Best of '24! AH020 - Why NADAC is a "Ray of Sunshine," with AJ Loiacono and Antonio Ciaccia

Transcript

Lightly edited for clarity.

[00:27] Justin Venneri: Hello and thank you for listening to this episode of the Astonishing Healthcare Podcast. This is another best of 2024 episode which included Antonio Ciaccia of 46Brooklyn and 3Axis Advisors and Capital Rx co-founder and CEO, AJ Loiacano.

This episode was unique earlier this year in that it covered the changes to NADAC - National Average Drug Acquisition Cost - the drug price index that we prefer. And given recent activity in Washington D.C. and the push for PBM reform with a focus on drug prices, we think this episode, which happens to be one of our most downloaded and most streamed episodes of the year, deserves some more airtime. Enjoy...

Hello and thank you for listening to this episode of the Astonishing Healthcare podcast. I'm Justin Venneri, Director of Communications at Capital Rx, and we have a special episode for you today. I'm joined by Antonio Ciaccia, President of 3 Axis Advisors and CEO of 46brooklyn Research, and Capital Rx Co-Founder and CEO, AJ Loiacono. We're going to be talking about NADAC, national average drug acquisition cost, and some recent updates to it, as well as its utility. AJ, let's start off with you. Thanks for joining us today and it's great to have you back on.

AJ Loiacono: Can't believe this is a repeat appearance. So, thanks for inviting me back.

[01:42] Justin Venneri: I know, so soon. We were supposed to wait for episode 100, but here we are.

AJ Loiacono: You know, look, when you have interesting topics, it's great to be pulled back.

[01:53] Justin Venneri: Cool. So, we were the first PBM to go with a NADAC based network. Can you just explain at its core what NADAC is? I know it's 101 level stuff, but we get a lot of questions on this from people with all levels of experience. And maybe can you add why it's so important?

AJ Loiacono: Yeah. NADAC - national average drug acquisition cost - comes to us from our friends at CMS. It is maintained by independent firm Myers and Stauffer and the goal of it is to provide visibility to price. More importantly, some level of acquisition cost. I say some level because drug pricing is not as simple. If you could see me, I'm drinking a can of coke right now. Ritual for the afternoon. We are not sponsored by Coca Cola in any way, but it is my preference.

But anyway, a can of Coke. You know, I often say, would you pay $20 for a can of Coke? No, you would pay $1 to $2, depending upon your level of thirst and the temperature, perhaps. But that seems like a fair price point for a can of Coke at retail. And the reason why is because we have decent visibility, we have decent experience with that price.

The problem with the US supply chain and pharmaceutical product is price is a very elusive target. Is it acquisition costs? Is it net cost? Is it net cost of different incentives? Is it a total acquisition cost, acquisition cost offset? There's a variety of different strategies depending upon who you're talking to in the supply chain -- is it a wholesaler? Is it a pharmacy? Is it a payer? Is it a PBM? And so price is a word that I would obviously have a footnote that says something like, your mileage may vary based upon who am I speaking with?  

But the reason why getting back to NADAC is it's so important is it is an average of experience from retail pharmacies that are reporting in and saying, this is what we're purchasing this drug for. And what this is creating is some semblance of understanding of what drugs should cost in the United States. And this is so important. It's also used for Medicaid reimbursement in 45 states. So, it's a proven benchmark for government transactions as well. And again, it's deeply rooted in reality -- what pharmacies are saying, hey, I buy this drug for this amount of money. And what this is really providing, the federal government is providing a national service. It is allowing us, both payers and patients, to rationalize price.

You know, as I mentioned before, price is a mystery. Drug pricing is an absolute mystery in the United States, and this is incredibly helpful. So, NADAC, I am a huge believer in, because the other thing is, we're not setting the price. I think when you take on the role of an administrator in any type of pharmacy benefit, I often say PBM, pharmacy benefit management, what are you managing? You are managing plan sponsor experience for the membership. And this is important to remember, because what you want to do is to make sure that you're providing all the administrative functions, but you never want to do that with bias. The bias being, back to if I make money on drug spend, or I'm setting prices on drug spend, unfortunately, you could make decisions that just benefit your financial interest. The inherent conflict of interest of making money on drugs is the more expensive the drug, the more money you make. And, you know, if I can create artificial variability on drug pricing, I could create more spread or maximize my return.  

