free market that you canpossibly imagine.
So to a point you made earlier,if we start getting
transparency and if consumersget information and if there are
multiple pathways to be able tobuy a drug, where I don't have
to go to A, I can go to B or Cor D, then we're approaching a
(15:36):
free market and that logic mighthold.
Then we're approaching a freemarket and you know that logic
might hold.
Today you used the T word soI'll bring it up again.
We have no transparency.
If I didn't know the folks atthe Canadian med store and know
the owners for the last 25, 30years, it would never have
occurred to me to call them upand go hey, you know this drug,
(15:59):
I'm taking this Eloquist stuff.
What does a 90-day supply of5-milligram Eloquist you know
cost if I take it twice a day?
And I would never have knownthat.
It was almost exactly the sameas the co-pay I'm paying after
two different kinds of insurance, which it turns out is 10% of
the retail price of the drug inthe United States.
Tell me in what universe thismakes sense.
Speaker 3 (16:25):
David, I don't know if I should be happy or sad that
that was the example that youbrought up, but my heart is
racing out of my chest.
I mean, this is the perfectexample.
So let me give you an examplefrom the emergency department.
You know, we have young peoplewho show up and have no idea
(16:48):
that they have a geneticpredisposition to clotting or
have no idea that, you know, forwhatever reason they have
developed this blood clot.
And you know our answer to themin the emergency department is
we do all of these expensivetests, we do the ultrasound, we
find the things and then we say,okay, whether it's something
(17:11):
that you know was caused by anoutside situation, or something
that is just you're predisposedto, either way we're going to go
ahead and put you on this bloodthinning medication that will,
you know, reduce the likelihoodof really terrible things
happening in the future becauseof this problem.
And it's infuriating becauseit's such an important thing to
(17:39):
happen.
It's such an importanttreatment that we believe
actually changes clinicaloutcomes that we are unwilling
to allow a patient to leave thehospital until we are certain
beyond the shadow of a doubtthat the patient is going to be
able to pick up this medicineand the reason that I have spent
(18:02):
many shifts that you knowthousands of clinicians, I'm
certain, have spent, you know,hours past their shift like on
the phone with social workfiguring all of this out.
It isn't because this drug issome sort of like special
unicorn that we can't findsomewhere.
It's because it's so darnexpensive that we know the
(18:24):
patients are not likely to beable to pick it up when they get
to the pharmacy, and so, anyway, it creates all of these
barriers to care for pricing.
And maybe you say, oh okay, well, this comes from this very
special plant or animal orwhatever and it costs us this
much to make it.
But that's not the case.
If it's not the case in Canada,then how is that the case in
(18:46):
the U?
S?
And I think, like we're nottalking, we're not playing games
.
This is a political game.
You know.
I brought up the thing aboutfree markets because because the
talking points from pharmaright, like, for example, one of
their largest lobbyingorganizations.
Their talking points were well,we oppose price controls at any
(19:10):
level, in any way.
And that's not what this isabout.
It's not about finding thecontrary opinion that isn't
really congruent with reality.
It's about figuring out how canwe help the patient in front of
us, and as clinicians we don'treally have the power to
necessarily change all of thesethings systemically, and we need
(19:30):
our health policy leaders andorganizations and our you know,
president and other other peoplein power Congress to actually
step in there and intervene andhelp us do this, and I hope that
is what is happening.
Speaker 1 (19:46):
Well, you know, you raised the rock and let the
critters scurry out, so I'llfollow it out into the hopefully
out into the sunshine.
There isn't an organization onearth that spends more money
lobbying than Big Pharma.
They were the first people inthe White House when ACA was
being considered.
They're headed by a guy who's aformer congressman from
Louisiana who certainly knowshis way around.
(20:07):
They spread loads of moneyaround on Capitol Hill.
So do you think that we're at atipping point now, where I know
the four guys who are at HHSare unicorns?
They're unique, you know you'vegot Marty McCary, who you
mentioned earlier, and JayBhattacharya and Mehmet Oz and
(20:29):
Bobby Kennedy, who is certainlythe outlier.
Do you think that they willmaybe be able to rally their
friends in Congress to maybetake a different path than just
sucking up funds from big pharmaand doing their bidding?
Speaker 3 (20:45):
I would say that that is probably my primary concern.
