The 'Dispatched' Podcast

The 'Dispatched' Podcast - Season 5, Episode 22

• Season 5 • Episode 22

Share episode

Use Left/Right to seek, Home/End to jump to start or end. Hold shift to jump forward or backward.

0:00 | 1:12:07

A small player with no market share and no real prospect of gaining any agreed to an almost 50 per cent price reduction to secure reimbursement. Who would have thought the market leaders would respond negatively? Discussion about the change to nurse prescribing, which has been a feature of the PBS for more than 15 years, and concerns over vaccine hesitancy.

Paul

Hello and welcome to the Dispatched Podcast. Week in review. Probably need to stop calling it that, I think.

Felicity

Are we actually recording this?

Paul

Yeah, we are recording that. We need to give it a different name.

SPEAKER_03

I can't believe we're still here. Episode numbers.

Paul

That's right. I can't believe it's a week in review. My name is Paul Cross, and I'm delighted to be joined by uh Felicity McNeil, PSM, Chair of Better Access Australia, Chair of Other Things, on other boards. All sorts of things now.

SPEAKER_03

Yeah. Girls gotta keep busy. Gotta keep paying those taxes.

Paul

See, I always thought that um I could never, you know, when people say, Oh, I'm just a you know professional director, you know, on board, and I I never knew what that was.

SPEAKER_03

Um now I know what still don't think I know what it is.

Paul

It's actually quite good. I think I think it must be good because you get lots of different perspectives on things. And I just so everyone knows I've got the World Cup on in the background, and Portugal have just gone ahead in extra time against Croatia, and this could be an issue for uh for us recording this because there are a lot of Croatian fans just across the road and if it's if it doesn't end well.

Felicity

Just to be clear, it's not in the background. Paul is looking at the entire time, just like he did last week when we started recording in the soccer roos we're playing.

Paul

Honestly, I'm not even a big footballer, I'm not a big soccer fan, but but uh you know, you've you've got you've got to get excited by a big global event. You've got to get excited by a big global event. Um Well, we're all excited by the big change.

SPEAKER_03

In policy, yeah.

Paul

In policy, the one that allows nurse prescribing. But as you've pointed out to me, nurses have been prescribing PBS medicines for 16 years.

Felicity

Yeah, since the first of November 2010. And in fact, anyone who reads a public summary document for a medicines consideration, it will have a specific paragraph about whether or not the m medicine is eligible for nurse prescribing. And that has been the case since 2010.

Paul

And th they've held systematic reviews of medicines over multiple, multiple, multiple years. So it is a very this is about the most subtle of subtle policy shifts.

Felicity

Yeah, and I I think it's I think we that people are trying to make more of it or less of it, depending on your your point of view. So under the 2009 initiative, which was given effect in 2010, it was for nurse practitioners. So uh for listeners, a nurse practitioner is someone who has done a master's degree in nursing, and that makes them a nurse practitioner. And when we rolled out that initiative in 2010, we were actually ahead of the game of the colleges because there were very few specific uh courses for the prescribing of medicines, even in those master's degrees. And so even uh nurses who were already a nurse practitioner were struggling to be able to make the prescribing criteria because we didn't have a specific course. That course is now available and standard in a master's degree, but also available as an ad hoc for people who want to do something later. And as I've spoken to you about, nurse practitioners are fantastic in my areas of work in opiate dependence and hepatitis C. Some of the greatest providers of health care to people who do not have the support of a GP and the standard primary care system. We're going through nurse practitioners. There are a couple of amazing nurse practitioners in Queensland who support the majority of individuals who are released from a jail and have started on an opiate dependence treatment, long-acting injectable, and then can't get access to it once they leave the correctional facility. So they have been groundbreakers. And in hepatitis, some of the greatest numbers of treatments were through nurse practitioners who will work in the community where a lot of GPs simply will not. And we can have that issue about conscious bias another day. But what you do see in this legislation is that rather than requiring nurses to do a master's degree, they will now be able to do a separate standalone course on prescribing and be able to prescribe on the PBS. Now, why do we need this now and why is it important? Because pharmacy in the state and territories do a standalone uh course with respect to prescribing of medicines, remembering this is about the legal prescribing of medicines first, and that they can do that in state and territory governments. This is the next step, which is once you're legally registered in your state and territory to prescribe because you've done uh your short course, you are then able to prescribe as a nurse a PBS subsidy, which of course at the moment pharmacy does not have the opportunity to do. So it's it's about an evolution of policy. And I guess it's a it's something like I said that's been going on for a very, very long time, 15, 16 years. But we're now making it much simpler for nurses to become a PBS prescriber and a general prescriber, uh, subject to those medicines. And that is bringing them into uh line with what is available in pharmacy, subject to PBS.

