Speaker 1 (00:04):
Welcome to 340B Insight from 340B Health.

David Glendinning (00:13):
Hello from Washington D.C. and welcome back to 340B Insight, the podcast about the 340B Drug Pricing Program. I'm David Glendinning with 340B Health. Our guest today is Andrew Lowe with Arrowhead Regional Medical Center in California. As you know, this November marks the 30th anniversary of the 340B Drug Pricing Program becoming Law. Arrowhead was one of the very first hospitals to enroll in 340B, and we wanted to speak with Andy about what the medical center has been able to accomplish in patient care in those three decades. But before we go to that interview, let's take a minute to cover some of the latest news about 340B.

David Glendinning(01:01):
The body of research demonstrating the strong connection between 340B and care for patients living with low incomes continues to grow. A new report commissioned by 340B Health finds that 340B disproportionate share hospitals provides 77% of all Medicaid hospital services in the U.S. despite making up less than half of all acute care hospitals. These 340B hospitals serve substantially more Medicaid and low income Medicare patients. And they are also much more likely to provide such essential community services as HIV aids care, behavioral health services, and trauma and burn care than non-340B hospitals. You can read the full report by visiting the show notes.

(David Glendinning 01:47):
A federal judge in Washington D.C. has ordered government officials to put an immediate end to Medicare outpatient drug payment cuts to many 340B hospitals that have been in place since 2018. You will recall that the U.S. Supreme Court unanimously decided in June that these reductions are unlawful. And Medicare officials subsequently announce their intentions to restore full payment rates to 340B hospitals starting in January.

David Glendinning(02:14):
But the latest court order says the Department of Health and Human Services should restore those payments without delay. The order states, quote, "HHS should not be allowed to continue. Its unlawful 340B reimbursements for the remainder of the year just because it promises to fix the problem later." End quote.

David Glendinning(02:35):
And there is a new bipartisan letter from Congress urging federal health officials to take stronger actions against the 18 drug companies that have imposed restrictions on 340B pricing through contract pharmacies. The latest letter comes from Senators Joe Manchin, a Democrat from West Virginia, and Mike Braun, a Republican from Indiana. The senators site examples of how 340B health systems and hospitals in their states use 340B savings to care for patients in need. They are calling on the HHS Office of Inspector General to determine whether non-compliant drug companies should face hefty federal fines for their actions. You can read the full letter in the show notes.

David Glendinning(03:25):
And now for our feature interview with Andrew Lowe, Clinical Director of Pharmacy at Arrowhead Regional Medical Center in Colton, California. Arrowhead has been part of 340B since hospitals were first able to enroll in December, 1992. And for all that time, Andy has had a front row seat to seeing how the medical center has used its savings to care for patients in need. Myles Goldman recently sat down with Andy at the 340B Coalition Summer Conference to learn more. Here's that conversation.

Myles Goldman (03:57):
Thank you, David. I'm joined by Andy Lowe. Andy, we are here at the 340B Coalition Summer Conference in our podcast booth in the exhibit hall. And one of the themes of this conference is the 30th anniversary for the 340B Program. And I know you have a lot of experience with the 340B program, working at A 340B hospital. And I'm looking forward to hearing your perspective of how 340B has evolved over the years. So, thank you so much for joining us, and welcome to 340B Insight.

Andrew Lowe (04:32):
Right. Thank you, Myles.

Myles Goldman (04:33):
And your hospital was one of the first in the nation to join the 340B Drug Pricing Program back in late 1992. Why did it join, and what would you say the biggest benefit of 340B has been to your system and its patients?

Andrew Lowe (04:50):
Well, the biggest benefit certainly, has been the savings in the cost. We actually, in the first year, we saved $2 million right off the top. And what that helped us do is start contemplating starting new programs.

Myles Goldman (05:08):
And I look forward to hearing more about some of those programs in a little bit during our conversation here. But how did things change when 340B became a reality? How were you handling the challenge of caring for low income patients in a world without 340B in the early 1990s?

Andrew Lowe (05:27):
Well, we had a program, a county sponsored program, which is what's called, The County Medical Services Plan. And nobody walked away without a prescription. However, we had to really spend a lot of money to cover those prescriptions. So what this helped us do is keep those costs under control. But at the same time, we were able to serve more with less money.

Myles Goldman (05:57):
And when you say, money was... and it's a county program, are you talking about like a taxpayer funded county program?

Andrew Lowe (06:04):
Correct. Yeah, that's all taxpayer funded.

Myles Goldman (06:07):
And of course, 340B isn't, as we know, taxpayer funded. The savings come from drug companies, so that's a big difference. Tell us more about the communities and patients that Arrowhead serves.

