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340B Insight provides members and supporters of 340B Health with timely updates and discussions about the 340B drug pricing program. The podcast helps listeners stay current with and learn more about 340B to help them serve their patients and communities and remain compliant. We publish new episodes twice a month, with news reports and in-depth interviews with leading health care practitioners, policy and legal experts, public policymakers, and our expert staff.
Speaker 1 (00:04):
Welcome to 340B Insight from 340B Health.
David Glendinning (00:13):
Hello from Washington, DC and welcome back to 340B Insight, the podcast about the 340B Drug Pricing Program. I'm your host, David Glendinning with 340B Health. Our guest for this episode is Ryan Cross with Franciscan Missionaries of our Lady Health System based in Baton Rouge, Louisiana. Ryan is part of the governmental affairs team for his health system, and he was on the ground to help drive support for 340B contract pharmacy protections that recently became law in Louisiana and neighboring Mississippi. So we wanted to hear his perspective on how those state legislative victories came about.
(00:56):
First, let's take a minute to cover some of the latest news about 340B. One of the latest 340B state legislative victories comes out of Missouri, which is set to become the eighth state to ban drug company restrictions on access to 340B price drugs through contract pharmacies. Missouri's governor announced that he would neither sign nor veto the contract pharmacy protections that the state's legislature had approved. Under Missouri statute that means the law will take effect on August 28th.
(01:37):
In a statement, the governor said that while he believes both 340B and the state legislation are flawed, he understands, quote, "The desire to ensure patients have access to discounted medications, particularly in rural areas where access is already a barrier to care." End quote. When the bill becomes law, Missouri will join the list of states with contract pharmacy protections that already includes Arkansas, Kansas, Louisiana, Maryland, Minnesota, Mississippi, and West Virginia. 340B Health members can visit the show notes for more details about the latest enactment.
(02:24):
Now for our feature interview with Ryan Cross. At the most recent 340B Coalition Summer Conference, Ryan appeared on a panel about state actions on the contract pharmacy issue. We caught up with him just before he participated in that session. Here's our conversation. I'm here with Ryan Cross, Vice President of Governmental Affairs with Franciscan Missionaries of Our Lady Health System. Little bit of a mouthful. So we're going to call it FMOL Health for short. Ryan, welcome to 340B Insight.
Ryan Cross (02:55):
Thanks, David. Thanks for having me.
David Glendinning (02:57):
So we're going to be speaking a little bit about state legislation on 340B. We've covered that on the program before, but we haven't actually spoken with somebody who's been in the trenches getting one of these laws passed. So before we get into that, tell us a little bit, please if you could, about FMOL Health and the patients you serve.
Ryan Cross (03:15):
Yeah. FMOL is Louisiana's largest nonprofit Catholic health system. We have 10 hospitals between Louisiana and Mississippi with 18,000 employees. We serve about 70% of our patients are government payers, Medicaid, Medicare. Our markets fall everywhere from Jackson, Mississippi to our flagship, Our Lady of the Lake Health in Baton Rouge, which is Louisiana's largest private hospital.
(03:40):
Fantastic organization that I've had the pleasure of serving with for about seven and a half years. We've been in Louisiana for over a hundred years. So we just celebrated at the Lake specifically, it's our hundredth anniversary. So they're doing incredible work every single day, caring for those most in need and guided by our Catholic mission and our Catholic faith. 340B plays a very important part in allowing us and enabling us to do that.
David Glendinning (04:03):
Well, thank you for doing that, all of that great work. We occasionally do have government relations or governmental affairs folks on the program. Could you talk a little bit about the kind of work you do in your role for your system?
Ryan Cross (04:17):
So I do political work by trade. I found myself in the nonprofit healthcare world after a career in political consulting, started out in public relations and then after the pandemic, moved into governmental affairs where I oversee our federal and state public policy shops in Louisiana and Mississippi. So responsible for both our federal policy, but also all legislation down at the state and local levels in the communities where we have facilities. Advocating before elected officials, working alongside our hospital associations and our trade associations like 340B Health, and advancing those public policy goals that enable us to continue serving our communities and providing that exceptional care.
