Finding the Balance: Innovation and Access

Welcome to Season 2 of ‘That’s Understandable’! In this episode, Brendan welcomes guests Dr. Cartier Esham of the Biotechnology Innovation Organization, Pam Traxel of the American Cancer Society Cancer Action Network and Diane, a cancer survivor in a conversation around drug pricing and medical innovation. 

The Biotechnology Innovation Organization (BIO) is a proactive voice of science and for science that is driving a “bio revolution” to cure patients, protect our climate and nourish humanity. 

The American Cancer Society Cancer Action Network (ACS CAN) is a nonprofit, nonpartisan advocacy affiliate of the American Cancer Society. ACS CAN advocates for evidence-based public policies to reduce the cancer burden for everyone. It engages volunteers throughout the US to advocate at every level of government. 

Transcript

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Hello, everyone, and welcome to season two of. That's understandable. I'm your host, Brendan McEvoy, US Head of External Communications at AstraZeneca. I'm so excited to be back so we can build on the meaningful conversations we had last year. This season, you can expect some new guest and even bolder topics. If you've enjoyed this podcast, take a moment to like and follow on your favorite streaming platform. And if you know someone who is interested in today's topic, be sure to share. You've just returned from a long trip. You noticed that your calf is red and swollen and it hurts badly. So you go to the doctor. She orders up an ultrasound and discovers you have DVT flats in your legs. She sends a prescription to your pharmacy for a new blood thinner one that doesn't require blood test. You go to pick it up and bam! You see the price and it's more than you can afford. Do you buy it and risk not making a rent? Or do you skip it altogether and risk something much worse? Around 9 million Americans are choosing the latter and aren't taking their medications as prescribed because they can't afford the cost. That's like all of New York City not taking potentially life saving medications. People with diabetes are rationing insulin. Patients with severe rheumatoid arthritis are trying to treat it with over-the-counter pain relief instead of taking their medications. People with mental illness aren't seeing care providers, and the list goes on. If that trend continues, it is estimated that drug costs related premature deaths will rise to more than 110,000 people in this country annually, making it deadlier than diabetes and the flu. So let's just lower prices and everyone gets what they need, right? Unfortunately, it's not that simple, because how a medicine is ultimately priced and what patients pay for it at the pharmacy goes far beyond anything that pharmaceutical companies can control. But we do play a part. Today, I want to focus on the innovation piece and the reality of what it takes for pharmaceutical companies to bring new lifesaving medicines to market because they can take years and billions of dollars of upfront investment to develop a medicine. And even then, there's no guarantee that the medicine will make it to market. I have three guest joining me today to break all of this down, and I want to kick off our conversation now by first introducing Diane, whose last name we won't use for privacy purposes. Diane is a cancer survivor who certainly has a point of view on the topic of medical innovation and subsequent drug pricing. Diane, hello and thank you for joining us today. Welcome to. That's understandable. Thank you for inviting me to come into the discussion today. So we'll jump right in. So, Diane, you realize I was late on my introduction in terms of details about you, and that's because I really wanted to hear directly from your voice or allow you the opportunity to share with our listeners more about you, your health journey and what all of that has been like. So let's start there. So thank you. Yes. My diagnosis was in 2010. I had a really pretty odd presentation because I had no symptoms. I felt great and always kept up with every preventative test that I could, and I had no issues. But I did have a little bit of fluid in the left side of my neck that was discovered by really sharp physical therapist, and she pointed out that I probably should have it checked, which I did. I had a Cat scan and all of that was normal, but I kept feeling the fluid pocket and it got bigger. And then after about five months, there was a tiny little pea sized lump in there. And so I knew that was not ever good news. So I had it further checked. They did a fine needle aspirate and another CT, and the aspirate came back showing adenocarcinoma, which was a huge shock. I didn't know how to cope. I had no coping skills for that. And telling my children was probably the hardest thing I ever had to do. But, I did have a biopsy. And from that biopsy, many, many fancy tests were done and the diagnosis came back. Ovarian cancer. So the biopsy told us that. But I then needed to have the bulking surgery, which is the removal of everything ovaries, tubes, uterus and part of the omentum. And even though scans showed nothing in my pelvis. The pathology showed a tiny dot in the leftover of ovarian cancer. So that makes this a stage four because it had gone up into my