When I look at all of this,when I see an initiative like
this and I get really excitedabout the world that this could
create, uh, the reason that Itell myself to just calm down
(21:05):
and not get, not get too workedup too soon, is, uh is because
I'm not.
I'm not sure about that, but Iam forever an optimist.
Uh, thankfully, I think, butthe way that I look at it is, um
, the chore.
The story, at least, that Ichoose to tell myself, is that
we really do have more powerthan we think, and some examples
of that that I bring up all thetime are if patients asked more
(21:27):
questions, there would be lessover-testing.
If patients asked a questionabout the CT scan that they find
on their medical bill thatnever happened, they would do
that less right.
And the same is true of doctorsand clinicians.
We all are up in arms andcomplaining about Epic and
(21:49):
declining reimbursements and allof these issues everybody wants
to be upset about.
But if we just opted out andsaid, no, I'm not doing that,
I'm actually not going to treatdiabetes and heart failure and
this wound that won't heal in my76-year-old patient in seven
minutes.
I'm not doing it, and I thinkthat the tipping point for that
(22:13):
is likely smaller than we think.
Right, so if 10% of people sawthe light and said, yeah, we're
not doing that anymore, I thinkthat real change could happen.
And I think my hope in thissituation in particular is if we
can get some traction on thesethings.
If we have seniors and kidswith rare diseases and we have
(22:38):
populations who were rationingtheir insulin and experiencing
life-threatening complicationsfrom doing so all of a sudden
have access to medication, theyhave access to medical treatment
, then that has the power tochange.
We won't stand for it anymore.
(23:00):
I think that Congress andpoliticians, after we've reached
that tipping point, aren'tgoing to be able to hide behind
oh well, it can't be done.
Oh well, we can't possibly dothis.
The implications are going tobe horrific, because we're going
to already see it happening,we're going to already see it
working and we're not going towant to to give that up.
(23:21):
And so that is, I think, thethe silver lining that at least
I'm clinging to, and it's partof the reason that I'm on this
show and I'm, like you know,talking about things as much as
I am.
It's not because I'm committedto any particular political
party or political ideology orwhat have you.
(23:41):
It's because I am 100 percentcommitted to transparency and
accountability and patientsgetting what they need without
being exploited by third partieswho produce minimal if any
value and and are destroying thehealth care system.
Speaker 1 (24:00):
So here's a question on something you said, because
you're in the trenches andyou're out there practicing
clinically a good portion ofyour time, when you're not doing
insightful articles and kind ofinteresting YouTubes and all
that stuff.
I mean, I've told you thisbefore Years ago.
One of my very first clients inthe insurance business
Dinosaurs I mean, I've told youthis before Years ago one of my
very first clients in theinsurance business dinosaurs, I
(24:21):
think had just left the earth atthat point was a hemoncologist
who said to me that doctors willget off their pedestals when
patients get off their knees.
Speaker 3 (24:31):
Yes.
Speaker 1 (24:32):
In your clinical practice?
You just said you know patientsneed to ask more questions.
In your clinical practice, areyou seeing a generational shift
away from this blind white coatauthority in patients and
patients asking more questions,or is it not happening yet?
Speaker 3 (24:47):
So I'm seeing a generational shift, but and I
wish that I could say that it iswhat you just described I wish
that I could say that youngpeople are now showing up and
they're saying no, I don't haveto do that.
Actually, why don't you explainto me how this test is going to
change your treatment, and thenyou know, and then we can talk
about if it's something that I'mwilling to do.
(25:09):
But honestly, at least in myend of one my personal
experience, I am seeing agenerational change, but it's
more of apathy.
I think that young people arejust beaten down right.
They don't believe, like theolder generations I would say
(25:29):
you know my generation and maybebefore.
They don't think oh, doctorknows best, of course, doctor,
I'm happy to listen.
They think well, you're likelyan idiot and some sort of pharma
shill, but I'm going to do whatyou say anyway, because I have
(25:50):
no power.
And essentially I mean that'sheartbreaking, that's
devastating to think that thereis a generation of young people
that are growing up and andcontinuing to follow the same
patterns of just doing whatthey're told In a.
In a lot of ways it reminds meof taxes.
So you know, there've been manyyears that people are like, oh,
(26:13):
you should ask your CPA aboutthis or that or whatever.
And I'm like I'm not paying aCPA.
And they're like, well, why youcould save thousands of dollars
because you're just throwingmoney away by not following
these, taking exemptions, that,whatever I could or whatever the
terminology is.