David Glendinning (04:56):
You had mentioned that part of your sphere of influence is Louisiana and also Mississippi. These are of course two states that have passed contract pharmacy protection laws, and that's what we're here to speak about today. So if you could please just give us a quick refresher on how the 340B contract pharmacy laws came up in those two states.
Ryan Cross (05:15):
So after Arkansas kind of led the way back in 2021 with those contract pharmacy protections, we saw other states begin to look and explore policy, policy goals to implement similar legislation. Louisiana became the second state to enact a law last year in 2023. Then just this last legislative session in Mississippi that wrapped up earlier the spring, we were able to successfully pass legislation there. So now we've got the protections in place in both of the states where we have facilities and are currently in litigation over both of those.
David Glendinning (05:46):
Well, that's great news. Not the litigation part, but the passing the legislature's part.
Ryan Cross (05:50):
It's okay, we'll win there too.
David Glendinning (05:51):
Being approved by the governors. In those two states, what do you think were the general keys to success in getting those protections put on the books?
Ryan Cross (06:01):
Look, I think there were three main things that we can boil the entire strategy down to. First, relationships. Second, the messaging. Then third, activating the grassroots. We created and cultivated relationships with other hospitals, with lawmakers, with public policy staff on 340B issues. In forming those relationships the old adage when you need a friend isn't the time to make a friend.
(06:26):
So we found that it was very important, the groundwork and the foundation that we had laid in building relationships with those key legislators, the chairman on the key committees of jurisdiction, in Louisiana it's the Health and Welfare Committee. Knowing the legislative leadership and having that level of trust and relationship built previously where there's a level of faith and trust in the work that you're doing as not-for-profit healthcare in the state of Louisiana and Mississippi.
(06:53):
So that when we came to them on this issue, which can get in the weeds, especially when you're talking about the 340B program at large, not just the language of the legislation, it's a lot easier to explain the impact, what it does, what it means to your systems personally. When you've got that ground level relationship, it's important whether you're a lobbyist or a public policy professional or if you're just a 340B expert inside your facility, maybe a small rural facility that doesn't have a government affairs shop, that you're telling the stories and building those relationships year in and year out so that when these issues do pop up, you're able to leverage those relationships that you've built.
(07:33):
The second piece on the messaging, our messaging was effective for why these laws were so important as we saw to ensure that we protected public perception and control the narrative. We were very direct in communicating the impact of 340B savings and the impact that that has on the patients and the communities that we serve across Louisiana, whether it's our rural hospitals in Louisiana, Mississippi or if it was our large urban medical centers that still serve a large portion of the underserved population. We were transparent. We ensured that we didn't hide the amount of the savings that we saw from 340B because again, we wanted to connect these meaningful savings to meaningful uses that impacted those patients.
(08:17):
Then we were also ready to explain the history and the intent of the program. As much as we would've liked to have just focused on anti-discrimination and the words that were on the bills that were being proposed, you couldn't really get there without first explaining and going back and telling a history lesson of how 340B came, what Congress's intent was in the language, and then how it's been distorted by big pharma in the years to come. It was a delicate balance and explaining the proposed language versus getting lost in the federal law. Then finally really getting into that grassroots. How do you activate your pharmacists, your nurses, your folks in those rural health clinics that are treating these patients every day to tell their personal stories?
David Glendinning (08:59):
Okay, so three big things you're talking about. Relationships, messaging, and grassroots. I'd like to discuss each of those one at a time just in a little bit more depth. So what do you really mean when you are actually going about building these relationships to try to get a positive policy change?
Ryan Cross (09:16):
The first time you talk about 340B can't be when one of these bills is first brought up for consideration, and it certainly can't be the first time when you're put on defense in explaining 340B. You have to have laid that groundwork with your state legislators, with the committees of jurisdiction that oversee health and welfare, with legislative leadership, the governor's office, those key public policy staff to ensure that they understand the impact, what it means, why it's important. The true intent of the program when there's not a fog of war, of a legislative battle that's raging behind the scenes because obviously things get twisted and taken out of context when you get down into that.
(09:56):
If you're in a large system and you're a 340B subject matter expert, you've got to get to know your hospital government relations people. You've got to get to know your lawmakers that are focused on that healthcare policy, those healthcare staffers who are so important to the public policy process, and be able to leverage all of those towards advancing your key goals. Like I said, if you're not a government relations professional, clearly if you have them, you want to connect with them to make sure that you're following your system or your hospital strategy for being successful here.