neck. So after the, surgery came the chemo. And over the next four and a half years, I had 17 cycles of chemo, with remissions lasting anywhere from two and a half down to one year. The fourth time this came back because of constant monitoring. I knew it was back again. I decided I really needed to branch out a little, and I decided to check my options at M.D. Anderson Cancer Center in Houston. So I had a friend who I knew knew somebody very important in the field of ovarian cancer research. So even though I hadn't seen her in 30 years, I emailed her the next day. She connected me by email to this friend who turns out he's the physician who discovered that ovarian cancer patients, 90% of them, shared a certain antigen, and he had developed the immunoassay for that. And he told me, if I could come to Houston, he may have a novel planned for me, which I did. So I came from Oregon to Houston. I had a huge workup, and he referred me to two clinical trials. I chose 1 in 2015, and I had been on it for over eight years. This trial is a phase one B it's an early faced trial, and the drugs that I was on had never been used in humans before. But amazingly, after seven weeks of being on this trial, seven weeks, all the normal things imaging and serology normalized on me. I had no evidence of disease. It lasted for eight years and I also didn't have any side effects. So it was it was just the most amazing thing to me. after eight years, I decided on my own, though, that I would discontinue the trial just because one of the drugs carried a little tiny chance for a hematologic disorder. And so I discontinued in January 2023, and it's been a while. I still have no that it's a disease. And they called me a neutral responder. So I'm hoping that this lasts for me. But none of us have any idea about the length of time that I'll be free of disease. I call myself off the leash because I'm not getting any treatment right now. First off, thank you so much for for sharing that whole journey. And I think I was fantastic to hear that everything is good. And, you know, in your life now and you're not experiencing any sort of issues. I think that maybe in some ways it was fortuitous in the way that you had sort of had the connection and found your way into a clinical trial. I'm curious, as you think about today's topic, we're talking about drug pricing, IT and innovation. I mean, from your perspective, is it fair to say that you feel like you've benefited from from innovation in healthcare, specifically through your treatment? So without a doubt, I am a very grateful recipient of, these forward thinking clinicians and scientists who really had made it their life's work to try to unravel ovarian cancer so that patient could have a chance at health. I was on two drugs. One was investigational, and one was actually FDA approved right before I started. And and those two drugs, as I said, had never been used in humans before, but in me, they were life sustaining. So I was extremely lucky. I'm very fortunate and also very grateful. And when we're talking about the cost of medicines, I would imagine, you know, going through a clinical trial, you're know, you're access to those medications is different. Can you tell us a little bit about your experience, or were there any issues with access to to the medicines, either the one that was part of the clinical trial or the one that was FDA approved? Did you encounter any of those issues? Well, in my experience, the cost of medication during that time was far less an issue than accessing some of the health care. so over the years, at the time, I had, employer provided health care insurance, but I've had both that and Medicare and, in both of those cases, my, my health care needs have been largely met. however, importantly, before I started this trial, I decided to get a nurse case manager who could really go to bat for me with insurance companies because they were the ones that had to pay for the ancillary care at the doctor's appointments. Let's visit some of the imaging. Anything that wasn't covered by the trial. My insurance had to pay for. So I really needed somebody to help me with that. And I remember telling the nurse case manager at the time, you know, it's far less expensive for me to be treated as an outpatient with oral meds than it would be for me to suffer the consequences that required my hospitalization and admission. So, you know, it really made more sense for me to to do it that way, but I'm very glad I did have a nurse case manager. Yeah, that was a very smart move on your part. Oh, and one thing I wanted to throw in, I did have the burden of travel getting myself to Texas from Oregon every 28 days, 13 times a year with my time, and I had to do that. But then, over the course of time, I said, you know, if I'm unusual responder, maybe I can cut down the number of visits I have. So they did each cut them down to every third cycle. And they said, well, by the way, you know, if I'm, your best responder, maybe you can cut down on the number of Cat scans. And surely they did. So I worked it down from four cities a year to one. So you got to just be an advocate. Absolutely. As people listen to your your experience, for those that maybe, you know, don't, where either clinical trial is not an option for them or, you know, one's unavailable