SPEAKER_00

So it's good change. May uh been just slightly oversold.

Felicity

It's something that's been highlighted as a really big issue. And I think that we need to recognise that nurses have been at the cornerstone nurse practitioners of PBS access now for 15, 16 years, and this is now about making sure that a broader work n number in the workforce can actually prescribe. What I find interesting, however, is that it says that the PBAC will now review the medicines to decide what isn't available. So my question on that one from a policy level is if a nurse practitioner has been allowed to prescribe a certain number of medicines and they have been systematically considering nurse prescribing on every single medicine they consider and every single review they do in a post-market space, what's changing here? Are you going to give more access or less access? Is there a risk that you're going to have a two-speed process? If you're a nurse practitioner, you can do X, but if you're a nurse prescriber, you're a Y? Where's that going?

Paul

Yes. Yeah. It's interesting. I mean, it's obviously a very positive change. I don't think it uh I don't think there was even a division when it went through the Senate. It was just, yep. Uh so I haven't heard from the doctors yet what uh they think, but they're not they're not great fans of scope of practice.

Felicity

No, and they I remember in 2010, so like I said, being there since the start of this one, the the nervousness and the same arguments that we are seeing uh with respect to pharmacy were also rolled out in respect of nurse practitioner prescribing and midwife prescribing. And again, very conservative lists were started with in 2010, and gradually that scope has been evolved over time, and like I said, it's standard consideration by the PBAC of every new medicine or every extension to a listing when it comes before them. They must make a uh ruling uh piece of advice about whether or not they believe it's appropriate for nurse practitioner prescribing or nurse prescribing uh under a PBS subsidy.

SPEAKER_00

Yes.

Paul

Okay. Uh let's talk about well, uh Natasha Robinson at The Australian has continued her series this week.

Felicity

Yeah.

Paul

Uh broadened it out a little bit, touched on the issue with uh two multiple sclerosis medicines.

Felicity

Uh yes.

Paul

Yeah, so it was opportunistic, wasn't it? An issue that's been tracking along for a while. Uh certainly got the attention it it deserved. My theory on this is that uh the officials have played a little game. They're unhappy that these newer therapies were listed uh and potentially around a loss of exclusivity time patients shifted because they're better you know, they're easier to use, better in many ways. Clinicians prescribe them their first line because it's multiple sclerosis, you can't really be mucking around. And so they decided to manoeuvre sort of a naive little company into offering up what I understand. I mean, people have said it's around 40%, but it's actually far closer to 50%. A 50% price reduction. So they got a little bit greedy. And maybe if they had said 10 or 15, maybe the companies would have accepted that. I I don't know. Uh but fifty was completely overplayed. Uh it was uh uh an attempt to sort of recreate for this one class or this one group of treatments, sort of a 2023 catch-up. Yeah. And the companies have said no. The companies have said no no way. And so the the minister, now you will understand this even better than I do. It's very likely that the minister has delegated all these pricing powers because obviously the minister can just sit at their desk and say, nope, we're not going to impose this price reduction. This is multiple sclerosis. These are patients, it's it's a it's a degenerative condition where uh your body essentially attacks you, and every time it attacks you, it gets worse. And these therapies delay that significantly. So they're amazing, amazing therapies. He could, if he had the power, which he does formally have the power, but uh he's obviously delegated it, or one suspects he's delegated it, and he could just say, No, we're not gonna pass on this price reduction. Uh he hasn't done that. He's or I suspect the delegate, again, the delegate has sought advice from the PBOC. And in that case, the minister and the minister has had to wander up to the press gallery because he knew it was the press gallery because it's got the it was the red carpet.

SPEAKER_04

Yeah, not the blue car and then the coffee carts just around the corner.

Paul

Yeah, not the blue carpet and the ministerial wing. Got a microphone and obviously lined up someone in the press gallery to ask him a question about it.

SPEAKER_02

Yes.

Paul

And done what ministers do. Sent the PBOC and his officials a clear message where he said, Well, obviously it goes to the PBSC because that's what happens. But I want this to stay on the PBS. I just want to reiterate, I want patients to continue to be accessing these medicines. So the question is whether they listen to him, I suspect they will. Uh, they do not like conceding on these things though. It goes into their legal framework. They do have all the flexibility in the world, but it really depends what outcome they want. But uh I I assume he doesn't I mean he could take back the power, but he doesn't want to do that.

Felicity

Well, you don't have to take back the power. What you do is when a minister is appointed, every time there's a change in government, all powers vest back in the the the minister until such a first thing a minister does is delegate. Yes. And the first time a new power is created, so you know I've been asked a lot about this in court, you know, that must have been very important because you know Minister Abbott decided to take the decision on that. You must no, it's because the first time a power is exercised under a new law, it must be exercised by the minister and thereafter they can delegate. But at any point in time, the minister can just because you delegate the power doesn't mean that you cannot actually still make a decision in respect of that law.