That I don't understand.
(26:33):
And my answer has all like itdoesn't make any sense.
And when I sat down and Ireflected and realized, like why
am I doing this really stupidthing?
I'm like a smart person and theanswer is well, because I feel
like I have no power.
I feel like I'm going to getscrewed no matter what I do, so
(26:53):
I might as well not try.
And it's.
It's really.
That's what I'm seeing frompatients.
Speaker 1 (26:59):
A wise man, not all that many years ago, said power
is never given, it's alwaystaken.
What's it going to take?
Or are we so far around thebend that we're going to have to
blow up what's here today inorder to get to patients saying,
hey, I'm in charge here?
Speaker 3 (27:14):
Hmm, you know, I hope that's not true, but I will say
that one of the positive thingsthat I have noticed in the
financial crisis essentiallythat we have in healthcare is
that the trajectory that we'reon is not sustainable.
(27:36):
And I don't mean it's notsustainable for poor people or
for people who make minimum wageor for factory workers.
I mean it is not sustainablefor anyone I routinely talk
about when I walk out throughthe waiting room at the
emergency department and I lookat the people who are waiting
(27:59):
there.
The people that are waiting foreight, 10 hours aren't just
people who are experiencinghomelessness or who perhaps are
uninsured or whatever the casemay be.
They're people with Mercedeskey fobs on their key chains.
They're all of us key fobs ontheir key chains.
(28:25):
They're all of us.
Every class, every patient groupin America is being affected by
the prices in one way oranother of healthcare, and what
I think could happen is that, asthese prices increase and
people get more and moredesperate, they are going to be
willing to accept things that goagainst the status quo, things
that go against the narrative,like maybe they're willing to go
(28:47):
to the pharmacy and ask thepharmacist hey, I usually use my
insurance, but could you tellme what the cash price is for
this medicine?
Maybe they wouldn't have donethat before, but when your
medicine's $10,000 a month,you're willing to ask that
question a lot easier, right?
So my hope is that, as theindustry stakeholders continue
(29:07):
to be more greedy and thingscontinue to go up, is that
patients slowly come to therealization.
And then, you know, theyrealize that one alternative
model works and is true andprovides great care, and then
they're willing to try some, anew one, and a new one, and a
new one.
Um, but either way, I thinkthat's where we're going.
Whether it's that you know wearen't willing to try anything
(29:28):
new and then, uh, the wholething blows up and then we have
to.
Or if it's that, you know,incrementally, more and more and
more of us are us are willingto try things like direct pay or
direct primary care, and youknow all of these alternative
models.
I don't know, but I certainlyhope that it will be a soft
landing.
Speaker 1 (29:45):
In the meantime, folks should check out your
YouTube channel, healthcareLiberty Lab, and also, you know,
your longer form stuff that youwrite on Substack at Red Flag
Hero, tiffany Ryder.
Thank you so much for being ourguest today.
It's been a pleasure having youon the podcast and I can't
believe I waited this long.
But thanks for being here.
Speaker 3 (30:03):
Thanks so much for having me, David.
I hope we talk soon.
Speaker 1 (30:12):
I want to give a quick shout out to our sponsor
and our producer, hatcher Media.
Hey, if you need podcastproduction or professional
graphic design, josh Hatcher isthe expert to contact For more
information.
Visit him at hatchermedianet.
That's H-A-T-C-H-E-R medianet.
Speaker 2 (30:30):
This Shift Chapers podcast is copyrighted content
and may not be reproduced inwhole or in part without the
express written permission ofShiftChaper Solutions LLC.
Copyright 2024.
President Trump's recent executive order on drug
pricing tried to answer somequestions a lot of us have been
asking for a long time, but italso raised a bunch of new
questions.
So what does it all mean?
We'll find out on this episodeof Shift Shapers.
Speaker 2 (00:17):
Change either energizes or paralyzes.
The choice is yours.
Paralyzes the choice is yours.
This is the Shift Shaperspodcast, bringing the employee
benefits industry interviewswith individuals and companies
who are shaping the industry'sshifts.
And now here's your host, davidSaltzman.
Speaker 1 (00:39):
And to help us discuss the executive order and
the issue of drug prices, we'veinvited our friend and emergency
medicine physician assistant,tiffany Ryder, who also hosts
the awesome Healthcare LibertyLab podcast and writes long form
on Substack at Red Flag Hero.