(10:23):
If you're in a small system where you might not have GR folks, you want to make sure that you are working with your executive team to have those direct connections, to share those stories, whether it's around a dinner table, whether it's around a site visit to one of your hospitals. We love the show and tell, to bring folks into our facilities where we've got unique programming going on and allow them to see that again before we get into the thick of a legislative battle.
David Glendinning (10:47):
Show, don't tell. I like that. Speaking of which, you did speak about effective messaging. What do you think were the messages that in particular resonated on the state bills in Louisiana and Mississippi?
Ryan Cross (11:01):
Look, at its core, the bottom line, our takeaway message was that big pharma is trying to take money away from not-for-profit hospitals and drive it out of state. That 340B at its core allows nonprofit hospitals and health clinics in Louisiana and Mississippi the ability to generate savings with the sole intent of redeploying those dollars to those that are underprivileged in the communities that we serve. We do that through a variety of programs, whether it's putting social workers in our ER, through feeding programs for those in food deserts or cancer navigators. Or just helping keep the doors open on rural hospitals in Louisiana and Mississippi. We're able to do that because of those 340B savings.
(11:42):
If we curtail that and we steer those dollars back to the pockets of big pharma, big pharma is not in our communities redeploying dollars to those folks that need it the most. They're trying to do it for one sole purpose only, and that's putting profits over patients and steering the dollars back to shareholders in New York and California. We're just not interested in doing that. Ultimately, our legislators were not interested in doing that. It's just a dichotomy that when you say it that clearly, the case sells itself. We did not want this to be a referendum on 340B at large. That's up to federal lawmakers. There's conversations happening every single day at the federal level on what the future of the 340B program is going to look like.
(12:21):
We ensured that in Louisiana and Mississippi that we kept the message focused on the program as it is today in ensuring that pharmaceutical manufacturers had to follow, NPBMs had to follow the laws, it's on the books and couldn't discriminate against our facilities based on the current law. If there's going to be changes made to that law, that's going to take place in Washington, not in Jackson, Baton Rouge. At the end of the day, the 1992 deal that was put together for 340B and creating it led to hospitals relying on those 340B savings. Now the question at its core up to legislators was would those dollars stay with the hospitals or would they be steered back to the pockets of for-profit entities? I'm proud of our folks in Louisiana and Mississippi for making the right choice there.
David Glendinning (13:06):
So interesting to hear that state perspective. 340B Health is a national organization. We focus a lot on Capitol Hill, but can be a very different scene in the state houses. The third key to success that you mentioned was grassroots action. So how did that play out in these circumstances?
Ryan Cross (13:25):
Look, a big part of our grassroots strategy is not just having it but knowing when to activate it. We've got, I mentioned just in our health system alone, 18,000 team members across Louisiana and Mississippi. That's physicians, nurses, pharmacists, pharmacy techs, folks that are 340B subject matter experts, folks that are in the trenches providing care in our communities every single day. Each one of those folks lives in a community that's represented by a legislator.
(13:52):
Knowing when to deploy those grassroots folks to make phone calls, to send emails to contact their legislators is important in any legislative battle. Obviously they have great impact when they begin to flood the switchboard or flood the email inbox of legislators, it gets their attention quickly. Knowing when to pull the trigger on that is important because if you're doing well and you're up, you might not want to stress out the legislators unnecessarily. You might want to save that for another fight.
(14:21):
We were very strategic on how our 340B experts engaged to advocate for why the bill was so important. We brought them before committees to testify. So again, kind of tilting back towards our messaging conversation, we were able to deploy 340B experts, pharmacists, hospital CEOs before the committee and big pharma flew in an attorney from New York to attack our hospitals and say that we weren't meeting the program's goals. That comparison shined very bright amongst the legislators and they saw that their local communities were rallied behind their local hospitals in this program.
David Glendinning (14:58):
This sounds like it was much bigger than just FMOL Health. It sounds like you worked very closely with other 340B hospitals in the state on these advocacy efforts.