Paul

Yeah, but it's undesirable.

Felicity

But of course it's undesirable to a point. But then also as a bureaucrat, I have previously explained to uh pharmaceutical companies who've written in despair and wanted to meet with me about decisions I've taken as a delegate and what they would like change. And I said, you have every right and you should go higher, because in the end, my decision can be overturned by someone at a higher level. So it's not just that the minister could make this decision. These powers, as we're seeing by who is signing the legislative instruments, are usually being exercised by um an SCS band one, occasionally an SCS band two, which means the SCS band three, the secretary, and the minister all have the delegation for an escalation of a process to make a different decision on the law with the information before them and on what they do or don't take into account.

Paul

In your years in that area, how many times did you see a minister reverse a delegate's decision?

Felicity

Uh when I was there as opposed to what I've seen since I left.

Paul

Yeah.

Felicity

And only in PBS?

Paul

Only in PBS, yeah.

Felicity

I've seen them reverse decisions. Sorry, they don't reverse decisions. I mean to be very clear under law. They make a different decision.

Paul

Make a different decision. And that's very, very important. But the effect of it.

Felicity

So we're not in the Yeah, I want to be really clear though, they make a different decision, they make a new decision, and I've seen that three times.

Paul

Three times, yeah. So it is it is unusual.

Felicity

It is unusual. Um, but also I think this is the point that you were trying to make is that this all stinks of overreach.

Paul

Oh. And so they got greedy.

Felicity

Yeah. And if you think about things that the history of the negotiations since 2017. So frustration that they signed an agreement and then the molecule that was supposed to deliver the majority of those savings didn't go off patent. If you look at uh frustrations with medicines that managed to avoid, had their risk shares removed, and then suddenly took off and there was no way of actually controlling the expenditure on those medicines, you get a reaction. We get changes in policy to try and catch things. When things move to different areas and something managed to move from F1 to F2 to avoid certain pricing, again, we see reactions in strategic agreements. And every time something that was forecast in a strategic agreement does not eventuate, uh the administrator are revengeful god and they will find a way. And you've talked about it many a time that you've seen what happens when you know you're at the receiving end of when you win the the battle and lost the war the next year. Uh the government holds pretty strong and firm. But this one really does stink of overreach. And like you said, if you'd just gone a little bit smaller, you probably could have maybe got away with it. Like the system may have taken it, the industry may have taken it. And I don't think we need to see this as some great conspiracy by the two companies as planning a plot to highlight something that's going on globally with respect to MFN, etc. They didn't ask for these price cuts. Like this is not a strategic plan to say I'm not going to list a medicine or I'm going to delist a medicine because I've suddenly changed my mind. This is the Australian government proposing to do something quite extreme to the pricing of these medicines. And on what basis they're doing it is not quite clear. And they're pushing back and saying no. So it does put the minister into an awkward position in that he might actually just have to stump up, like you said, and what he's done, which is sometimes you've actually got to say, this is my PBS. I am legally accountable for it. I do represent consumers and patients in this matter, and this is what I intend to take into account. So he has signalled that if he is asked to make a different decision, he has said what he will take into account, that patients retain access. So the PBSC and the department can either choose to listen to that now, and as an advisory committee, PBSC, no power, no right of determination, can say, on that balance, we think X, Y, and Z and we note that. Or they can sometimes do what they did to Minister Hunt and just say, Well, you made us do this, but we're going to tell you what you want and tell you what also you don't want to hear. But I I think yes, he's already signalled, and if I was to look at how that would be appealed in court, the minister has already signalled what he will take into account in making perhaps a different decision. Because you must remake an entire decision, not part of it.

Paul

But he in signaling se sending them the signal of what he wants, he's giving them a chance to succeed or fail.

SPEAKER_02

Yes.

Paul

Because they they will not want a minister to say because it is very rare. Very rare for a minister to formally reject advice. Formally.

SPEAKER_04

Yes.

Paul

I've said I saw it once. Uh and I don't know that it's ever happened. How many times has it actually happened where the minister says I reject this advice?

Felicity

And again, if you're talking about PBS versus MBS versus um NDSS versus a few other bits and pieces, you you do see it, ministers reject advice.

Paul

Yeah. In this area, it's very uh PBS is very unusual. But it's it's interesting. Uh it'll be interesting to see what they do. But uh my my view is that it's just massive overreach. And that's that's always where the bureaucracy gets itself in trouble, and particularly this part of the bucracy is they go too far. Yes. And you know, the you've got to sort of whack give them a bit of a whack to get them back in line. The silly thing is that in the last few weeks we've had breast cancer. Look, this is all none of this is related to Trump or MFN. None of this is related to Trump or MFN because MFN is prospective, it's for new drugs. This is probably China, I suspect. So we we as a country, because the Chinese do these random international benchmarks that include Australia.

