June 3, 2020

JC Scott (00:08): Welcome to the Pharmacy Benefit, a podcast where we talk about issues impacting patients, consumers, and affordable access to prescription drugs and better healthcare through the work being done by pharmacy benefit managers or PBMs. I’m JC Scott. Thank you for joining me.

Our topic today is especially relevant and timely. We’re all navigating continued uncertainties as our country deals with the COVID-19 pandemic. But as we look at the role of prescription drugs in the supply chain, there are reasons for hope as well as important considerations as we work to balance patient access and avoid drug shortages. I know that among the many questions Americans are asking right now is whether they’re going to be able to continue to get their prescription drugs and how they can do so while practicing social distancing. Many are also wondering whether if they get the COVID-19 virus, they’ll be able to afford the treatment.

Joining me today to talk about these questions and others is Tim Wentworth, the president of Cigna Health Services. Tim’s responsibilities include oversight of Cigna’s Express Scripts pharmacy benefit management business, their home delivery pharmacy, and subsidiaries including their specialty pharmacy and medical benefit management.

From this perch, Tim has visibility into a broad cross section of several important aspects of our healthcare system. Tim has a particular passion for service, excellence and innovation. Under his leadership, Cigna is working to put patients first as we all work to respond to COVID-19. Tim has held a number of leadership roles in the PBM industry over the years, and also serves on the board of directors for the Pharmaceutical Care Management Association or PCMA.

Tim, thanks so much for joining me. I’m really looking forward to your insights

Tim Wentworth (01:47): Hey, great to be here with you, JC Look forward to the conversation.

JC Scott (01:51): Why don’t we start by letting our listeners get to know you a little bit, Tim, and have you tell us a bit more about yourself? How did you first get involved with healthcare and what led you to the PBM industry?

Tim Wentworth (02:01): Well, like most kids, I didn’t grow up thinking I wanted to work at a PBM, but I found my way here in sort of a very direct way coming from the payer side. And so a long part of my career I had spent in human resources and had had to defend benefit cost increases as far back as the 80s and 90s when there was some significant government intervention being contemplated at that time. And so I’d had a career in consumer products across a couple of different companies, when an ex colleague in 1998 called me and said, “I think you’d be perfect for Medco.” Which was at the time, one of the major PBMs. They were owned by Merck at the time.

I said to him, “I don’t know the thing about sort of Medco. Merck’s a great company. I know you’re happy there.”

And he said, “You’ve been a buyer of benefits. You understand what the challenges are, and our customers are all big buyers of benefits, whether they be health plans or they’d be large employers, governments, labor units, et cetera.”

And so the job was to take care of the entire book of paying clients, the book of business that provide the benefits to the members. And so in 1998, I joined and would never have guessed, I guess, that we’d be sitting here now 22 years later with such an important role for the industry still. It’s evolved a ton over the last 22 years. But the role of driving affordability, driving safety; driving access; driving innovation, frankly, and celebrating innovation when pharma’s able to price it right, all sort of continue to be pretty fundamental to what we do.

JC Scott (03:32): That’s terrific. We can hear the passion that you have for the career that you’ve had in this industry, and I want to tap into that a little bit. Before I do, because we haven’t talked in a little bit, Tim, how are you and your family doing in our new shelter-in-place world? And as you’ve approached this environment as a leader now of Cigna Express Scripts, how are you managing this situation for your employees?

Tim Wentworth (03:57): I appreciate the question. Obviously, Robin and I quickly decided we’d better take care of ourselves and our kids first, and then we’ll be in a position to take care of others, including all of the employees that I’m responsible for. We sheltered in place in mid-March in Northern New Jersey here. It’s where two of our three girls are. We actually have my youngest, who’s just starting a doctoral program in New York City, actually living with us with her guy. We’re here. We’re a safe. We are being thoughtful about our interactions outside the four walls of the house, and I’m finding working at home to be tremendously efficient. I’m looking forward to one day getting back into the office, but we’re doing well.

