What motivated you to pursue a career in internal medicine and public health, and how have these fields influenced your approach to patient care?
What I really enjoyed about internal medicine was the opportunity to be a detective for my patients. Every aspect of caring for patients was an opportunity to bring evidence-based medicine to bear on their behalf. I had the opportunity to do a fellowship in Health Services Research, funded by the Health Resource and Service Administration (HRSA), and get my Masters of Science in Public Health (MSPH). It was an amazing experience, and the opportunity to delve into evidence about common conditions and improve outcomes became a lifelong focus. I think today, we would call it “Real World Evidence.”
What’s struck me more in the last five years is that issues we were addressing 25 years ago, like post-acute coronary syndrome discharges, have not actually improved. Patients are still frequently not discharged on the evidence-based treatments, and we see that in real-world outcomes that do not match the promise of clinical trials across specialties. There is a fundamental opportunity to get very real about influencing human behavior—for both patients and physicians. That is a missed cornerstone of achieving better outcomes.
Throughout your career, you've been involved in initiatives aimed at reducing healthcare costs. Can you share specific strategies or programs you've implemented to make healthcare more affordable for patients?
Absolutely. I think there is a nasty paradigm of blaming patients for not following recommendations. I have heard from physicians over and over that it’s our job to make recommendations, and it’s up to the patient to follow through. Well, I don’t think so.
The patient’s out-of-pocket share of their care is a significant driver of their ability and willingness to follow through with recommendations, and ultimately, this impacts the outcomes they realize. In the U.S., it must be considered. Putting tools in the patients’ hands to access affordable care has been ignored, in my opinion. As a patient, you’re really left to your own devices in finding how to follow through.
The importance of meeting the patient with trusted and comprehensive information was reinforced by my experience as the governor-appointed physician board member for Colorado’s high-risk pool. At that time, million-dollar grants were available annually to help this critical group of patients access health insurance and care. We used those grants to develop early telehealth programs, create incentives to improve physician practices for these patients, and encourage high-value care in both primary and specialty settings. The most impactful thing we did was remove cost barriers for patients.
Transparency is crucial in building trust between patients and providers. How have you worked to enhance transparency in healthcare practices, particularly in your role as Chief Medical Officer at Express Scripts?
When I arrived at Express Scripts, my mandate was to improve clinical solutions for patients and providers. There were things that amazed me:
- The speed with which ES could respond to a policy issue.
- The size of the problems.
For example, I saw ES incorporate discount cards into claims adjudication so patients received the best price available that day, create a fully transparent pharmacy benefit, and allow OTC meds to adjudicate against pharmacy benefits—all incredible for consumers. However, these innovations were not implemented broadly due to perverse incentives at the payer (employer or health plan) and retail pharmacy levels.
I was shocked by physicians’ disregard for evidence-based medicine. “My prescription should be law,” was a common attitude. I even had a prominent chemotherapy manufacturer reach out because they estimated 40% of prescriptions were for patients who were never tested for the immune target. They were concerned about misuse of their drug.
What guidance would you offer to new healthcare professionals who are passionate about making healthcare more accessible and transparent?
Honestly? Pharmacy Benefit Managers (PBMs) get such a bad rap for not being transparent, but think about this:
- Physicians can (though they don’t always) know whether the prescription is affordable and choose between cost levels.
- Physicians can submit prior authorizations directly through the EMR.
- Prescriptions provide a guaranteed, reproducible, and consistent price across multiple pharmacies.
- If a discount card from GoodRx offers a better price for a drug on a given day, Express Scripts, at least, could adjudicate the lower of either the Express Scripts price or the GoodRx price at the point of sale.
Now compare that to medical benefits, where you often have no idea what the cost will be until you get the bill—and it can take 3-6 months to process.
Accessibility is another issue. Virtual health should be the standard, but the U.S. still hasn’t managed to enshrine a covered virtual health benefit across two administrations, leaving the majority of Americans—Medicare patients and anyone with an HSA—without this essential service.
But more important than transparency and accessibility is outcome and accountability. If Americans only take the recommended therapy 40% of the time (e.g., prescribed hypertension medications), there is NO benefit. It’s all waste.
So, let’s talk about how we support patients and providers in achieving the outcomes that clinical trials promise in the real world. That’s the real key to improving healthcare.
Who else in healthcare inspires you, and why?
- Eric Bricker, MD: He’s out there explaining the complexities of the system to everyone who will listen, breaking it down in a way people can actually understand.
- Sami Inkinen: Sami is promoting health and outcomes for ALL people—indigenous populations, veterans, Blue Cross patients—through Virta’s diabetes reversal program. It’s the most data-driven patient program I’ve ever seen. People are extremely polarized by it, and there are some crazy stories that come with it, but it’s incredibly impactful.
- Bicycle and Eleanor: Because there has to be a better way to help people with addiction than running them through ineffective inpatient programs that drain their savings and their families’ resources.
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