And so what I love about NADAC is it's a third party. It's our federal government. It's used in Medicaid reimbursement in 45 states. It is a good benchmark. It is deflationary in nature. It's something that people overlook all the time. AWP for generic, which is the most commonly used pricing benchmark, is inflationary for generics, which makes no sense whatsoever. Anyone who's ever purchased generic drugs know that generics are deflating, conservatively, 10% each year. And so, you want a benchmark that at least directionally is making sense. If you say gravity is going down and suddenly you experience weightlessness, you know, that doesn't make sense. This is what we want people to understand -- is it's fair, it's directionally sound. We have nothing to do with the price setting. And we often tell our retail partners, in fact, we tell them all, hey, if you can beat NADAC, please do. But this is the starting point. And if you beat it, please know, because we don't make money on drug spend, there's no spread, there's no excess profitability. We won't keep the better price. It also helps people have more consistency. If you're filling a drug in Maine, or Arizona, or Washington state, or Florida, it's the same price, you know, regardless of what pharmacy, and you're starting from the same price point, the only difference is going to be your dispensing fee, which is going to have very little variability on the price. And that dispensing fee is going to the pharmacist for their services. So, you know, I could go all day on the reasons why we've selected NADAC, the importance of it, but again, I go back to, it's the only ray of sunshine and truth in a very complex and opaque drug pricing system.  

[07:22] Justin Venneri: And AWP is acronym for Average Wholesale Price. And there could be more acronyms throughout this episode, so we'll try to try to lay those out.

AJ Loiacono: You'll be our acronym tracker.

Related Content on NADAC and NADAC vs. Other Drug Price Indexes:

• ‍What is NADAC & How Does It Differ From AWP?‍
• Why Use NADAC-Based Pricing Over AWP
• ‍Medicaid.gov - Drug Pricing (where NADAC lives)
• Methodology for Calculating the NADAC for Medicaid Covered Outpatient Drugs (Feb. 2024)

[07:31] Justin Venneri: No problem. And that's a good segue, actually, to Antonio, because I think you're very well known for your work on national drug prices, gross to net bubble prices, and studies you've done in various states. So thank you so much for joining us today. From your seat, what would you add to what AJ just ran through? And can you tell us a little bit about your background to start, if you want to take a quick step back to frame things?  

Antonio Ciaccia: Yeah, I think NADAC is really a cornerstone of our story. To AJ's point. We know that drug pricing is often a moving target, and it is a moving target that exists within a giant black box. My background was in pharmacy, and in my home state of Ohio, pharmacists were often complaining about PBM reimbursements, or pharmacy benefit manager reimbursements, for drugs that they were dispensing to Medicaid beneficiaries. They would buy a drug for, let's say, $10. They'd get reimbursed $4. You can't run a business like that.  

Well, amidst those complaints that pharmacists were getting paid less and less for medicines dispensed within the Medicaid program, on the other end of the transaction, you had the State Department of Medicaid saying that they had never spent more for medicines than what was occurring over that same time period. So those two things don't match up right. If pharmacies are getting paid less, by extension, the person putting money into that system should be also paying less. And so our state government was not really interested in the business of answers to why this diverging experience might be occurring. And so, we, as startup drug pricing analysts back in 2016, looked at the cost that Medicaid was incurring on a drug-by-drug basis, thanks to the Centers for Medicare and Medicaid Services having a data set available called state drug utilization data, which is tracked for the purposes of the Medicaid drug rebate program. Within that file was a drug by drug, quarter by quarter, state by state accounting of what the state of Ohio was paying for medicines. Also sitting on CMS's website was this National Average Drug Acquisition Cost.  