or they, you know, don't have access to it, you know, given a variety of factors. But maybe there are other sort of resources available or approved medications or treatment options for them, as you think about that scenario, maybe those that, you know, dare I say like maybe less. I hate to say fortunate, right? Because obviously it was you you were dealing with with cancer, but fortunate in the sense that you were able to access the clinical trial and try and have a treatment plan that that was able to, to benefit you. But for those that, maybe who may not experience the same. How do you do you ever think about what your health journey may have been been like, had you not sort of had access to the clinical trial or the or the treatment options that you did? Well, I think about it all the time, and I'm fairly certain I would not be part of this discussion today if I didn't have that trial. I would have, gone down the road of, that's two treatment options that I had left. And as I did that the period of health would shorten with each relapse. And then that would leave a huge question mark because the, statistics for ovarian cancer are very grim. So, yeah, all the time I think about that. It was clear through her story that drug innovations had a large impact on Diane's life. As she spoke, she really set the table for a discussion on the value that investing in and pursuing new treatments brings for patients who have exhausted all other alternatives. With her perspective in mind. I thought we were ready to start the discussion on drug pricing and its relationship to innovation in earnest. I think it's now a good time to bring in two other guests to provide some additional perspective. So I'm going to invite Doctor Carter Hesham, the chief scientific officer and executive vice president of emerging companies at Biotechnology Innovation Organization, also known as Buyeo and Pam Track. Salt, who is senior vice president for alliance development and philanthropy at the American Cancer Society Cancer Action Network. First off, hello and thank you. Thank you for joining today's conversation. Thanks for having me. Thrilled to be here. So you both just had an opportunity to hear Diane's story and to learn a little bit, you know, her perspective and experience. I really want to get to the heart of what I think is on many of our listeners minds. So I'm going to ask you both a two part question here. The first part is how do drug prices end up so high in the US? And then what role does innovation play in our drug pricing? So Doctor Esham, I'll start with you and then Pam, I'll, I'll go to you next. But sure. And I will say like I was as I was getting ready for this podcast this morning, it it occurred to me that the title of the series that's understandable is a bit of, amusement for today, because I don't think anybody would define our health care system as necessarily understandable. it is it does seem to be, unnecessarily complex. a lot of the time they produce because we keep building on an integrative framework that, at its inception, was really focused on managing sick people, not getting and keeping people well. but let me step back for just a second, because I wanted to share some thoughts about the sort of investment landscape sort of set the stage for, for this conversation. because I think it's important to note that developing next generation medicines is a high risk and cost intensive, endeavor with an overall success rate of advancing a clinical a single clinical development program from phase one to approval, hovering, on average, around 8%. the cost of developing a single medicine can cost over $2 billion in costs, and requirements for development are going up and not down. And the cost for manufacturing and delivering medicines are going up and not down. it's also important to note that small pre-revenue companies are advancing the majority of the early stage clinical trials in the pipeline. and they're doing that with at risk investment dollars. Our most recent estimate is about 65% of the 2023 approvals originate with small companies. So I say that and, you know, sort of to sum up, there is a significant amount of investment in risk required, in this field. and there's less than 10% chance of success. and, and I say this to emphasize that when we advance and enact laws that affect our ability to conduct innovative medical research, and impact how we go about setting prices and receiving returns on investment, it's important to recognize that it's an ecosystem and one that, if not fostered, can be broken. And we need a policy environment that always considers in concert what will help advance our scientific understanding of diseases. What do we need to ensure the effective transfer of technology to the private sector? What policies are needed to ensure there are incentives for the significant investment required? What policies are needed to ensure effective and patient centric drug development review processes? And what policies do we need to ensure patients have access to breakthrough medicines? So you need to look at it holistically. You can't bring a spoke in a wheel and expect it to keep functioning, in the same way. And one of the things that we as an organization have always been focused on is how do we reduce out-of-pocket costs for patients while