SPEAKER_03

Yes.

Paul

Uh someone's a couple of people have told me this week that the published price of some medicines in Australia is now higher than the published price in the US. Now, that's not going to work because the US are not going to fall for that. But it is an interesting, it is an interesting outcome. But we're getting squeezed by these two behemoths, the big global player in the pharmaceutical industry, and the emerging big global player in the pharmaceutical industry. And I thought the minister's comments this morning, he did a interview with Radio National this morning. And I think full credit to the Australian and to Natasha, because her focus on this in the last couple of weeks has got Radio National acknowledging the need, the ABC acknowledging the need for potential change. And historically, and Mark Butler until recently, in response to a question about a more assertive US on pricing, would have said, no, under no circumstances, no concession, was sticking up for the intent, bar, but you know all the lines.

Felicity

Like he did three months ago, four months ago.

Paul

Didn't do that this morning. Now we have to see a fit see it a few more times before it becomes an absolute pattern. But he was not conceding the need for change.

SPEAKER_03

But he was talking about he wasn't disputing the need for change.

Paul

No, he wasn't dismissing it out of hand that silly way ministers have done for years and years and years. Because I keep telling people, honestly, the US couldn't give two, you know, watts about the PBS unless it starts impacting the US. That's why the free trade agreement was significant. Because it was it was an opportunity for the PBS to impact in the US. Uh and so it became highly relevant. But it hasn't been relevant since. Well now all of a sudden it's relevant again. And we need to be adult about it. And I thought the Medicines Australia comments gave they they sent to me yesterday, I was like, oh wow. Wow. Because my view now is that uh and and their view is a little bit different than mine. My view is that going into this negotiation, which is obviously coming up, I think the framing of it has to be you can forget about it, government. We're not doing anything. You can forget about it. We're not going to agree to anything. Doesn't mean you can't do it if you can get Parliament to support it, but think about the damage, unless you accept the need to have a conversation about this big issue, this emerging global issue, where it's not MFN alone, it's also China that is it that is affecting Australia. Because I have this horrible, horrible feeling. Horrible feeling that there are some companies looking to get out of Australia and looking for excuses, like they did New Zealand 25 years ago. So when companies, when Pharmac came along and just wiped out the industry, and New Zealand has a very proud pharmaceutical history, Glaxo Smith Klein essentially came out of a little pharmacy in a little country town in New Zealand, right? So it's Smith Klein Beach. There's a long history, but but we need to get our head around that. We need to be honest about it. So you've got this weird disconnect, and I wrote About it this morning, you know, because the HDA institution is like the the bang entry, I call it, where nothing can grow beneath it. It's completely self-protecting and it kills everything else. And we see that with the Delphi survey, which is now in phase three, where there's no consensus. And, you know, someone said to me I can't say who, but um someone at Medicines Australia said to me, you know, there's no consensus. There is a consensus. The people who actually work on submissions and do submissions have an absolute consensus around what this should be, and the people who've never seen a submission have have a belief about what it should be as well.

Felicity

And they're different?

Paul

Yeah, and they're completely different. Right, but I don't know, why are we letting people who've never seen a submission even have it have have a perspective on this? I I don't understand that. But but there's so there's this little self-perpetuating bang-in-tree approach. And then there's the reality over here that companies are going, forget about it. Forget about it. We're not we're not we're not doing it. If you're gonna impose and I know that the price cuts that have driven issues in the past few weeks have nothing to do with HTO, they're just price cuts, although that you know it's a comparative issue, but it's i they're driven by by procurement practices.

SPEAKER_00

Why is an HCA advisory committee deciding the future?

Paul

So we have this massive disconnect and incoherence in the framework. And so going into an agreement negotiation, I think I'd be saying, this is all real and good. If you want to talk about price reductions, probably not the greatest time to be talking about price reductions. But before we start a conversation, we need to have a conversation about managing the new global reality. That is, if you want medicines in this country, because MFN is going to affect all the new medicines. But we've got a situation here where there's another big global player impacting medicines people are already on. But like these are very sensitive patient groups. We've got breast cancer, we've got multiple sclerosis, and this where you have confirmation from a company that an ODT medicine's coming off the PBS.

Felicity

So we're a lot to unpack there.

Paul

I think You always say that when I've said too much.

Felicity

No, you know, it's just when you raise a number of different things that I may agree or disagree with. I don't have a problem with people that don't put in submissions together, commenting on the Delphi survey, because that by the argument that someone who doesn't put in submissions shouldn't be contributing to that.

SPEAKER_00

Oh, that's true, that's fair.