Again, to AJ's point, not perfect, but much better than pretty much everything else that is being used in this marketplace, giving us a directional representation of the underlying costs of medicines over that same time period, we were able to stitch those two data sets together. What the cost of the drug is – NADAC -- what the cost was from the state of Ohio's perspective after PBM sent them the bill. And what you found was that a growing disconnect between the real cost and the billed cost amounted to about $245 million over a single year of Medicaid.  

The state of Ohio proceeded to fire their PBMs that were engaging in this practice of spread pricing. And regardless of whether spread pricing is in fact okay or not, and I would argue that spread pricing is not necessarily something that's in the interest of the end payer. But regardless, spread pricing is a concept of arbitrage. It is taking advantage of an asymmetry of information on either ends of a transaction. What NADAC represents is a directional truth of what the real cost of a medicine should be. What that means is that a better NADAC, a greater accounting for what the real costs of medicines are, the better understanding we have as plan sponsors who are paying for benefits, patients who are paying for medicines at the pharmacy counter, or pharmacies that are buying drugs from a wholesaler, and or getting paid by a PBM. NADAC represents a bit of a truth serum and a sobriety check for whether or not the numbers that are spitting out at the end quote make sense.  

[11:24] Justin Venneri: Got it. And in mid-April, there were some changes to NADAC, the methodology, and market observers have noticed some deflation. I'll stick with you. Antonio, you mentioned it's a survey. AJ mentioned it as well. Just to clarify, it's a monthly survey with weekly updates. Is that correct?

Antonio Ciaccia: That is correct. So what CMS does is they work with a CPA firm. The current vendor, and really the vendor forever, has been Myers and Stauffer. What Myers and Stauffer does is they send out a survey to thousands of pharmacies on a monthly basis and simply ask them, what did you pay to put the drugs on the shelf? With that, we understand anywhere from 400 to 600 pharmacies tend to respond to that survey. And with enough data collected, they will create this NADAC benchmark. And so it is updated based upon the responses to this call for survey prices.  

[12:18] Justin Venneri: And I think there were a couple of things that happened at once. The methodology changes, a couple of things that basically help with the calculation itself of the NADAC price per NDC. But then also people noticed a large submission at a high level to the file. Could you maybe describe what's going on there and what's important about this for the market?  

Antonio Ciaccia: Yeah. So for those that are unfamiliar with some of our work at 46 Brooklyn Research, which is a nonprofit that we use to basically take a lot of the things that we learned in Ohio and build from there.  

The first dashboard we ever created was a look at what Medicaid programs in every state were being charged and comparing that to the NADAC, the underlying cost of the drugs. Well, since then, we've taken more publicly available data and worked to contextstualize the impact of pricing changes over time. Looking at NADAC changes, looking at manufacturer list price changes, examining what's happening within Medicare expenditures, Medicaid expenditures, etc. One of the things we do every month over at 46 Brooklyn is in addition to tracking drug manufacturer list price increases on brand drugs over time, what we also do is look at NADAC changes every single month. We don't just examine, hey, Lisinopril took a 10% decrease this month, and buprenorphine naloxone took a 10% increase. What we do is we say, let's not look at every price change in isolation, although we do do that, but we say, what is the impact? Because we understand that some drugs are very expensive versus others that are very cheap. Some drugs are very popular, meaning a lot of people take them, and some drugs are not. What we should not do is necessarily treat every drug price change as equal to the next.  

So what we do is we rely on the data set that I mentioned before, the state drug utilization data, which tells us how much every Medicaid program buys and what the pricing impact is quarter by quarter. So with that, we can look at any changes in NADAC over time and overlay those changes with the degree with which a large program like Medicaid is buying them. So it gives us, again, not perfect, but better than not having any contextualization at all, some ability to weight the impact of NADAC changes over time.  