As it relates to Cigna, we’ve been really focused on, and particularly my part of the business, in making sure, I’m sure we’ll talk more about this, that we keep our employees safe, that we keep our customers taken care of and our patients well sort of supplied with the drugs that they need, and really going about the work that we do pretty much uninterrupted. We saw certainly a spike in volume that we had to manage through sort of in the back half of March. But besides that sort of unique, single spike, what it’s been is all about being there for our patients and making sure employees felt safe and engaged. And we moved tens of thousands of employees to home in very, very short order.

Amazingly, we did an engagement survey recently and they were feeling, actually, as are more engaged than they had about a year ago when we did our more formal survey and that was at a very, very high level. And so we feel we’ve done a good job taking care of our employees.

And then most importantly, taking care of the patients. We have a thousand nurses for example, that are going into homes and where we can’t convert those to televisits, we have to make sure we’ve got the PPE they need. We need to make sure the patients are comfortable with them coming in. That it’s an effective and efficient visit. And we’ve been able to continue to maintain all of that through this process.

And so, it continues. We raised pay 20% for folks who were not able to go work at home. For example, to let them know that we recognize that they don’t have some of the flexibility that some of their colleagues would have. But how important it is that what they’re doing, have them be in an office or visiting patients’ home. So again, we’re kind of learning as we go a little bit, trying to lead and to listening very carefully to our employees to make sure that we’re tuned into their concerns.

JC Scott (06:23): Well, it sounds like you’ve created a great place to work, and you’re obviously thinking about what your folks need as we all are at this difficult time. And what I also heard, Tim, as you talked about your history of getting into the industry, both as a purchaser of benefits and a big provider of benefits, I could hear in the words that you chose your focus on the consumer and the patient who’s on the end of that. That seems to be, correct me if I’m wrong, really front of mind for you, in particular during this time, as you pursued the company’s mission. And I’m curious how you shifted at a high level, how you shifted the Cigna posture as it relates to COVID-19 to take on that mantra of patient first?

Tim Wentworth (07:05): Well, I’ve got to say I’m fortunate that our industry, by the way, I think has done a great job of keeping that focus up on the individual patient and the reason that, frankly, we exist. Cigna clearly had that same appreciation. And so from that standpoint, I have a group of leaders that I work with and for that are very aligned around making sure that we take care of the member or the patient, whatever you want to call them, all the time. It’s not a big transitional shift in thinking during this pandemic to say, what do we need to do different?

Now, we certainly have asked ourselves, what do we need to do more of, less of, start, stop, continue kind of thinking. But it’s been from a very long history, both inside of Cigna and inside of Express Scripts, of putting the patient first and having that really drive how the business success is derived. And so as we’ve worked through this and as we’ve thought about our employees, we’ve concurrently thought about our patients.

And as you know, I was at the White House two months ago now because Cigna was the first company to actually waive the cost of testing for all patients. Again, bringing that access sort of mentality and evolving it for the particular circumstances that we’re in, and making sure that every patient that should get a test doesn’t stop and worry about what it’s going to cost them.

We’ve continued to challenge ourselves. And certainly as a member of the team, I’ve continued to challenge our team. Our industry continues to challenge itself to, what more can we do? And you’ve seen broadly in healthcare and then specifically PBMs a continuation of things like waving formulary things where there might be something that would be short of supply for a period of time. Waving refill too soon where it makes sense at an individual patient level, where a pharmacist can consult and use his or her professional judgment to do that. We’ve, again, evolved a lot of the practices of the PBM without really changing a bit the philosophy, which was patient first.

JC Scott (08:54): Terrific. Thanks, Tim. Let’s get a little bit more granular and I’m going to put myself in the role of the consumer or the patient here, because I am, we all are, and ask you a few questions that might be on our listeners mind. For me, I rely on the daily dose of a statin to manage my cholesterol. That’s a true story. Should I have any concern that I’m going to run out of my supply? Should I be trying to get extra supply? And what should I be thinking about when I look ahead to my own needs for access?