we're ensuring that the overall ecosystem supports continued innovation? So an example of that is a provision that was included in the recently enacted Inflation Reduction Act. where there is a provision that will cap out-of-pocket spending for patients in Medicare 2000 a year starting in 2025, and also allows people to spread costs over time. But to be clear, you know, there's a lot more work needed to to decrease costs for patients at the pharmacy counter. and I you know, I think I'd be remiss in pointing out that there's a lot of debate content that's continuing. and a lot of that debate often focuses on quote list prices, you know, list prices that biopharma companies put out, but they never received payment based on those list prices. There is extensive and significant rebate and discount processes with every public and private payer. But unfortunately, in our view, not enough of those savings are being realized by the patient. So, you know, one thing, one of the things we are we are working for is to ensure that pharmacy benefit managers really utilize the rebate system with patients top of mind. So again, that, you know, we think that rebates, you know, views from that perspective, could be celebrated. But too often those discounts aren't being realized. And enough by the patients. And you ask sort of like, you know, how does all this, like marry up and, and, and align with the role of innovation? And I would say, you know, look, the role of innovation writ large is to make the world a better place. In our particular field, it's our mission to develop medicines that cure or significantly improve the quality of life for patients and their families. And access is key to achieving that. So again, we need to keep working on getting those out-of-pocket costs at the pharmacy counter down for patients and make sure that policies that govern how biopharmaceutical companies and payers negotiate prices, is done in a way that is that is truly balancing the needs to continue to support continued innovation and reduce out-of-pocket costs. Thanks, doctor. and maybe before I turn it over to Pam, I have a couple points. I think your description of it as an ecosystem, right. And multiple players involved, I think is a helpful visual, hopefully for our listeners that to your point and you've shared, not only the the various stakeholders like pharmacy benefit managers that are involved, but also policy interventions and all of that also comes into play. So it's many factors involved, that are either or either could potentially support innovation or could impede it. And so yeah, no, I just thought that was a sort of a helpful way to describe that. The, you know, the variety of players involved and, you know, ultimately, to your point, the end goal should be reducing out-of-pocket spend for for patients and really increase their ability to access medicines. Pam, if I turn to you now that you sort of the same, sort of same question or if it isn't, you know, specific builds or reactions to anything that Doctor Esham had shared. Yeah. I think for me, I start with the fact that I think you you asked like, why? Why are drugs so expensive? No one knows. No one knows. Not even sometimes people inside, pharmaceutical company know. and I think that one of the things that's challenging and building off of what Doctor Esham said, I think, you know, we think of healthcare as a system. We talk about the health care system. It's not really a system. It's also not a perfect market if you're an economist. And so there are a lot of different twists and turns, and there are a lot of different things that impact, what patients pay. it's not, you know, the same thing as, you know, going to the grocery store and buying a gallon of milk. There's actually labeling that tells you how much that milk is really. Health care is a little bit like going and going to the store, and there is no pricing. And wait, what's even better is everyone who checks out pays something different, and you pay something different every single day you go to the store. And so I think from, from my perspective, what's most important is to ground in and the story that Diane has told, because I think it's really important. Sometimes when we talk about health care, we lose sight of patients like Diane. And that's what to me is most important. So what do I take away from her story? I take away from her story the importance of innovation, not just now, but in the future. So Diane was very lucky and a very empowered patient who was able to find a drug that has led to some great survival for her, and she continues to be engaged because she knows that she needs to be looking out for what's the next innovation in case she has a recurrence of her cancer. What we need is a system that is cheering for Diane, right? That is doing the work to bring Diane and other patients like Diane there over 20 million cancer survivors in this country. The innovation they need to kind of go from drug to drug to extend to their lives and in some cases cure their cancer. And in that process, they also need to not bankrupt people like Diane. Right. So she talked very briefly about the cost of going to a clinical trial and negotiating with a trial. Navigate not nurse, about how many scans she had to go to and how many times she had to go to see her