When we do that month by month, what you'll see is that there will be ebbs and flows. The weighted impact of the NADAC changes month to month could go from very insignificant movement, meaning like 1%, if not no change at all. What you could see are significant swings where the net amount of change, when all price movements are considered, could have a weighted impact to Medicaid of just over $100 million. That's usually like the most extreme swing that we can see. In this most recent month, we looked at the changes and weighted it against Medicaid utilization. The change almost hits $500 million. So we're talking about almost a 5x multiplier of the most extreme instances that we've seen over the last few years. So the question then is, what changed?  

Well, there are two things that happened this past month that are impacting the significance of the swing. First and foremost, what we understand is that there's been a new participant in the NADAC survey. When Myers and Stauffer and CMS send out this survey, again, it is voluntary in nature. So, the degree with which NADAC yields prices in the past, we based upon who's been voluntarily submitting, in our experience, what we understand is that the people that are participating tend to skew more towards independent small and mid-sized chain pharmacies. What we understand this past month is that a large pharmacy organization has started participating. What that means is that their pricing dynamics are now mixing with the legacy pricing dynamics of how NADAC has been computed. What we know in this small pharmacy marketplace is that oftentimes their buying agreements with wholesalers will have certain cross subsidization going on, meaning that they might be acquiring generic drugs at a somewhat inflated price to make up for perhaps lesser prices on the brand side. While we don't know this exactly, we can stay with high degrees of education around how this stuff works is that larger chains are not engaging in that degree of cross subsidization. So what we understand is that the large pharmacy organization that's now participating in the NADAC survey has inserted their buying dynamics into the overall calculations, which is creating a significant swing in generic deflation. And the question remains on whether or not we'll see brand prices kind of pop up, but the aggregate impact is a significant decline in the overall value of NADAC prices.  

[17:43] Justin Venneri: Interesting. Okay, AJ, do you want to jump in here, explain maybe from your CEO of a PBM, what this means and the implications for different stakeholders in the market.

AJ Loiacono: I mean, the first thing is, I say that typically the us supply chain operates like a clock. It has a cadence and rhythm and this is what allows you to keep good time. And I feel like the supply chain has events that move in somewhat predictable cycles. And so, we typically see things like price increases for brand and specialty products in the January ish cycle and the June, July-ish cycle. You can see some level of material price deflation. It could be biannual. Again, it could be quarterly depending upon purchasing cycle and how people are reporting into the survey at NADAC. So, I think one of the things that I took note of personally, and this is just a me observation, is it wasn't expected. You know, it was like looking at your watch and being like, wait, wait, what time is it? Like, why is this happening now? I mean, Antonio, I don't know if you felt that way as well. Like, I was kind of like, I wasn't expecting to talk about a material price decrease at this point.

Antonio Ciaccia: Well, we were expecting something to change, but not this significance. The one thing that I didn't mention is that the same time a new pharmacy organization started submitting, Myers and Stauffer had also implemented a few policy changes and methodology changes that was going to create new price points or freshly updated price points that based on prior methodology had not necessarily been updated. We were watching this month with a couple magnifying glasses and so when the numbers spit out, we were shocked to say, oh my God, like, this is way more than we thought. And our suspicions were, well, maybe that one methodology change was responsible for all this, when in fact we now realize, no, that was actually a very insignificant component relative to the significance of a large pharmacy organization submitting. So I agree with, with you, AJ, we were expecting something. It just wasn't an earthquake that we were expecting.  

AJ Loiacono: Agreed. I think, you know, back to my somewhat poor watch analogy here, which is I was expecting like, hey, I was expecting to look at my watch, and it was 04:00. And I'm like, wait, why is it 07:00? The other thing is, and this is a broader discussion, and this may be getting a little bit too geeky, Antonio, which is, you know, when I start to think about pricing of drugs in the United States, and this is why, again, I really and truly appreciate NADAC, because it is this, this ray of light, this source of truth that kind of holds the world somewhat sane in pharmacy benefit management. Because without it, I wouldn't know what to believe.  