Ryan Cross (15:07):
Absolutely. The Louisiana Hospital Association is very strong in the state of Louisiana and organized. Everybody was aligned on the strategy following their lead to get this legislation across the goal line. The association really provided a lot of air support, strategic guidance, creating things like handouts that we could share with legislators, fact sheets. They were creating myths versus facts to fact-check big pharma and some of the things that they were saying to try and keep the narrative on the right path and not let it get off into misinformation. While all of our 340B covered entities in the states, whether it was FQHC's, rural hospitals, not-for-profit hospitals were able to do the blocking and tackling of really working on individual lawmakers in the districts where we have facilities to put the votes together to ensure that it didn't get away from us.
David Glendinning (15:56):
Did you run into any hurdles, any roadblocks that you had to overcome to try to get these laws onto the books?
Ryan Cross (16:04):
There were a couple at the beginning that we were worried about, but we were able to navigate through them. The statewide Chamber of Commerce initially opposed the legislation in Louisiana because of a private right of action, a cause of action that allowed the individual hospitals to file suit. So to work through that, the compromise that we quickly came to at the very beginning of the discussion was just to make the calls go through the state attorney general's office under the unfair trade practices. So we were able to get that language out of the bill, get them back to neutral.
(16:35):
We also saw some efforts from pharma to add some transparency and reporting both on the covered entities and even on the PBMs, trying to drag them into the fight a little bit to get them to further oppose it. We work behind the scenes to explain why that wasn't necessary. The transparency discussion is a difficult one to navigate because you don't want to come out as against transparency or against reporting, but rather highlighting that the 340B program and the covered entities are already subject to great amounts of regulation through HRSA, annual audits.
(17:07):
Every covered entity that I've ever talked to always has a very tight reporting program already in place to ensure that the dollars are being used appropriately, tracked appropriately, and all of those things. Adding more transparency, legislation language was just going to be overly burdensome, create unnecessary work for our staff. It was going to further allow them to water down the program. So we were able to work behind the scenes to push that back.
David Glendinning (17:33):
Louisiana is certainly one of the pioneers in this field. Mississippi not very far behind it, and of course, we're hoping that additional states come around with their own legislation. The 340B hospitals certainly can help in those states to try to advocate for that. So what advice might you have for those 340B hospitals working in other states to try to pass these laws?
Ryan Cross (17:54):
Look, different states are going to have different political climates passed that they have to navigate potential pitfalls and dynamics that are unique to that specific state. Louisiana is not Mississippi and Mississippi is not going to be Montana, North Dakota, or California. At the end of the day, if you could fall back on immediately beginning to build those relationships and establish that level of trust, know your messaging and ensure that it's crystal clear as you try and navigate the political climate in your state. Then ensure that you've organized your grassroots army and that they're ready to activate if you really get into a fight.
(18:32):
At the end of the day, protecting 340B is a strong message that's going to resonate with your elected officials. It's important that you share the dollars that are saved, the dollars that are generated, not at taxpayer expense and how those dollars are used in the communities that you serve. When you do that transparently, it speaks for itself and it's hard to argue against it. Articulating that message is critical, not getting caught playing defense. Being able to clearly ensure that they understand where the program came from, where it's going, how important it is to keeping our rural hospitals open, to keep ensuring that care is provided for those most in need, you're going to win that legislative battle.
David Glendinning (19:11):
Well, Ryan, we certainly appreciate you being down in the trenches for those battles. I know that is not entirely won even in the states that do have this legislation now moving into the courts. Then of course there's always 340B and drug pricing and hospital issues that do come up. So thank you for your work in that area and thank you so much for sharing your insights with us today.
Ryan Cross (19:33):
We're going to keep fighting.
David Glendinning (19:34):
Our thanks again to Ryan Cross for continuing to fight the good 340B fight in the state houses, and we commend him and the other health systems in those states that have achieved these successes to date. If your state is still considering 340B legislation during its current session or considering proposed bills to file for the next session, we would love to hear from you. You can email us at podcast@340Bhealth.org. We will be back in a few weeks with our next episode. In the meantime, as always, thanks for listening and be well.
Speaker 1 (20:12):
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 at 340B Health, and submit a question or idea to the show by emailing us at podcast@340Bhealth.org.