Welcome, tiffany, how are youtoday?
Speaker 3 (00:56):
Hey, I'm great.
How are you?
Speaker 1 (00:59):
I am awesome.
I'm better now having you onthe podcast.
Speaker 3 (01:01):
I'm so excited to be here.
Speaker 1 (01:04):
We're going to have fun and we're going to try to
bring some sense to all of thiscraziness.
But first we typically askguests a little bit about your
background, because yourbackground is more unique than
pretty much anybody.
I know from how you got to whatyou were doing and what you're
doing today.
Give us a quick summary of yourbackground and how you came to
be doing what you're doing.
Speaker 3 (01:23):
Sure, yeah, I used to be a little embarrassed of my
nonlinear path and now it's, Ithink, one of the greatest gifts
that I've had the pleasure ofhaving.
But basically, you know, Iactually grew up in rural
Louisiana in a poor community nohealth care, no health
(01:43):
insurance or access to thosesorts of things, and that was
just sort of part of thebackground.
When I was first starting outas an adult, I moved to Maryland
and found myself in a positionwhere, as a young mother in
college you know, just trying tofigure out life was looking for
something big and ended upbecoming a professional dancer
(02:07):
and really having all of thisexposure to these big people in
DC doing cool stuff, especiallyin the health care space.
And so when I finally retiredfrom dance, I was living in the
EU and decided it was time tosort of go back to my roots and
figure out how to have an impacton people who were growing up
(02:30):
in similar situations to the waythat I had been, was enrolled
in medical school, movedoverseas, finished up here and
found myself in rural ERs as aPA, and that I thought thought
was my path to fixing thehealthcare system and really
having the impact that I dreamedabout and really it was all.
(02:52):
It was all a nice fantasy butwas not playing out.
So I started getting involved.
I read Marty McCary's book nowthe FDA commissioner.
He was a surgeon at Hopkinswhen I read the book and really
changed the way that I thoughtabout healthcare and that I
understood some of the healthpolicy and business aspects, and
(03:16):
so I've spent a little timehelping out in compliance and
marketing and all of thesedifferent spaces.
But where I see myself now ismoving the message forward,
trying to use some of thoseskills of being plain spoken,
from Louisiana and and alsobeing in the emergency
(03:36):
department, you know, sittingwith people with varying degrees
of health literacy and beingable to take more complex
messaging and actually helppeople understand it, because I
think that's where we all needto be looking to in health care
in general.
Speaker 1 (03:53):
And that's a great jumping off point.
So let's talk about this.
What were your key takeawaysfrom the executive order?
Speaker 3 (04:00):
Yeah.
So you know it was a littlescary at first because I, you
know, initially read the initialheadlines that came out and the
big talking points that werejust quickly thrown out into the
universe and it sort of lookedlike price controls to me, just
(04:27):
because in my experience, in myreading and experience in life,
you see price controls come upand immediately you think of
things like shortages and reallythe cessation of development of
new ideas and new solutions.
And in healthcare that isabsolutely a devastating concept
.
Right, it's got a huge impact.
But the more that I have lookedinto it, to be fair, there
(04:58):
aren't a ton of details onexactly how the nuts and bolts
of all of this are envisioned towork.
But through watching the pressconferences that again Marty
McCary has given and PresidentTrump gave officially the day he
signed the order, and readingthrough the White House
information that they've put out, it looks a lot less like price
controls and a lot more likealmost like we see things
playing out in the normalmarketplace.
(05:20):
My husband owns a just starteda coffee company of all things.
It's a product-based companyand when I look at the
distributors that he buys fromor the stores that he sells to,
every bit of pricing works withthis sort of understanding and
(05:43):
formula that the larger theorder is, the more favorable the
pricing is.
And given that Americansrepresent only 4 percent of the
global population but we areactually providing 75 percent of
pharma profits, I think thatdoes speak somewhat to the fact
(06:04):
that we're sort of not operatingin the same way that every
other industry is operating, andthis executive order seems to
be an attempt to rectify andsort, of course, correct some of
that.
Speaker 1 (06:17):
Yeah, I mean, even if you make the argument that
there might be a drag ondevelopment of new drugs and
whatnot, the question is, whywould you require one country to
subsidize all of the otherstuff?
Why wouldn't you spread yourdevelopment costs over your
entire marketplace rather thanjust one?