doctor. That is extraordinary advocacy for someone who's fighting cancer. What we need to really work about is a system that is clearer and more transparent so that we understand, you know, how this is going to work and how patients can benefit. So what I tell people when we talk about, drug pricing and innovation, I ask everybody to think about a quarter and I want you to balance that corner quarter on its side and think of that innovation on one side and access on the other. So you need new drugs in order to fight your cancer, because cancer will kill you without new drugs. You also need to be able to access those drugs. Right. And where I think we're sometimes lost in this conversation is it's all to one side or all to the other, right? Nobody's really thinking about the true balance that we need to have here. And they're also making it way too complicated. Not every patient is as smart as Diane. Not every patient is as empowered as Diane to make those choices. Thanks, Pam. And that the coin analogy is a helpful one, that you do need both sides and in talking with Diane up front, I didn't highlight all of the components that it is just beyond. There are many factors beyond just the actual care itself, but sort of the all of the everything it takes to get to a clinical trial and the resources you need and transportation and all of that in order to, you know, realize the potential opportunity with that, with a treatment or a medicine, clinical trial or not. Well, and I would and I would add to that, Brandon, sorry to interrupt you, but what I think people need to understand is that when we think about cancer, we're talking about hundreds of diseases. Every cancer patients journey is different. And for many of those patient patients, drug cost is not their most important thing, right? It could be transportation. It could be parking at the medical center. It could be surgical cost. It could be radiation cost. It could be a caregiver at home because of, you know, reduced either physical or mental capacity. So I think that we do ourselves a little bit of a disservice when we talk about innovation and we talk about our health care ecosystem. to just narrow down in on drugs, because that is not the the experience of a lot of patients. I would also say that a lot of times we're missing something that I think is very important. Imagine a therapy which actually doesn't cause you to have surgery. That doesn't cause you to have to go back to the doctor. So many times, these are the things that things that we're really striving for. These things like effective cures that we're seeing in therapies like Car-T that are very, very exciting. Right? And while they might seem like they have a big cost, we need to think about the overall picture here. And so as somebody who actually works inside Washington, DC and, you know, is one of those crazy people that, you know, a lot of people across the country don't really lose, I think sometimes we need to like, zoom out for a second and really think about what's happening in the lives of real patients and the costs that they are really the most concerned about. It was enlightening to hear Pam and Doctor Esham, really break down the balance between innovation and drug pricing, especially doctor s comments about making sure that efforts to improve the system didn't hinder the brilliant people who are tirelessly working to bring new lifesaving treatments to patients, as well as Pam's perspective that while we continue to push medicine forward, we don't forget about continuing to strive to provide access to those breakthroughs to the people who need them. Which brought me back to Diane. And I think to that last point there are I'd love to go back to you, Diane. You know, Doctor Esham, Pam, sort of, you know, both just share perspectives. You know, in from, I'll say, sort of an industry perspective as well as a advocacy perspective. I'd love sort of any any reactions from you? from the from what they shared. yes. Well, to me, it's a very complex issue. I call it a soup. I think, Doctor Esham’s analogy of that ecosystem system ecosystem was wonderful. But in this soup there's so many variables, that a patient wouldn't know about or couldn't know about and are out of their control. And so, really in the, in the inpatient of all of this trial and error and, and cost and, and thought process is the patient and a patient is really a fighter. We just want to comply with the doc's recommendation. We want to do it in a logical fashion. And it gets really frustrating if there is a denial of drug or difficulty in getting a therapy, because that could mean a delay in keeping the patient on track. What's there with their, treatments. So it really is it's a significant impact to the patients if it doesn't go smoothly. The important thing is what is getting people well, what is allowing people to go to continue to work with their families, to live longer, quality lives? How do we go about calculate that is is so critical right now. And I you know, I was going to talk about this later, but I'll just kind of jump into a little bit now as a teaser. You know, I think we really need to align on how we are defining and calculating value and how those calculations are being considered. during negotiations between any innovator or physician, and any payer. And