Felicity

Therefore, their I as a patient should have no right to be contributing to that. So okay, maybe within it's I think sometimes it's good to actually stop the people who do submissions day in, day out, and who think they own the unicorn, but as you always write about and doesn't exist, because they always put in thinking my medicine's definitely going to qualify for this on my device. So I encourage everybody to participate because I don't think it should be defined by a small group of people who work who are so ingrained in the HTA process that they can't see what the rest of us see. Second thing with Natasha, I think she has done an amazing job, and I think she's done more to promote what the industry might need to be arguing with government than they've done in the last couple of years, and they owe her a lot of credit for actually going into that and raising those issues. I think one of the things that I have been concerned about is the translation of that into the social media clips and the Australians' push of that and everything leads with, you know, a video of Donald Trump, President Trump. And I don't like that because when you're it it goes to bias, as in not their bias, but as in the way that people see it's still about, you know, people are very polarized on President Trump and it can really form a view on how they see this issue. So the moment you lead with a clip of President Trump, people have to go, oh yeah, this is you know America telling us what to do, and people act irrationally to that instead of actually going to what is really the issue here, my medicines. Uh the third thing for me is yes, this is a pricing issue. What um Navardis and Rocha are doing at the moment is a pricing issue. And you're right, we convolute it between HTA and pricing, and we need to stop that. It it's slightly based on the comparator. What pricing policy in Australia on the PBS has done is weaponise the comparator, not for the first time in the listing, but for actually moving forward in the way pricing will be done in future years. So it's what you're seeing now is not because these medicines couldn't list in the first place because of comparator erosion, although it was a struggle, but how once that link is established, it continues in perpetuity to allow things to be done. So, you know, this is nothing new in MS. MS has been a bugbear for the department and uh the PBAC now for a good decade. And you've seen them try and play with it. So when we had uh a really the the long-term injectable by Merck, Mavenclad, there's a really good example of a medicine that was a once-a-year treatment that lasted for four years or can last for four years or two years, and the PBSC said, we'll accept two, we won't you're not going to look at four. But when trying to ratchet down the price, you can read the PSD on that and they say, Look, we appreciate it'll probably replace, I think back then Galenia, uh Fingoli mod. But hey, some people might have been on a PEG interferon, and some people might have been on this, and some people might on that. So although we've cost minimized you to this medicine, we're going to look at all these other things too, because you might replace them, even though that's not the accepted comparator, and we're going to try and push your price down. That's when the real game playing starts to go on, which is that's when the system goes too far. That's where comparator erosion has really happened, because it's not just the medicine that you are evaluated against, it's what you might replace at some point in time in the history of a disease that's chronic and goes for 25 years. So that is where the sophisticated policy discussions need to be happening as well, too. Because when you just focus on the original listing, and I get that's getting harder and harder. But part of the reason that's getting harder and harder is because you allowed the erosion in these baskets of goods you might replace. And that's something that should have been very quickly stamped on. Um, but it also took off a lot more once the industry gave up its comparator erosion protection, which remember when you used to be able to list at a higher price, recognizing that your comparator would go down over five years and you'd be insulated against it. So I guess I also encourage that different thinking. And for me, always it's like fine. What ends up happening in these negotiations when they do what I don't happen is yes, it does all become about the pricing policy. It's a pricing agreement. And the irony right now, and I hope that uh the companies and MA are putting it forward, is this the government, both small G and big G, because this government has honored it, put up the price of all medicines under $4 by up to $4 in 2022 on a basis of we may or may not have supply, it wasn't targeted. It wasn't whether you had 20 versions of Resuvastatin or one or two versions of Resuvastatin, we just went all in on that supply program. A universal increase in pricing. So when we're starting to have this, and that was about supply access, it wasn't about pricing in respect of comparatives with what China might be looking at. So if the system's been able to do that, then why, if we can do that in F2 in a highly competitive price disclosure market, can the system not be having a grown-up conversation about what the F1 medicines might be struggling with right now and how best to do it properly?

Paul

Yeah, and that's that's that's partly why the word of the week, the stupid word of the week this week is evidence-based decision making. Sorry. Because that was a really bad laugh. But we'll we'll get to that. But but it's it's a it's a really it's a really good point because it's become a sport. It's it's become a sport. So what we do is we get we're unhappy that these products have been listed, and we're getting the generics in these other products, and we have to find a way to link them back. So we're going to maneuver this naive little company and legend manipulation into thinking that they will only get a listing if they agree to this massive price cut and then flow it on. And I'm sorry, I'm sorry, I don't I look, you don't have to be Milton Friedman to know that if point a company that represents 0% of the market removes 50% of the value of it, that other companies, the dominant players, might say thanks, but no thanks. Now, in fairness, companies accepted almost 40% price cuts in 2023.