I mean, it's kind of arhetorical question, but then
(06:38):
again it's not.
So I digress the bill.
The bill, the executive order,seeks to set up what they call
most favored nation pricing.
What does that mean and what doyou think the impact might be
on us mere mortals here in theUnited States?
Speaker 3 (06:54):
Yeah, there's a spectrum to look at impact and
you know I've attempted toreally find diverging viewpoints
on this and basically thespectrum at the moment, from
what I've seen, runs from youknow, it's actually not going to
(07:15):
do much.
It's a big nothing burger.
It's a PR stunt which, as faras worst case scenarios go, that
is not the worst one I couldimagine.
Right To this, could you knowif it works?
(07:50):
The way that talks aboutcreating a direct-to-consumer
path.
It's not clear what that is.
The order provides for HHS, theDepartment of Health and Human
Services, to come up with somesort of structure for a
direct-to-consumer area.
(08:11):
It also alludes to some powerto source drugs from other
countries, which, for those ofus in this little corner of the
healthcare disruptors, we knowthat this is already happening.
But something that I think isparticularly interesting about
that as far as outcomes go is,you know, when you think about
(08:35):
other industries again, likemaybe a new parent who needs to
buy a car seat or a crib and hasnever done that before, you
have no idea sort of what thepricing is going to be for those
things.
Like what to expect, what'savailable in the marketplace.
You go to Amazon or whateveryou type in the search term and
then you get an idea.
In healthcare, if I have neverreally paid attention, I've
(08:59):
never had a chronic diseasebefore and my doctor prescribes
metformin I have really no ideawhat to expect.
Why is the CVS metformin adifferent price than maybe
Walgreens, than maybe myindependent pharmacy?
I have no way to shop and Ithink some of the unintended
(09:19):
consequences certainly might benot advantageous to different
stakeholders in the marketplace.
But one of the unintendedconsequences that I think could
result from this is really thatconsumers have a place where
they can go and start to informthemselves on what's possible
(09:41):
and what to expect in regards todrug pricing.
You don't have to buy itthrough this direct-to-consumer
area, but you at least start toget a transparent overview of
how healthcare works, and that'ssomething that I kind of love.
Speaker 1 (09:56):
Well, it's kind of hard to imagine that it won't
have a significant impact,assuming it gets implemented.
And there's a long way.
As everybody knows, there's along way between an executive
order and actual implementation,especially around things like
drugs where there's efficacy andsafety issues and all of that
kind of stuff.
But an example yesterday I wentto Walgreens.
I picked up a medicine afterMedicare, after my Part D
(10:20):
supplement, which is healthy.
It covers a lot.
My out-of-pocket was $144.
If I call up my buddy at theCanadian med store who's been
doing this importation stuffdirect from factories for years,
and I get the same drug, myprice is $140.
Which means that someplacebetween $140 and the retail, the
(10:42):
quoted retail price of the drug, which was $1,600, there's a
whole bunch of people making awhole lot of money.
And do you think that's part ofthe reason for trying to go
down this path?
Speaker 3 (10:54):
I mean, I absolutely think it is, and you know that's
not just speculation, that'ssomething that they certainly
brought up in the pressconference in a comedic way.
If I say so myself, it was alittle bit like I don't know.
We're not going to name all ofthese middlemen, but certainly
middlemen are involved in everystep of the process.
(11:14):
Pbms comes to mind, clearly.
But I want to go back tosomething that you said about
research and development,because I think that you know
bipartisan discussion andefforts and promises, quite
frankly, to reform and addressthe escalating cost of
(11:37):
prescription drugs have beengoing on for years and every
time you know this really comesup.
The one of the big argumentsagainst doing any sort of reform
is look, we believe in, youknow, capitalism to whatever
degree, we believe in freemarkets to whatever degree.
And if you take a, a companythat exists, pharma right,
(12:00):
whether it's Pfizer or whoeverit is, and you tell them, well,
we're going to take away yourability to make profit, then
obviously that has an impact onhow much they're willing to
invest, because the return oninvestment has now decreased.
What I thought was reallyinteresting about this approach
(12:22):
is that the goal of this orderand of the way that it's
structured isn't to decrease theprofits of pharma whatsoever,
right.
But if 75% of the profits areonly coming from 4% of the
population, then what ifeveryone just pays a little more
(12:44):
?