I would literally have to go and start a pharmacy, you know, all over again. And so being on the payer side, being even on the patient side, this is a helpful source of information that does not sit behind a paywall. You know, I always want to make this clear. If you want to use AWP, you know, you got to become a client of, I think, Walters, Kluhr, and, you know, obviously subscribe and gain that information. This is free information from our federal government. But the other thing is how things are interconnected. And this is the broader topic I was referring to, which is sometimes wholesalers will say things to me, I'll just stop dead in my tracks and be like, wait, could you repeat that again? And they'll say things like, and Antonio, I want to get your thought on this in a second. They'll say things like this be like, hey. Like, yeah, generic drug prices probably should be even cheaper, but sometimes we use it to subsidize a lower price on brands. And I'm like, what? And I'm going to tell you what that means to me in a second, but I just wanted to get your thoughts on a statement like that, Antonio, from wholesalers to pharmacists.

Antonio Ciaccia: It's an admission that wholesalers have a role in determining what prices are. When I hear things like that, it's the equivalent of walking into a department store or grocery store where there's a loss leader. Right? Like in pharmacy world, if you're unfamiliar, there's the Walmart four-dollar generic list that they used to have. Right, right. You know anything about pharmacy? Between the cost of the drug and the cost of the pharmacy service and the overhead, nothing is worth $4. It's more than that, right? It was done as kind of a business gimmick to say, come on in and get something cheap so that we can balance it out on something else. Right? Whether it's overcharging on a different medicine or relying on you coming in to buy overpriced gallons of milk, or bags of M&Ms. It's a pricing strategy, right? It's not inherently wrong, but what it is is that admission that they're creating some sort of false favoritism in some category of what they're selling in order to create premium opportunities somewhere else.  

[22:55] AJ Loiacono: I agree. And I think, you know, I was trying to explain this to someone because I was talking about this literally over lunch earlier today. You could tell we have a really exciting lunchroom discussion here at Capital Rx.

Antonio Ciaccia: That sounds fun to me.

AJ Loiacono: Antonio's like, I'm in. Like, you know, you should come on in. But you know, over sandwiches we were chatting about this and they were like, well, what do you mean exactly? Imagine like, you know, you're in a local shopping experience. You know, take your pick, big box, small store, grocery store, I don't care. But let's just say you walk in and you typically buy, you know, a six pack of coke. You buy a dozen eggs and milk. Odd buying arrangement here, but this what's on my shopping list – and bread, okay? But let's just say eggs go up in price, but you know, to make up for it, we'll give you a discount on the bread. I'm like, that's not how efficient markets normally operate, at least in my head, which is the egg person is doing their egg thing, the bread person's doing the bread thing. And my whole point of this is each one of these things represent different sellers, not just in the category, but the category itself as sub-manufacturers or producers providing access to this.  

And I think about the pharmaceutical supply chain, which is like, hey, it's not just a manufacturer that has a suite of branded products or generic offerings, but there are multiple manufacturers and many GPI. I try and rationalize this in my head where it's almost as if someone's playing God with drug pricing. And you have this moment where like, look, I have, let's just say round number, $100 of drug spend and that represents brand, specialty, generic. And you know what? On that hundred dollars discounted, you're used to paying $80 all in. And you know what? Some things go up, some things go down, and I'll magically change prices to make it all work out. But the problem I have when people start saying things like this, and it makes me nervous, is I start to believe there may be no individual drug pricing left. Like how much truth is left when people are able to manipulate entire categories? 2030, 40%. And that's weird to me.  

I'm a practical person. At the end of the day, and maybe I've been spoiled by the efficiency of other markets. I just find when you start to talk about global absolutes of offsets on cost and just be like, hey, generics probably should be cheaper, but we've been subsidizing brands and now generics might be down and we might have to increase brands to make up for it. I'm like, who's in charge of drug pricing in America? Because I feel like there's an outsized role between the manufacturer and the pharmacy and the patient and the payer. It's just I don't get a sense of clarity there. And that's what I'm struggling with at times when, you know, for every good thing we uncover sometimes someone in the comments, when you're just asking naive questions, I mean like, hey, what does this mean? Big picture? And they're like, oh, by the way, we might have to increase brands to offset this. And that was kind of the moment in my head, Antonio, where I was kind of like, wait a second.  