they need to really be reflective of what matters to the patient. Again, what will keep the patient well, but will keep the patient, have a quality, and, active life. and, and again, also balance that with what we need to support and continued innovation. Thanks, Doctor Esham. I some one one thing that, that Pam, you were reminded me of as you were talking about and is, you know, Diane, I you know, you are you know, as you're talking about being a, you know, a champion for yourself and for your care. I, I imagine through your experience, you have also connected with, with others who are going through a very similar experiences. And so, you know, I, I think I, you even sort of describe yourself as, as an advocate, writer or a champion for others, which is, you know, wonderful. And, and I think today is a great example of, of you doing just that by sharing your experience. And I'm sure folks will take something away from this, that, that hopefully betters their situation. As as we think about today's topic, is any perspective and conversations you've had with with others who are who have experience? you know, who are experiencing cancer or have experienced cancer and, and maybe different circumstances where they, you know, were not able to get on a clinical trial or, you know, maybe did encounter access sort of affordability challenges, any, any, you know, perspective or insights that you could share as an advocate? Yeah. You know, I do talk to a lot of patients, and I have for the last eight years say, and I hear so much about, a difference in co-pays. I hear about denials of treatment, and I hear about an appeals process that it just takes time and delays treatment because you're fighting the system. and I have a couple of examples. This one I was talking to recently, there's a drug which is given in connection with chemotherapy. And it it actually prevents blood vessels from forming around the two or invading the tumor. It's pretty expensive. And so even with, some good insurance and decent co-pays, it can be prohibitively expensive for a patient to receive that therapy. And I know, for example, at Indiana's Anderson, it is big. And they do have, multiple clinics. Each clinic has a team of financial people who will sort out the patients family, benefits with insurance so that they can, ahead of time, make sure that this patient can have the access to this drug if they need it. and I know whether, you know, local, my own office locally does have, financial team also. So it's worth asking about that if the need arises. And then a recent patient I was just talking to her a couple weeks ago. she was on a Parp inhibitor, which is a very important drug for ovarian cancer maintenance. Was on it for a couple of years, but her insurance considered it a tier five drug. So that meant that she had to pay about 5 to 7% of the drug cost herself, which added, she said thousands every month. So that's an out-of-pocket expense. and I know, there's also the second opinion fact if a patient wants a second opinion that is never covered by insurance, which means it's prohibitive for, say, 90% of patients, because that's an out-of-pocket expense, too. And then you have a variation in hospital bill coverage. You know, based on everyone's insurance provider. So, you know, as the the grocery store analogy, Pam, about everybody goes in, but they all pay something different when they come out. Thanks, Diane. Yeah, it's helpful. And to your point, you're you're shedding some additional light on, again, the variety of factors. Right? We're not talking about just one piece of the pie, but everything you shared around is a patient's journey through. This is they're likely to encounter some sort of access or affordability challenges. And I think if I go back to, you know, Pam, both you and Doctor Esham spoke about this too, that we should be thinking about things more holistically. Right. And it's not just about the the medication or the treatment itself, but really what are all of the the factors that need to be considered when we think about what obstacles are, what may what limitations might be put in place that would prevent someone from getting the best care. So if I go back to, you know, this sort of how do we reconcile this, this piece around, you know, the cost of innovation, what the consequence of drug prices, essentially, you know, being so high as it relates to when, when a patient gets to the the pharmacy counter, what can we do or how do we better understand the relationship there to make it make sense? Yeah, I, I think that there's I think one of the things people need to think about for a second is what are we really talking about? Are we talking about the price of drugs? Are we talking about what patients pay? Because that's two totally different things. And so I think that that challenge that we see with cancer patients is that that journey, as Diane aptly illustrated, is long and it is complicated. And you have no idea when you're diagnosed what that's going to be like. And you have no idea how much it's going to cost you. No insurer would even tell you. By the way, this is not like having a baby where you can call a doctor and they can give you a price range. You call them, you say what kind of cancer you have. And they're like, good luck. We can't tell you that. So