SPEAKER_03

Yeah.

Paul

Okay, so maybe they think, well, if you can accept 36.8, you can accept almost 50. But we just need a bit of common sense. We need a bit of common sense is that if you're basically destroying the value of a market by almost 50% based on a player who's got 0% share and probably will maintain close to 0% share, even when they're on the market, there's gonna be a there's gonna be a response by by other players, and we need to have a sensible conversation about it, which is why I don't I don't know. I'm I'm I'm glad that Medicines Australia said, well, we yesterday in reply in in reply to my questions, well, yeah, it might be uncomfortable having a discussion about pricing, but it's gonna be more uncomfortable having a conversation about medicines patients losing access to their medicines, particularly when they're in these very vulnerable patient populations. So uh I I I'm all for a sensible, meaningful conversation about the need to pay more. And the really silly thing is that if the government said just like in 2021, when we spent several billion dollars increasing the price of generics, we're gonna increase the price of these medicines that fall into this category. However, it's temporary, and in return, you have to agree to all of these horrible things. Imagine what they could get companies to agree to in that. This is the craziness of it, is that eventually the price increases it would wash through and they'd be left with all these policies they've been dreaming of for years. And it's but they just don't they don't think in policy terms like that anymore.

Felicity

No, they don't, and um I've been the BAA is gonna put out with getting a submission ready, not that we've been asked for it, but we've got our submission ready to go to the government and the industry on what we want to see for the PBS starting from 1 July next year.

Paul

And I Do you think you're gonna be asked? Do you think anyone's gonna be asked?

Felicity

Of course not. I doubt it, but we're we're ready to go. We've we're not waiting to be asked. We're gonna send it to a lot of things to other patient groups, etc., and say, this is what we think. Uh these are some of our ideas. Here we're we've even modelled stuff, you know, because we sat on the back, you know, uh, and what we think should be happening and you know, talk to you about it next week. But there do need to be these broader conversations. And I think, you know, when I look at the USTR 301, you know, in April this year and some of the conversations that there's a marked change in that. It focuses on risk share arrangements, it focuses on the ridiculous nature of uh caps, it focuses on comparative erosion to a point, but that's a very different signal that the US has sent compared to the previous 10 years where it was mostly about patent protection. Um it's really hard to argue patent protection when you're as an industry for 11 years now, have agreed to price cuts in F1.

Paul

Savage price cuts peril.

Felicity

Yeah, yeah.

Paul

Um it's completely self-inflicted.

Felicity

It is. And I I think I think there is a some some a philosophy in, and I I was rereading articles that you wrote in 2016 where the then the new uh first assistant secretary of the then PBD was doing a briefing with the industry and they were saying how great it was, you know, she was open and transparent and was really listening to them as they had explained that these price cuts of like five and ten percent would seem massive delistings, you know, it was a big risk to the supply chain. And I giggled because I actually used your um VPD insights to look at how many times they've commented and threatened list delistings every time something happens in the system. And that's what you and I have often talked about. Like third 36.82%, the industry said the world was going to crash. And didn't still didn't crash. Now, to be fair, the ministers' delegates did actually provide some exemptions to small medicines, to, you know, like areas that you know didn't have competition and were particularly high cost. But at the same time, during that process, they also eroded the concept of remember it used to do roughly 30% for cost of goods. And that's now gone. I don't even know how many people realize that the the department has actually eroded that now and said, yeah, we just don't believe that anymore. You don't just get that. Like we just uh you've been here a while, we'll make it 10, make it 15. More and more of this erosion and these changes. So I look at that and go, well, why hasn't that been in the issue? When we look at the cost of goods that have been coming in, we we agreed to it for you know small molecules. I watch the generics industry talk at your conference and at other conferences about what it costs them to bring stuff into the system. And yet the innovative sector hasn't tackled this. So I think there are a lot of opportunities, and I think it's okay. It's about time to just talk about price. And I think the more you focus on the HTA, you take away the opportunity to go, that's actually not your biggest risk these days. You certainly you need to tinker with some things, but if you've got a principles base which says that we're actually going to start paying a little bit more and might actually tell the PBSE to stop being on this fanciful trip, that will come. But at the moment, there is so much more happening once you get to the listing process that you everyone's focusing on the unicorns and getting it listed. What terrifies a minister? Why did Mark Butler call that press conference? Because you and I both know a medicine that's never in the country, he can cope with. A medicine that comes off the PBS, he cannot cope with. That is the biggest fear of a minister. I lost medicines on my watch. Yeah, no, that I didn't list them, that I lost them.