What if the deals are juststructured a little differently?
And you know, and it makes thisequalization effect.
And I love that right, becauseI feel like that argument and
that concern which, as aclinician, is concerning to me,
I, I want pharmaceuticalcompanies making, um, drugs that
(13:06):
are impacting lives.
Not a lot of those.
Those products don't have alarge effect, but some of them
do and, um, and, and I thinkthat this order does uh, is has
the potential to lower priceswithout having those negative
effects.
Speaker 1 (13:27):
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And now back to ourconversation.
One of the things that you saida moment ago as the predicate
(15:10):
to your answer is in a freemarket.
Speaker 3 (15:13):
Yep.
Speaker 1 (15:14):
This is not a free market.
No, what we have today isprobably the furthest thing from
a free market that you canpossibly imagine.
So to a point you made earlier,if we start getting
transparency and if consumersget information and if there are
multiple pathways to be able tobuy a drug, where I don't have
to go to A, I can go to B or Cor D, then we're approaching a
(15:36):
free market and that logic mighthold.
Then we're approaching a freemarket and you know that logic
might hold.
Today you used the T word soI'll bring it up again.
We have no transparency.
If I didn't know the folks atthe Canadian med store and know
the owners for the last 25, 30years, it would never have
occurred to me to call them upand go hey, you know this drug,
(15:59):
I'm taking this Eloquist stuff.
What does a 90-day supply of5-milligram Eloquist you know
cost if I take it twice a day?
And I would never have knownthat.
It was almost exactly the sameas the co-pay I'm paying after
two different kinds of insurance, which it turns out is 10% of
the retail price of the drug inthe United States.
Tell me in what universe thismakes sense.
Speaker 3 (16:25):
David, I don't know if I should be happy or sad that
that was the example that youbrought up, but my heart is
racing out of my chest.
I mean, this is the perfectexample.
So let me give you an examplefrom the emergency department.
You know, we have young peoplewho show up and have no idea
(16:48):
that they have a geneticpredisposition to clotting or
have no idea that, you know, forwhatever reason they have
developed this blood clot.
And you know our answer to themin the emergency department is
we do all of these expensivetests, we do the ultrasound, we
find the things and then we say,okay, whether it's something
(17:11):
that you know was caused by anoutside situation, or something
that is just you're predisposedto, either way we're going to go
ahead and put you on this bloodthinning medication that will,
you know, reduce the likelihoodof really terrible things
happening in the future becauseof this problem.
And it's infuriating becauseit's such an important thing to
(17:39):
happen.
It's such an importanttreatment that we believe
actually changes clinicaloutcomes that we are unwilling
to allow a patient to leave thehospital until we are certain
beyond the shadow of a doubtthat the patient is going to be
able to pick up this medicineand the reason that I have spent
(18:02):
many shifts that you knowthousands of clinicians, I'm
certain, have spent, you know,hours past their shift like on
the phone with social workfiguring all of this out.
It isn't because this drug issome sort of like special
unicorn that we can't findsomewhere.
It's because it's so darnexpensive that we know the
(18:24):
patients are not likely to beable to pick it up when they get
to the pharmacy, and so, anyway, it creates all of these
barriers to care for pricing.
And maybe you say, oh okay, well, this comes from this very
special plant or animal orwhatever and it costs us this
much to make it.
But that's not the case.
If it's not the case in Canada,then how is that the case in
(18:46):
the U?
S?
And I think, like we're nottalking, we're not playing games
.
This is a political game.
You know.
I brought up the thing aboutfree markets because because the
talking points from pharmaright, like, for example, one of
their largest lobbyingorganizations.
Their talking points were well,we oppose price controls at any
(19:10):
level, in any way.
And that's not what this isabout.
It's not about finding thecontrary opinion that isn't
really congruent with reality.
It's about figuring out how canwe help the patient in front of
us, and as clinicians we don'treally have the power to
necessarily change all of thesethings systemically, and we need
(19:30):
our health policy leaders andorganizations and our you know,
president and other other peoplein power Congress to actually
step in there and intervene andhelp us do this, and I hope that
is what is happening.
Speaker 1 (19:46):
Well, you know, you raised the rock and let the
critters scurry out, so I'llfollow it out into the hopefully
out into the sunshine.
There isn't an organization onearth that spends more money
lobbying than Big Pharma.
They were the first people inthe White House when ACA was
being considered.