I think one of the things that we have to do is make sure that insurance and health care works for patients, which means that as doctors make decisions with patients about the care and treatment that they need, the patients have the ability to afford those drugs and that treatment and that care. And so that means making sure that health insurance works. Doctor Esham mentioned that in Medicare, there will actually be an opportunity to cap out-of-pocket costs for part D and dog drugs at $2,000 a month. That is a huge step forward, but I'm sure there are many people listening to this phone that are thinking, I don't know if I have $2,000 hanging out someplace to pay for that. I would ask all of you to think a little bit about your household budgets. If you were a responsible human being and you know you have to pay your mortgage and your car insurance and for your kid's school and all this other things, how many people are saving money every month to pay for health care out-of-pocket costs? You might be behind budgeting to pay for your premiums, but are you really paying for budgeting for health care out of pocket costs? I'd say most average Americans aren't. And so I think we need to do more, more to work together to make sure that patients can afford their care. Because otherwise, what happens to patients is when they don't have access to this life saving therapy, and they happen to be cancer patients. Horrible things happen. Patients die. Patients go into the hospital, they go into the ICU. You know, it is not just that they go quietly off into the night and don't incur costs both for themselves and for the health care system. So I think we all can agree that we're committed as a country to making sure that people who are sick have an opportunity to live healthier lives. How do we make those pieces work? And I think it really begins by looking at how we can make sure that patients have every avenue available to be able to afford their care, and that's there are many, many pieces to this puzzle. But I sometimes think that there is an alignment about what success looks like. Success for me is that Diane is able to manage her care so that she is this far into her cancer journey, still has money available in case she needs to go to another therapy. There are so many patients who exhaust all of their life savings in the very beginning of Diane's story, and by the time they get word, Diane's there in medical bankruptcy. That is not, I think, the country that we're seeking to really establish. Think about Diane. She's an exceptional responder. There is something really exciting about what this drug is helping Diane do with her cancer that people want to learn about, right? Because we're going to learn not just about Diane. We're gonna learn about the drug. We're going to learn about how it treats the cancer. This is really exciting, but it's not exciting. If Diane continues her care and how many patients would not be able to do that. So I think we need to really look at policies that allow researchers and biopharma companies to develop drugs and other therapies to treat serious diseases like cancer, while also making sure that patients can have access to those drugs because otherwise we have drugs that nobody can take, and that's not what we seek to do. I'm not sure I could speak any more eloquently. The Pam just did, again, I think she she she said it very she said it very well. all the things that that are important and, you know, it's almost like saying we need to reverse engineer from what matters the most. And that is what is going to make a patient, healthier and live a more productive life. in a way that does not break the bank, you know, and not just not break the bank, but is entirely manageable, to to achieve the, you know, to obtain the health care, that they need to reach that goal of living a healthy and quality, life. and to, you know, try to get to a place where we can cure diseases, to get to a place where we are improving call quality, of patients who are suffering from diseases. so, again, you know, we just not really been reverse engineering with enough focus on that in game. in my opinion. and again, that goes back to how are we calculating value? How are we really incorporating a calculation of value that matters? and is that are those calculations being done across the health care system, in a way that will improve care for all? I will note, you know, on on a side, on a side note, a slightly off topic, but I think it's important to raise nonetheless is, we also still need to keep trying to advance, research, technologies and approaches that can help us drive down costs of R&D and try to improve our success rate. So again, that's more maybe of a biopharmaceutical industry insider conversation, but no less important. And we are working on that. We're trying to make things, you know, fail earlier so that, you know, we sort of get that that those lost costs down significantly. And that's really important for this entire conversation as well. but again, at the end of the day, it is it is trying to balance needs, supporting innovation that will improve the lives of patients and, and getting those out-of-pocket expenses, significantly down. And frankly, I think a lot of policies enacted to date over the course of this more than decade long debate