Paul

Yeah, no minister is going to want to have to deal with that. A reluctance, reluctance to talk about pricing like mature adults or at all. It's it's it's so it's so counterproductive. It's like it's like you know, your house is burning down and you're arguing with your neighbours about mowing the lawn. It's kind it's it's like we missed the point. We don't even talk about things. The one lever the government has to address these issues is price. But we've spent five years in this review process talking about everything but because the first options paper said we're not going to talk about price. Like, well, okay, well, then that's very self-defeating. So the minute you refuse to talk about price is the minute the conversation effectively ends, meaningfully, anyway. So we need to be grown up about it. We have had price discussions in this system before. The generics being the classic example where they just did an across-the-board price increase for thousands of brands, basically, hundreds of medicines, hundreds of eight or nine hundred or whatever it was, and and then the all the brands sitting under them. So I I I don't know what the number was, but but it was it was a big, big number. And why can't we have a conversation at the other end of the life cycle? But as you say, the one there, the the thing that they get worried about, particularly this week, because there were MS patients all through Parliament House this week, the that a lot of events and MS. I mean, I you know, you can imagine he's going, We did we've got to talk about the Minister's social media posts too. Oh my god. That yeah, uh yeah, that's put me off that one. But but it's just to me, they got all of that great credit for the women's health package. Who suffers from MS mostly? It's mostly women.

SPEAKER_04

Mostly women. Mostly women mostly suffer. Migraine and women mostly suffer from breast cancer.

Paul

Yeah, working. So if I'm the minister, I'm saying, why am I having to deal with this? Why I mean because I don't know what his office is like. Ministers' offices, the two I I worked in, were at times functional, most of the times dysfunctional. You know, he had that weird op-ed last week that was m had mistakes in it.

Felicity

Yeah, there's a man that's too busy focusing on the NDAS.

Paul

Yeah, wasn't picked up because everyone knows he's no one should think for a second that he's his death, he has his desk tapping that out.

Felicity

No, but he does read and approve them. Yeah, and he would normally let that be.

Paul

Yeah, so and and the fact that it was so it wasn't on the PBS and the fact that it's the drug that he described as well, he was questioned about.

Felicity

Was MSAC preventable deaths?

Paul

Preventable deaths. So that was kind of strange, and now he's dealing with this. I would be frustrated. But is it is it an office where a minister expresses their frustration, or they just go in their office and close the door and stew? I don't know. Who knows? You can't know unless you're there. It's like looking at someone's house and understanding what goes inside those four walls, it's very difficult to know.

Felicity

Do you think that's why he did all the social media posts? Because his communication people said, We'll give you something happy, we'll we'll help you chew yourself up.

Paul

Was that about?

SPEAKER_03

Which one? They were oh shock.

Paul

The one where he's dancing.

SPEAKER_03

Oh yeah.

Paul

I I saw that and I thought, hey, he's about he's the same age as me. Okay, and I don't have a team of 25-year-olds telling me how to do social media. So yes, I'm when it comes to social media, not not with it at all. I don't get it. My social media feed is full of bass and hounds and other dogs, burnadoodles and burnadoodles, just dogs. Uh but you sent me the one where he's dancing in his office, and I think minister You know who in your office is saying maybe that's what you gotta do these days. I don't know. But I just saw that, and I saw I Anne Rustin as she's kind of edited it. Uh I just think he's out there because he did that Elvis thing a few years ago. So he's a bit of an obviously a bit of an extrovert, and that's that's all well and good.

Felicity

Uh but I just look no, I just thought But for me it was also like dancing, but you're also dancing on the graves of people like the CGT stuff and things. I'm like, sorry, you've really destroyed some people's retirements and saving plans right here.

SPEAKER_02

Yeah.

Felicity

You you've distorted the market, you've devalued our first owners, negative equity now. So do you perhaps not want to dance on our graves? Because that's what it actually felt like to some people. I f I found it quite interesting, which is you know, here we go, it's all been such a great week. But also you're dancing and laughing because you went to an election and you specifically said you would not do something, and now you're laughing and going, ha ha, fool ja. Like that's something my kids do. Uh, my favourite one he's been putting out a lot this week, of course, so was we know looking for your Medicare card to, you know, because that always helps. So my my Medicare card doesn't help with most of my healthcare, but thanks anyway, for that whole getting to your urgent care clinic and your bulk billing, etc. So um look, and I know I get it's easy for them in in a sitting week to all run around and and Labour's a big fan of the the social media, you know. Oh yeah, it's so cool, like the little but uh yeah, and like I said, it's a part of it's a generational thing, I I suspect. But also, you know what, it's also generationally perhaps not necessarily respectful because you know, younger people do also have intellectual curiosity and capability to and aren't always just um influenced by the I don't know.

Paul

Obviously, whoever is advising there they all do it. So whoever is advising them thinks it's a good idea. Vaccines. You want to talk about vaccines?