Tim Wentworth (09:25): Well, I appreciate very much that question because I would want all of our listeners to know that first and foremost, they should be taking their statins, they should be taking their insulin, they should be taking the drugs that help them to stay healthy. More than ever now, we know this about this virus, which is, it is brutal on folks who are not taking care of themselves. And so from a standpoint of remaining on your drugs, you should do it and you should do it knowing that the supply chain is there for you.

We’ve seen nothing as it relates to shortages for things like lisinopril, things that take care of your cholesterol, things that take care of your heart disease, things that take care of your depression, et cetera, et cetera. We’ve had a couple of areas that we’ve watched. We’ve watched inhalers. But what we’ve seen is the FDA approving additional generics, and we’ve managed the supply chain to ensure we could continue to provide a safe supply of inhalers to patients. We did for a period of time evaluate what they had on hand. And if possible, we cut back a little bit to be sure that we had more than enough. Again, the industry and our company very dynamically managing sort of the supply chain in the context of what we see.

I think the other area we’ve been watching would be the drugs that would be potentially available to help COVID patients, and what we want to do is be sure to protect the patients that take those drugs today for other things. Hydroxychloroquine, for example, which is indicated and has long been indicated for rheumatoid arthritis and lupus, we wanted to protect those patients even as hospitals were looking to potentially add supplies of that in advance of some of the research that now appears to be maybe a bit more questionable as to whether that particular drug is going to be therapeutically effective for the majority of patients. There’s still some trials going on, but I know a couple of the major medical journals have both kind of declared not likely.

And listen, there’s no one more than a than us and me and you, I’m sure, you want to see an effective therapeutic. It’s a key to our getting back to normal. But what we’re watching for is where it looks like an existing drug that has existing patients on it may find some additional benefit. That was the case, again, with inhalers a little bit, either in treating or recovering of this disease. We’re working upstage in the supply chain to ensure that we’ve got the right kind of availability. You should be taking your drugs is my answer to you, J.C.

JC Scott (11:42): Well, I appreciate that reassurance, and the question or the issue that you raise of drugs that may now be serving more than the purpose for which they were originally innovated, right? They’re identified as potentially helping with COVID. It seems from just a political perspective that what we hear from policymakers is they want everybody who wants as much of any given drug to have access to it as possible, right? They’re telling me as the individual patient on the chronic medication, “Go and get your 90-day supply.” And they’re also promising if you’re diagnosed with COVID, “We’re going to make sure you get this drug as well.”

You talked about it some, but talk further about how do you manage that balance? Are you having to think about some refill limitations in some instances? Are you having to deliver a message back to policy makers to help them understand the balancing act that you’re going through?

Tim Wentworth (12:36): Well, we’ve engaged very, very much, first of all, with policy makers. Because as you can appreciate, this is not only federal, this is at the state level as well. Pharmacy laws is by its nature state. And so we have engaged in every place where we saw a conversation going on, which may have led to a place where the intentions were good but the unintended consequences could have actually caused more stockpiling, more shortages without really benefiting patients incrementally in terms of having what they need.

And so what we’ve reinforced is, first of all, a pharmacist has always been in a position to use his or her professional judgment, as I mentioned before, to override any sort of a refill too soon. That if the patient has a reason that that pharmacist is comfortable with clinically, that hasn’t changed. But we have worked with the states to ensure that there’s a thoughtful refill regulatory environment, and we’ve been very successful at that as an industry. You and your team have been terrific in that respect. And I think it’s important that our industry as an industry, including by the way retailers; frankly, including pharma, as it relates to nobody wanting to see unnecessary shortages that are caused by an unintended consequence. We’ve done that.

What we’ve also done though, again, watching the supply chain closely. And right now we haven’t had to exercise these playbooks, but we would be able to open up for many drugs, formulary access to competitive products where in the time that’s more normal, you may be able to choose one drug against another. And both of them being therapeutically effective; and therefore, the one that’s most cost effective being the one on formulary and the other one not. But for the period of time of a pandemic like this, you would certainly open up therapeutics, and we’ve got a playbook to do that.