They're headed by a guy who's aformer congressman from
Louisiana who certainly knowshis way around.
(20:07):
They spread loads of moneyaround on Capitol Hill.
So do you think that we're at atipping point now, where I know
the four guys who are at HHSare unicorns?
They're unique, you know you'vegot Marty McCary, who you
mentioned earlier, and JayBhattacharya and Mehmet Oz and
(20:29):
Bobby Kennedy, who is certainlythe outlier.
Do you think that they willmaybe be able to rally their
friends in Congress to maybetake a different path than just
sucking up funds from big pharmaand doing their bidding?
Speaker 3 (20:45):
I would say that that is probably my primary concern.
When I look at all of this,when I see an initiative like
this and I get really excitedabout the world that this could
create, uh, the reason that Itell myself to just calm down
(21:05):
and not get, not get too workedup too soon, is, uh is because
I'm not.
I'm not sure about that, but Iam forever an optimist.
Uh, thankfully, I think, butthe way that I look at it is, um
, the chore.
The story, at least, that Ichoose to tell myself, is that
we really do have more powerthan we think, and some examples
of that that I bring up all thetime are if patients asked more
(21:27):
questions, there would be lessover-testing.
If patients asked a questionabout the CT scan that they find
on their medical bill thatnever happened, they would do
that less right.
And the same is true of doctorsand clinicians.
We all are up in arms andcomplaining about Epic and
(21:49):
declining reimbursements and allof these issues everybody wants
to be upset about.
But if we just opted out andsaid, no, I'm not doing that,
I'm actually not going to treatdiabetes and heart failure and
this wound that won't heal in my76-year-old patient in seven
minutes.
I'm not doing it, and I thinkthat the tipping point for that
(22:13):
is likely smaller than we think.
Right, so if 10% of people sawthe light and said, yeah, we're
not doing that anymore, I thinkthat real change could happen.
And I think my hope in thissituation in particular is if we
can get some traction on thesethings.
If we have seniors and kidswith rare diseases and we have
(22:38):
populations who were rationingtheir insulin and experiencing
life-threatening complicationsfrom doing so all of a sudden
have access to medication, theyhave access to medical treatment
, then that has the power tochange.
We won't stand for it anymore.
(23:00):
I think that Congress andpoliticians, after we've reached
that tipping point, aren'tgoing to be able to hide behind
oh well, it can't be done.
Oh well, we can't possibly dothis.
The implications are going tobe horrific, because we're going
to already see it happening,we're going to already see it
working and we're not going towant to to give that up.
(23:21):
And so that is, I think, thethe silver lining that at least
I'm clinging to, and it's partof the reason that I'm on this
show and I'm, like you know,talking about things as much as
I am.
It's not because I'm committedto any particular political
party or political ideology orwhat have you.
(23:41):
It's because I am 100 percentcommitted to transparency and
accountability and patientsgetting what they need without
being exploited by third partieswho produce minimal if any
value and and are destroying thehealth care system.
Speaker 1 (24:00):
So here's a question on something you said, because
you're in the trenches andyou're out there practicing
clinically a good portion ofyour time, when you're not doing
insightful articles and kind ofinteresting YouTubes and all
that stuff.
I mean, I've told you thisbefore Years ago.
One of my very first clients inthe insurance business
Dinosaurs I mean, I've told youthis before Years ago one of my
very first clients in theinsurance business dinosaurs, I
(24:21):
think had just left the earth atthat point was a hemoncologist
who said to me that doctors willget off their pedestals when
patients get off their knees.
Speaker 3 (24:31):
Yes.
Speaker 1 (24:32):
In your clinical practice?
You just said you know patientsneed to ask more questions.
In your clinical practice, areyou seeing a generational shift
away from this blind white coatauthority in patients and
patients asking more questions,or is it not happening yet?
Speaker 3 (24:47):
So I'm seeing a generational shift, but and I
wish that I could say that it iswhat you just described I wish
that I could say that youngpeople are now showing up and
they're saying no, I don't haveto do that.
Actually, why don't you explainto me how this test is going to
change your treatment, and thenyou know, and then we can talk
about if it's something that I'mwilling to do.
(25:09):
But honestly, at least in myend of one my personal
experience, I am seeing agenerational change, but it's
more of apathy.
I think that young people arejust beaten down right.
They don't believe, like theolder generations I would say
(25:29):
you know my generation and maybebefore.