I love NADAC and I stand by my prior statement. It is an important ray of truth and sunlight to a highly opaque and complex pricing system. But I also get nervous sometimes when people start talking about what almost sounds like price fixing, you know, which is like, there are no individual prices. I'm just going to treat this back to, you know, the aggregate. What are your thoughts there, Antonio?

Antonio Ciaccia: Well, I think you said like, you know, who's the God of drug prices, right? I think the truth is, is that this is like ancient Greece, man. There are many gods that are impacting the prices. And I think it should be stated unequivocally that there's no perfect panacea model for how we price medicines, especially in an environment in the United States where ultimately the prices are going to be subject to a negotiated experience. Nobody is selling drugs with prices that are, quote, kind of all in. Wholesalers have a gross to net experience. Pharmacies have a UNC versus a net experience. Manufacturers have a list price and a net price. Pbms are arbitraging both ends of the transaction, et cetera. The key here is what is a best of solution.  

We know that the legacy pricing models that are predicated on average wholesale price, whereas I like to call always what's profitable. But there's a lot of opportunity underneath the bogus inflated prices to engage in pricing manipulation. NADAC is not impervious by any stretch, but NADAC represents two, actually three, very important things. One is that it's an actual representation of the going rate at the layer of the channel that probably matters the most to the end payer, which is the pharmacy counter, and there might be some degrees of inflation within. But the good thing about NADAC is that because it's not operating off of bogus inflated sticker price when you're off, the off impact is relatively insignificant. It'll be the difference of pennies and nickels rather than hundreds of dollars on the AWP side.  

The other beautiful thing about NADAC is that it is publicly available. It is downloadable by anybody at any given moment. Those who have tried to ask a pharmacy or a PBM or a wholesaler for the true net negotiated prices, good luck. Get in line. You probably will not get them if you're a plan sponsor. Listening to this, I would venture a guess, you've had a difficult time getting an itemized receipt from your PBM for exactly what has been negotiated on your behalf.  

The third thing that NADAC represents is a cleansing of conflict. Obviously, this is a Capital Rx discussion. It's not just home field advantage that I'm providing to you here. But I would say this in any environment, anybody that's in the PBM industry that has absolved themselves of price manipulation is conveying a degree of trust to the end payer. What I mean by that is that if you are a PBM today operating in an AWP world or a MAC pricing world -- maximum allowable cost -- this gives you tremendous flexibility to play both ends of the transaction. And in doing so, when you have market moments when significant deflation occurs, the PBM ends up being rewarded if they go out and negotiate lower prices, or if the marketplace is yielding lower prices. PBMs traditionally are playing the float, capturing the benefit that competition in the marketplace is providing and remaining, or keeping billing stale, old inflated rates back to the end payer. The beauty of those who operate in a true cost plus model, where they're not inventing a price, but instead operating off a foundational benchmark of price that might ebb and flow, is that when massive moments of deflation occur? And AJ, you could correct me if I'm wrong here. You know your business model far better than I. But when deflation hits, and when the benefits of competition yield lower prices, you don't get to benefit from that. The benefit ends up being passed through to the end payer. So if you're somebody who's operating in a NADAC based world and all of a sudden generic drugs go down in prices, they always do that, savings is immediately transferred back to the end payer.

[30:52] AJ Loiacono: Completely agree. And it's universal. You know, the other thing is we talk about the use of NADAC, which goes hand in hand with what we talk about, which is a single- ledger model, which is all of our customers get the same price. What drove me nuts when I started looking at claims data was like artificial variability between the perception of big customers get better prices, small customers get worse, and sometimes vice versa. It makes no sense. There's no reason why we needed to follow a model like this for so long. One of the reasons, again, why we went immediately to NADAC when we built our network out is I think it is critical we remain unbiased. We have nothing to do with price fixing.

As Antonio points out, its pure pass through on the benefits. So the moment deflation happens, all of our customers realize it at the same time, in real time. There's no benefit to our organization other than the smiles of the membership and the plan sponsor.  