If, for some reason, we ran short… In fact, we’ve worked with our couple of our industry colleagues who have mail service operations as well, that aren’t as robust as ours, to back them up in case they ran out of this product, or more likely, if they had a temporary shutdown because of an outbreak in one of their facilities. And so we agreed to work with each other to backstop each other.

That’s what you see the industry doing to really think through end to end patient continuity of care, whether it be regulatory, whether it be cooperating with traditionally our competitors, whether it be working with retail to make it easier for patients to get something sent to their home from retail, something a lot of our plans don’t normally allow. But again, we’ve got playbooks that we’ve used for things like hurricanes. Those tend to be zip code kind of driven or regionally driven, and we’ve just taken those playbooks and we’ve nationalized them and we’ve sort of applied them in the case of this national pandemic.

JC Scott (15:12): Thanks, Tim. So if there’s a couple of takeaways from what you just said, one, we should all have confidence in the supply chain. And it sounds like not only the PBM industry, but others up and down the supply chain, are working together to try and create as much confidence for all of us as patients and consumers. That we’re going to have access to what we need. And two, that your company, Cigna Express Scripts, as well as others in the industry are showing a lot of nimbleness and flexibility right now, recognizing this situation we’re in and maybe changing some of the things that are normally in place because it’s what’s necessary to get individuals through this current situation.

Tim Wentworth (15:50): Yeah, no question. And I think we in our industry, but we as a company, got out ahead of it early too. We saw the toilet paper shortages, right? And that same psychology times 10. Because think about it, my health is way more important, frankly, I think, than my toilet paper supply. And so we were very concerned that, again, you would get this shock to the system that would bear no resemblance to newly diagnosed patients driving incremental volumes. It would just be a bubble problem through the system, and we got out ahead of it early. We counseled patients. We counseled physicians.

I appreciate your characterization of it. We really have been very careful and thoughtful to get to a place that now as things kind of normalize a bit, and I recognize we’re still a long way away from being back to normal, we’ve seen the ability for the system to act responsibly and therefore not have any concerns.

The other call out I would say, because this is probably not well known about PBMs and particularly about our company, is we have line of sight all the way up to the raw material. One of the early concerns was that the raw materials for some of these drugs, particularly generics, which as you know are 90% of all drugs prescribed. We’re very heavily sourced in China or in some cases, India, both of which were going through their own situation.

And while in the long-term, I’m sure that the generic manufacturers are going to look at the diversification of their raw material base, that’s not in our company’s bailiwick, but we certainly were watching all the way upstream and seeing pretty confidently that we thought that we should be able to continue a good, reliable supply, which is what we’ve seen for most of these products.

Again, longer term, you’re going to hear a lot of talk I think about China and about reliability as a source. And I think the pharma companies will look to do what you do after a disaster like this, which is diversify your sources in the context of a disaster recovery playbook. But we’ve had good visibility to that, continue to and are very comfortable we can continue to take care of patients.

JC Scott (17:50): Tim, I’m going to ask you a little bit of a left field question. But it’s interesting as you talk about the dynamics around manufacturers, you mentioned retailers, meaning retail pharmacies, independent pharmacies, it strikes me that the collaboration between stakeholders in the supply chain is really different right now compared to where it has been in recent months and years around issues related to cost. And I’m wondering as you look forward, if you think that the new dynamic where the supply chain is working together on behalf of the patients a little bit better right now, is that here to stay? Are we going to see any fundamental shifts in stakeholder dynamics going forward?

Tim Wentworth (18:33): It’s early to be an optimist, but I’m always an optimist. I think that we’ve demonstrated clearly in these last several months that we are not anti-retail, not anti-pharma, but not anti all the things that we get painted as. That we know how to collaborate to create real value, real access. That we have a long history of it. We didn’t just start doing it because there’s a pandemic. It’s just that’s not what was capturing the headlines. And a lot of that was because, quite frankly, there is an affordability crisis in health care, drugs are part of it and we have a job to do as it relates to trying to make sure every dollar that’s spent is spent wisely.