They don't think oh, doctorknows best, of course, doctor,
I'm happy to listen.
They think well, you're likelyan idiot and some sort of pharma
shill, but I'm going to do whatyou say anyway, because I have
(25:50):
no power.
And essentially I mean that'sheartbreaking, that's
devastating to think that thereis a generation of young people
that are growing up and andcontinuing to follow the same
patterns of just doing whatthey're told In a.
In a lot of ways it reminds meof taxes.
So you know, there've been manyyears that people are like, oh,
(26:13):
you should ask your CPA aboutthis or that or whatever.
And I'm like I'm not paying aCPA.
And they're like, well, why youcould save thousands of dollars
because you're just throwingmoney away by not following
these, taking exemptions, that,whatever I could or whatever the
terminology is.
That I don't understand.
(26:33):
And my answer has all like itdoesn't make any sense.
And when I sat down and Ireflected and realized, like why
am I doing this really stupidthing?
I'm like a smart person and theanswer is well, because I feel
like I have no power.
I feel like I'm going to getscrewed no matter what I do, so
(26:53):
I might as well not try.
And it's.
It's really.
That's what I'm seeing frompatients.
Speaker 1 (26:59):
A wise man, not all that many years ago, said power
is never given, it's alwaystaken.
What's it going to take?
Or are we so far around thebend that we're going to have to
blow up what's here today inorder to get to patients saying,
hey, I'm in charge here?
Speaker 3 (27:14):
Hmm, you know, I hope that's not true, but I will say
that one of the positive thingsthat I have noticed in the
financial crisis essentiallythat we have in healthcare is
that the trajectory that we'reon is not sustainable.
(27:36):
And I don't mean it's notsustainable for poor people or
for people who make minimum wageor for factory workers.
I mean it is not sustainablefor anyone I routinely talk
about when I walk out throughthe waiting room at the
emergency department and I lookat the people who are waiting
(27:59):
there.
The people that are waiting foreight, 10 hours aren't just
people who are experiencinghomelessness or who perhaps are
uninsured or whatever the casemay be.
They're people with Mercedeskey fobs on their key chains.
They're all of us key fobs ontheir key chains.
(28:25):
They're all of us.
Every class, every patient groupin America is being affected by
the prices in one way oranother of healthcare, and what
I think could happen is that, asthese prices increase and
people get more and moredesperate, they are going to be
willing to accept things that goagainst the status quo, things
that go against the narrative,like maybe they're willing to go
(28:47):
to the pharmacy and ask thepharmacist hey, I usually use my
insurance, but could you tellme what the cash price is for
this medicine?
Maybe they wouldn't have donethat before, but when your
medicine's $10,000 a month,you're willing to ask that
question a lot easier, right?
So my hope is that, as theindustry stakeholders continue
(29:07):
to be more greedy and thingscontinue to go up, is that
patients slowly come to therealization.
And then, you know, theyrealize that one alternative
model works and is true andprovides great care, and then
they're willing to try some, anew one, and a new one, and a
new one.
Um, but either way, I thinkthat's where we're going.
Whether it's that you know wearen't willing to try anything
(29:28):
new and then, uh, the wholething blows up and then we have
to.
Or if it's that, you know,incrementally, more and more and
more of us are us are willingto try things like direct pay or
direct primary care, and youknow all of these alternative
models.
I don't know, but I certainlyhope that it will be a soft
landing.
Speaker 1 (29:45):
In the meantime, folks should check out your
YouTube channel, healthcareLiberty Lab, and also, you know,
your longer form stuff that youwrite on Substack at Red Flag
Hero, tiffany Ryder.
Thank you so much for being ourguest today.
It's been a pleasure having youon the podcast and I can't
believe I waited this long.
But thanks for being here.
Speaker 3 (30:03):
Thanks so much for having me, David.
I hope we talk soon.
Speaker 1 (30:12):
I want to give a quick shout out to our sponsor
and our producer, hatcher Media.
Hey, if you need podcastproduction or professional
graphic design, josh Hatcher isthe expert to contact For more
information.
Visit him at hatchermedianet.
That's H-A-T-C-H-E-R medianet.
Speaker 2 (30:30):
This Shift Chapers podcast is copyrighted content
and may not be reproduced inwhole or in part without the
express written permission ofShiftChaper Solutions LLC.
Copyright 2024.
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