And the last thing I want to really just touch upon, which might be a bit of an ominous warning, is I think because NADAC has served us well, we've certainly seen people try and replicate the model, which I applaud. I mean, there's no greater form of flattery than someone copying your work. I mean, like, that's amazing to me and I'm talking some of the largest competitors out there. But I think the other part of it is now we're seeing pushback from some vertically integrated members on the use of NADAC and they feel threatened by NADAC. And I think there's going to be a little bit of a dust up in the future where some retailers want to take control of drug pricing and set their own cost plus model. And I think that's okay as long as there's a backstop to truth. And I go back to my only source of truth in the US supply chain, at this moment, is NADAC. And so, a world without NADAC, I don't even want to even conceive. And so that's how important I think it is for every single payer, every single patient in this country. You know, without NADAC, we are all flying blind. And I just want everyone to remember that.

[33:07] Justin Venneri: That's clear. And then I guess I do have one more quick question here. Thank you both for taking the time to chat with us today. It's really enlightening. Antonio, you referenced it earlier. I guess we have to wait and see now what happens with brand prices and sort of how things settle with NADAC. Is that true?

Antonio Ciaccia: It is. I mean, if, again, if what we know about the marketplace bears out, if generic drugs have been slightly inflated on NADAC historically and now are being cut down to size by a new entrant, it stands to reason that either that individual is getting tremendous pricing on generic drugs and they're getting the same pricing on brands, meaning there's no cross subsidization, or more than likely they are getting essentially a more equitable model, meaning that both brands and generics are essentially being treated equally and there's no inflationary or deflationary gimmicks that are happening in either direction.  

It could be seen that brands could see a slight uptake under NADAC. If ultimately that bears out to me, I think if you’re sitting there wondering, okay, well, what's that impact to me? Should this be concerning? Well, I think in general, if NADAC is more erratic, obviously, I don't think that's a great thing from a predictability perspective, but I think it underscores the importance of having NADAC perfected. I think AJ would agree NADAC represents much better than other alternatives when it comes to how we price drugs at the pharmacy counter. But again, it is not perfect. Currently, there is legislation being considered at the federal level that would mandate participation of pharmacy providers in NADEC. What that would mean is that a lot of these things that could create subjective swings based upon survey participation, classes of trade, all of a sudden those things go away. Weve analyzed the Ohio AAC model. Ohio has an actual acquisition cost.  

It's like a state-based NADAC where they compel pharmacies to participate. Alabama has something similar. Other states have adopted this approach to say, we believe in the philosophy of NADAC, but what we want is better data. We want everybody participating. I think we would all agree that nothing will ever be perfect. But the more data you have, the more participation in the survey you have, the better that NADAC will become. So, I think this is a great moment to underscore the importance of, hey, we've done something very good in the creation and use of NAADAC. I think we can make it even better. And I think we're really close to getting that done.

AJ Loiacono: No, I agree entirely. Both points from Antonio, the first one being as kind of referring to it earlier when I was talking to wholesalers about the price shift, is they were like, generics were down, but most likely buckle up. We need to offset with a little brand work here. And I was like, huh. The Lord giveth, the Lord taketh away. We'll see what the ratio is, but the other part of it is, again, NADAC is constantly improving. Amazing. Whoever was the additional chain of pharmacies that reported in, I applaud them. I think legislation that supports more robust or routine reporting for more entities, if not all entities. I used to often say, if you participate in Medicare and Medicaid, you should probably report. You know, I think that's a fair offset for participation in those programs.  

But again, every data point counts. Every data point makes NADAC better. NADAC has been a huge benefit to our organization over the last six years, and I look forward to another six or 16. You know, let's, let's keep it going and it has my full support.

[36:55] Justin Venneri: Well, great. I think that's a good place to wrap today. So thank you, A.J. thank you, Antonio, for joining us and sharing your thoughts.

Antonio Ciaccia: Great to be with you.

AJ Loiacono: Yeah, thanks for joining us, Antonio.

Antonio Ciaccia: Always.

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