And sometimes that pits us in a situation where we aren’t going to completely agree with some of those other players. But I think what we agree completely at a fundamental level with all of those other players on is the importance of taking care of the patient. The importance of the patient being healthy and getting what they need. And we all go about that with an incredibly, I think, strong and good intention. Despite the fact we have significant, at times, disagreements over what value is and so forth.

I think that’s healthy. I think it continues to be a good thing. And all you have to do is take a look at the company Gilead, who was being so pilloried because of the price of their new, highly innovative hepatitis C drug several years ago, is now being looked to be truly, potentially a key part of getting this country back in business by virtue of having a therapeutic.

And from my perspective, I don’t see that those are two different conversations. I see those as one. I see Gilead as being amazingly responsive to this opportunity to help. I’d like to believe that they have a fundamental view. I believe they’d have a fundamental view that says access is critical. And I think we had the same goal. You’ve got this opportunity for us to continue to redefine what it means to collaborate. You saw us launch something recently that required mega amounts of collaboration with retail pharma and us to put an uninsured program in place that has deep, deep discounts for uninsured folks. That would not have happened if we were not able to collaborate, and I see that continuing.

JC Scott (20:40): That’s a great transition, Tim. Because we’re turning to the here and now, we are seeing a lot of people, a growing number of Americans losing their jobs. That’s going to have an impact on their access to health care and their ability to continue to get medications. Can you talk a little bit about what Cigna’s been thinking about to help those individuals?

Tim Wentworth (20:59): Sure. I appreciate it. We obviously have challenged ourselves both on the pharmacy side as well as actually on the major medical side. And so I don’t have anything to announce today on the major medical side other then tell you we are looking very, very thoughtfully at how we can benefit folks who either can’t afford their Cobra or are truly in between jobs and don’t have any insurance at all. Because we recognize while a lot of employers, thankfully, are trying to bridge their employees through and maintaining coverage, and we’re working with those employers to drive affordability, for those patients that don’t have the good fortune of that, we’re really trying to think through what’s a way to demonstrate clearly that we can take care of them.

And so on the pharmacy side, we launched last week a product, I guess I’ll call it, called Parachute RX. And as I just said, it really brought together almost every major US pharma company, all of whom had compassionate needs programs, but this brought those programs and the dollars that they would typically fund through those, to a much more centralized, easy to access place for a patient. We then got retail pharmacies to come, as well as our own mail service pharmacy and our inside RX cash chassis to drive generics discounts.

What we ultimately ended up with was something that was going to give these patients certainty that doesn’t require them to buy anything or sign up for anything, but it caps their generic out-of-pocket costs on a monthly basis for almost every generic $25, and 90% of all prescriptions are generic as we know, and then it caps a significant number of very heavily used brands at $75 or less per month. And so relative to going into paying pure cash for these products, it’s meaningfully valuable and gives those patients a chance to stay adherent and on their meds while they’re bridging to their next employer where they will hopefully then pick benefits back up again.

Again, that doesn’t just happen in pharmacy. We’re looking at doing something similar on the medical side as well. I know our industry continues to challenge itself around access beyond just for COVID patients’ testing and COVID patients’ treatment, to look really at that unemployed group of Americans now over 20 million plus as a group of patients that also need to have a solution. And we’re going to continue to challenge ourselves as we did last week by launching something like Parachute.

JC Scott (23:12): That is terrific. As you think about that program, and obviously we’re in the here and now, we’re seeing the unemployment trend lines heading in the wrong direction. A program like that is absolutely necessary. How long do you envision that you’re going to have that in place? Is there a lifecycle to it?

Tim Wentworth (23:27): Yeah. I’d love to tell you that three months from now we’re not going to need it, but I don’t believe that to be the case. And so we announced that it’s going to go to at least the end of the year. And I think what we’ve shown you at every step of the way has been based on the facts and circumstances at the time, we’re going to make the right decision to care of patients. And if that means extending the program longer than that, I sit here fairly confident that our pharma partners, as well as our retail partners, would stay in the game. And we would certainly continue to be happy to convene it, and at our mail service too and at our chassis for administration and so forth, and ensure that those patients have continuity of their care all the way until this thing is much more behind us than it certainly is today and maybe at the end of the year.