Andrew Lowe (06:19):
San Bernardino County is the largest geographical area county in the United States. It borders Los Angeles County, goes north all the way up to the Nevada border, and goes east and south all the way to the Riverside County. So, the patient population that we see there is largely indigent and largely uninsured. And as a result of that, their needs were over the years have been very, very intense. For example, the many times, people had to make a choice between putting food on the table or getting their insulin or their hypertension medications. So consequently when we started getting a 340B program, we were able to actually help them with that, allowing them to get affordable medications.

Myles Goldman (07:13):
And if they're not able to get affordable medications, what happens?

Andrew Lowe (07:19):
Well then their diseases continuing to progress and they get sicker. And when they get sicker, they're more likely to come into the hospital. And certainly, your life expectancy is not going to be as high.

Myles Goldman (07:32):
Can you give us some tangible examples of how 340B has improved Arrowhead?

Andrew Lowe (07:40):
Yes. We have been able to address a particular need for the treatment of hepatitis C patients. We have actually created a hepatitis C clinic that will actually have pharmacists in as well as physicians. We have also done a lot of work with oncology. We are affiliated with the City of Hope and we're able to provide treatments that normally would not be available to an indigent population. We're talking about thousands and thousands of dollars of chemotherapy and biotherapy as we see now for oncology patients. So, those are just two examples of what we can do now under 340B costs.

Myles Goldman (08:33):
And I'd be interested to hear more about the hepatitis C program. Can you tell us a little bit more about that?

Andrew Lowe (08:38):
Yeah. Well, several years ago new antiviral medications became available for the treatment of hepatitis C, which were really a game changer. If you do not treat hepatitis C, that can progress to liver cancer. That may make the patient in need for a liver transplant. Both of these can be quite a drain on the healthcare system. So, we're able to take care of patients with hepatitis C by using these antivirals.

Andrew Lowe(09:10):
Now, these are not for the faint at heart. The monthly cost of an antiviral regimen is about $80,000, and that's actually after recent discounts. So, it is fairly serious business. But by treating the patients we are preventing... Each patient with treat, preventing the transplant, we're preventing the development of fulminant liver failure.

Myles Goldman (09:41):
Have you seen improved patient outcomes through this program?

Andrew Lowe (09:45):
Oh, absolutely. And it's not only with us but the literature is replete with data. You can have up to 80, 90% cure. Some of the newer drugs, they claim 100% cure, but that's a little too early to tell. But I think we have significant cures. Before, hepatitis C was not curable. Now, we actually see cures.

Myles Goldman (10:07):
Yeah. I mean, it's really interesting to hear that because we're celebrating the 30th anniversary of 340B and there's all these new drugs that have been developed during this time period. From the programs you've spoken about there, are there specific patient stories that come to mind?

Andrew Lowe (10:27):
There certainly are patients that, the oncology patients, who have been able to actually achieve cures, or at least have had a delay of the progression of their cancer. On the hepatitis C side, we see a lot of basically cures, which we didn't see before. So, too many to mention.

Myles Goldman (10:54):
With all the controversy around the program these days, do you ever worry about what Arrowhead would do if 340B went away or was cut way back?

Andrew Lowe (11:05):
Oh, yeah. We always worry. And in fact, that's one of the reasons we really are sticklers about compliance. Because if we lost 340B, we would have to drastically cut back on services. And what that would look like, I don't even want to begin to imagine. Because really for 30 years now, we've been taking care of these patients, we've been able to provide these services. And suddenly if we went away, it would be a real problem for our patient population.

Myles Goldman (11:40):
Well certainly that really, I think, emphasizes the need to keep advocating for the program. What are some of the things you talk to policy makers about, as you advocate to protect 340B?

Andrew Lowe (11:51):
When we meet with Congress people, the policy makers, we talk about the existing threats. So, we are bringing them up to date with those. And then we ask them to support initiatives that are meant to enhance the program, but more importantly to protect the program.

Myles Goldman (12:15):
You've been a long time member of our community, Andy, and thought this was a good opportunity for people to better understand your background and perspective. Can you tell us a bit more about yourself and how you got into the world of safety net hospitals and 340B?

Andrew Lowe (12:31):
Yes. Well, I was a resident at San Bernardino County Medical Center. And during my residency, I was able to see firsthand the effect of these medications and the effect of being able to provide patients with medications they would otherwise not afford.

Andrew Lowe(12:49):
I remember seeing a patient in clinic who had not had her insulin for several months. And when I asked her why, her insulin was fairly straightforward, "I just couldn't afford it." And so when I looked at that and I looked at my own medication needs, this was really foreign to me, because I was used to, if I needed a medication, I would've gotten a prescription, I went and picked it up at the pharmacy. Well, a large segment of a population cannot do that. So in my practice, I've been able to see the effects of a program like 340B.