have not really focused on on that imperative near enough. That's a great point. We need to think about the end result, the success story of the patient first, and then work our way back. We are, believe it or not, sort of nearing the end of our time together. Before I close, I wanted to just take an opportunity to give each of you, if there's anything else on your mind, Senate still sitting up there, that that you want to make sure our listeners share. I'll just maybe open it up to any of you if there's a sort of something that's on your mind that you didn't get a chance to say, I'd love to create some space for you to to do that now. Well, I have one thing. And again, sort of reacting to to some points, I think that Diane and Pam alluded to and that really is, the importance of sort of building and fostering a localized approach to education about how to, assess things like clinical trial opportunities and medical treatment options in a way that sort of available is continuous and not one off endeavors. that's certainly something we admire or try to, work with community leaders and how we can support those sort of local, local efforts. And again, like, you know, Diane, you mentioned like, nurse managers, like, we need to really be supporting people that are helping people be empowered to gain more control over over their health journey. So I just wanted to highlight, how important I think that work is, as well as the other things we've discussed today. Thanks, Doctor Esham. I am, I would say one of the things that I would ask folks to think about, and this is such a highly charged issue, is what is, Diane, where your mother what would you want for her? And I think oftentimes, you know, we talk about what's these people and it's this and it's this constant acronym, acronym, acronym, acronym. And what I think we need to really think about is the people who are at the center of this and the people who love them, and how we need to create solutions for that. Because I find oftentimes it's very easy for people to make these broad, sweeping statements about the impact of different things. It's really different when it's somebody that you love and somebody that you care about. And unfortunately, with cancer, every American is in some form or fashion touched by this disease. We can do better in treating this disease and making sure people survive it. But that can't come at trying innovation out, right? Because things just cost too much. And I don't think that I would want that for Diane. I wouldn't want that for anyone I know that has cancer. So we have to kind of move beyond that paradigm to become truly patient, centered in our work and really think about, you know, Doctor Esham mentioned last, what is value? It's what the patient values. It's what the family values. And we have to look for public policy solutions that keep that at the center. Because when they don't, they fail all of us. Thanks, Pam. Diane, final final words from yes, I would just throw in, advocacy again because as as a single advocate, I've tried to speak to decision makers, I've spoken to legislators, I spoken to the speaker of the House of Oregon before she was governor. I, I really think getting my story out there and, and showing that the end result is a good one if there's access to good medical care, that's what I try to get across. And I think a good example in an organization that I'm, familiar with is the OCRA Ovarian Cancer Research Alliance. They have Advocacy Day once a year and they go, these advocates, maybe over 100 of them go up to Capitol Hill, and they talk to the health care teams of each congressional office, and they ask for things. They ask for more money for congressionally mandated funding for research. And last year, it was over 55 million given in these congressionally mandated funds just for ovarian cancer alone, plus all the others that they give money for. they asked for funds for more education and awareness programs. It asks for funding to increase for example, genetic testing in Medicare patients. And then finally, they've been addressing the critical cancer drug shortage. So I think taking the squeaky wheel can really get some results because, you know, as a patient, we're asking just to have more birthdays. And and it all matters because this is the reason that that that people do their work is so the patient like me can have a good chance. Absolutely. I think that there's not a better point to end on. Thank you all for joining and having this discussion, bringing your varied perspectives. It's such an important topic, and I think we've obviously only scratched the surface. I think the opportunity to continue these conversations to learn more and then to Diane's point, advocate that will help to push progress on this topic. As we said throughout, drug pricing is incredibly complex. And while the cost of innovation is just one factor, there are several components that play just as big a role, if not bigger. Hopefully, this conversation helps shed some light on balancing the importance of innovation with the need to keep medicines affordable for the people who need them most. Thanks again for joining us on. That's understandable. For more information about today's episode, be sure to check the show notes. Until next time, be well. Be healthy. Be understanding.