JC Scott (24:09): Tim, you mentioned a moment ago that as you were thinking about this program, you’re also thinking about coverage for testing and treatment for COVID. You obviously have a great position to look across the healthcare industry, and I’m curious on two fronts, what’s your optimism level for how quickly we’re going to have a really effective treatment and/or vaccine in place? And then how Cigna ESI is thinking about providing access to those once they come around?

Tim Wentworth (24:37): Yeah, that’s a great question. We obviously are as hopeful as everybody is for a vaccine, as well as, frankly, treatments that help a patient who have COVID. Those are two key things along with, I think, adequate testing and some of the contact tracing and so forth that the people have talked about, social distancing, et cetera, to really getting us back on a meaningful track to normal.

And listen, nobody has a crystal ball. Certainly, I don’t. I’m really encouraged by what the WHO would claim there’s a hundred vaccines in development. I think just today in front of Congress, Dr. Fauci talked about something over a half a dozen that he actually is feeling good about in terms of kind of their continued progression. A company like Johnson & Johnson has decided to manufacturer at risk. They’re confident enough in their vaccine that they don’t want to find out it works and then have to school up manufacturing. They’re taking the risk of actually making it concurrently with those trials. That’s unprecedented. I think the science behind all of this is unprecedented.

We’re optimistic. But that being said, not to be a Debbie Downer, but we’ve had AIDS around for over 40 years and there’s not a vaccine today for it, so it is very hard to get a viral vaccine that that can work. I don’t know enough of the science of COVID to know sort of the unique challenges as it relates to getting this particular vaccine, but I know this. We are so fortunate to have the biotechnology companies and the pharma companies that we have, who are working collaboratively with each other, as well as obviously working very aggressively to put a vaccine in place.

I think the therapeutic side, there’s all sorts of trials of different sorts of drugs going on right now. We’ve got to be smart about that. We can’t jump to hoping something works. We’ve got to prove that it works. And if we do all that, back to the core of your question, Cigna, and I believe our industry, is going to find ways to ensure access. There’s simply no other answer. We can’t have people not vaccinating themselves because of cost. We can’t have people not taking care of themselves when they’re sick or not getting tested if they think they’re sick because of costs. It’s a public health decision more frankly than it is a commercial decision, but I think the entire world is going to watch how we respond.

And I think they’re going to see the best of the US healthcare system. We often get maligned, but I think you’ve seen our industry up till now take extraordinary steps without being told to. And I think you’ll see us continue to take extraordinary steps to ensure that we can maximally create this access that’s going to be so necessary when we have those therapeutics and those vaccines.

JC Scott (27:13): That leads me, Tim, to probably my final question. I’ve taken a lot of your time today and we appreciate how generous you’ve been with the conversation. It strikes me that we’ve been talking for about 30 minutes and we haven’t talked about drug prices or rebates or some of the traditional topics that most people would associate with the PBM industry. As you reflect on what you want our listeners to take away from the conversation today and what you want viewers of the industry to take away from what our companies have been doing to step up and help patients, what is the one thing you would want to share? What are you most proud of that our industry has been doing that perhaps will help people have a broader understanding of the value of a PBM?

Tim Wentworth (27:54): Great, last question, and what I’d say is this. Our industry is pro patient. We have our patients’ backs. And we can be painted as anti pharma or anti innovation, and it is wrong. We are pro access. We are pro affordability. We are pro headroom for real innovation so that pharma can really innovate and what the system can afford it by getting the waste out that would otherwise prevent that affordability. And so that there is nothing to our industry and nothing to our company that is more important than the health, the well-being, and the peace of mind of our patients. And we will get through this together, and I believe the patients will remember how well we did.

JC Scott (28:35): Awesome. Well, Tim, thank you. Well, we’ll leave it there. I want to thank you for joining us today and I also want to thank all of our listeners for tuning in. I hope you enjoy the conversation and we’ll come back again.

You can subscribe to our podcast on Spotify, Google Podcasts, Apple Podcast, and all other major platforms. I’m JC Scott and this is the Pharmacy Benefit.