Andrew Lowe(13:22):
And certainly after my residency I stayed on staff first as a clinical coordinator, then as an associate director and the director of pharmacy. And all the while, I had my hand on the pulse of what effect this program has had on healthcare. Even today, I see patients in clinic and I can say, "Thank goodness for the 340B program.", Because otherwise, especially with some of the fancier, newer drugs that have really good outcomes, it would be impossible for them to get these drugs.

Myles Goldman (13:59):
That's really interesting to hear, Andy. When you say you're seeing them in clinic, is this like a primary care clinic set up or?

Andrew Lowe (14:06):
We have several pharmacists that manage clinics. One of the clinics that is see patients in is a lipid management clinic. If we get their cholesterol under control, it increases the chances of avoiding a heart attack. Then we have a hepatitis C clinic, and mostly specialty clinics. And we have a very robust anticoagulation program that is managed entirely by pharmacists. We have close to 400 patients in that program. So, I see those on a regular basis.

Myles Goldman (14:40):
It also really struck me, something you said before about how when 340B first started, patients were saying medications were too expensive. And we're still hearing today 30 years later, talking about the cost of medication being a barrier to them accessing treatment. What do you sort make of that observation?

Andrew Lowe (15:01):
Well, it's still a problem. I think not only the manufacturers, but also the PBMs are putting a lot of obstacles to patients getting medications at an affordable price. I'm hoping that some of the changes that will come with upcoming legislation will help us.

Myles Goldman (15:18):
What do you like to do when you're not working outside of the office?

Andrew Lowe (15:23):
Well, I enjoy reading, I enjoy skiing. I really enjoy travel, particularly to distant lands, and it's a lot of fun. And anytime I travel to another country, I make a point in walking into pharmacies and see how pharmacies practice in those countries.

Myles Goldman (15:44):
Oh, that's really interesting. Yeah, at the 340B Health office actually, we have photos on the walls of actually pharmacies in different places as well. What would you say to someone just starting out in their career working in 340B?

Andrew Lowe (16:01):
Well, number one is, stay compliant. Don't take big risks, stay compliant, because it's a noble mission. And the cost of not staying compliant will be fairly high.

Myles Goldman (16:15):
Are there any resources that you think they should be keeping in mind in that mission to stay compliant?

Andrew Lowe (16:22):
Oh, yeah. Number one resource that... Actually, I mandated any of the staff I work with that I involved in 340B, is to take 340B University, both online and in-person. Otherwise, 340B Health, the website has got a lot of really useful, really good information. So if somebody works in a facility that's not a member of 340B Health, I really encourage them to be.

Andrew Lowe(16:50):
And I was fortunate at the time when we joined, when I asked the CEO at the time, of the hospital, I said, "We really need to join. And can I go ahead and sign up?" And he says, "Well, are you saving at least that much money?" And I told him it was several orders of magnitude higher. And he says, "Well, there's your answer." So, I was fortunate. Not everybody was as lucky as having him as an administrator. But all the same, I think one good way of justifying, this is how much we saving, this is how much it's going to cost. Well worth it.

Myles Goldman (17:30):
Well, Andy, it's always certainly good to... We agree. Certainly work with your C-suite in terms of engaging on the 340B Program. And we appreciate you joining us here at the 340B Coalition Conference to help us celebrate the 30th anniversary and everything it's done to improve access to care. So, thank you so much for joining us.

Andrew Lowe (17:54):
Thank you. Thanks for having me.

David Glendinning (17:57):
Our thanks again, to Andy Lowe, for joining us to discuss the proud history of 340B and the part that Arrowhead Regional Medical Center has played since the first days of the program's existence. The success of 340B over the past 30 years, owe much to the hospitals and health centers, such as Andy's, that have helped prove its worth for the healthcare safety net since the very beginning.

David Glendinning(18:21):
When did your hospital start participating in 340B? No matter when it did, we would love to hear your stories as we continue celebrating the 30th anniversary. You can email us at podcast@340Bhealth.org. We will be back in a couple of weeks with our next episode. As always, thanks for listening and be well.

Speaker 1 (18:47):
Thanks for listening to 340B Insight. Subscribe and rate us on Apple Podcasts, Google Play, Spotify, or wherever you listen to podcasts. For more information, visit our website at 340Bpodcast.org. You can also follow us on Twitter @340BHealth. And submit a question or idea to the show by emailing us at podcast@340Bhealth.org.