Felicity

Oh, yeah. Look, um you well, you've been writing a lot about vaccines the last couple of weeks and the the listings, etc., that have uh been made. But the the Lancet uh did a safety and efficacy of mRNA vaccines, a mechanistic and public health perspective uh release uh on the 30th of June. And I think it was interesting. There's a lot of things there about how mRNA vaccines are actually very efficacious, about how we're starting to, you know, the the ability of them to, you know, have like 30 antigens in one vaccine as opposed to, you know, what do we have at the moment four uh in like in some of the other products. It also talked about you know the future of these vaccines and how they're going to be um you know modified for for cancer and for for rare diseases, etc. And it's got a good evaluation of the safety profile of what we were seeing and and some of the fears that that generated. And it made me reflect because this is this is an important point in policy right now because one of the things that this also talked about was vaccine uh reticence. And there's a kind of a stinger line in there which is about the vaccine mandate during COVID and just how that created distrust and reticence in the community to now vaccine. We're seeing it in Australia, we're seeing it globally, which is when you rush people into having to take something when it's at cutting edge of technology, but also saying if you do not have this vaccine, I will lock you up, I will take your job, I will not let you see people in the community, I will destroy you, I will, you know, I will vaccine shame you in, you know, you you're an outlier, all these things that happens with that and the the damage and destruction that's done to confidence levels. And now how we have to build foreign on that. And so you know I look at things like I I commented last week on One Nation's various policies in the government waste area. And one of the areas that they were talking about is that they want to you know abolish the TGA and put it in within the department, which it already is in there. And just you know streamline it and they wanted to review the $3 billion worth of listings during the COVID period, primarily targeting the vaccines and the the the COVID treatments but I I commented in the media that it wasn't the $3 billion in listings that worried patients. It was the $3 billion in listings that didn't proceed that were worrying patients because our issue is not getting timely access to vaccines and medications not that we want to see things that were listed during that period removed. But it also made me think about we've moved a target now into the Technology Assessment and Access Division. So it's now actually part of the big mean green machine and the hypocrisy of government policy in this area. So the capacity we we literally put this country on its knees we went into massive amounts of debts and said no one's getting out of their house, no one's getting their job back unless you have a vaccine and the importance of that I watched today where we're saying oh no we've got another outbreak of measles and you know everyone go to the mattresses on this. And yet we are already seeing the return to well do we want vaccines and are they worth it and what are the discount rates and you know should we be you know immunizing you know the the broader population to just save 20 kids under 18 where is the policy consistency? You know we've got governments that have also invested in mRNA facilities here in Australia. They've consistently invested in CSL over the years as well too we've always said that preventive health via vaccines was an important thing. It's in the national preventative health strategy. And yet when I read something like the Lancet this week I know that government policy is not there and our financing policy isn't there. And so it doesn't matter what you do to the HTA system, unless the government aligns its uh narrative on what it actually thinks is important for the community and prevention of uh disease, we're going to end up in the same process again where we're not going to have confidence in vaccines and we're not going to have access to them. And as the AHW has shown us year in year out, but again as recently as twenty you know November 2025, vaccine preventable diseases are in the top five of possible hospital prevent preventions every year. They cost us like $860 million a year for people to end up in hospital for treatment when they should have actually had a vaccine and not require hospitalization in the first place. So I just think it's a really timely moment that we have so many policy issues to tackle right now. And when I look at the continued um distrust that COVID 19 vaccines has created in the community and vaccine reticence it's another reason why not having that Royal commission into what we did in in COVID across all aspects of COVID healthcare, treasury you name it we're never going to actually restore that that community confidence.

Paul

No we're in a little bit of denial about it. It's a bit like to me I would compare it to the tobacco excise issue the legal tobacco industry has been completely taken over and frankly overwhelmed by illegal tobacco because I don't smoke cigarettes so what are they $50 a packet now? At least yeah it can be up to $75 as much depending on the size and I don't smoke either by the way they have been completely overwhelmed by the illegal tobacco. I know some of my neighbours smoke because you know I live in an apartment building so I see I see see the recyclables and it's the good old Manchester cigarettes if you want to know illegal cigarettes and this is not a poor part of the world so but but I don't know what they cost but let's say they're $20 and the legal version is between 50 and 60 it's fairly objective but we are just not even having so so it's not just that we're not having a conversation about it but what's happening is the government's revenue from tobacco excise is just falling off a cliff because you can't collect tax on illegal products.

SPEAKER_02

No.

Paul

So that to me is it's a bit like this vaccine issue.

Felicity

So we just we just look the other way we do and we we don't and you know I know we've talked about the the tobacco and I'm glad you've mentioned it again because it is the prime example of where you start something and then you get it's the same with HGA you get wedded to it. So they've got the same you know true believers then what no no we that would be seen as like failure.

Paul

That would you know we got awards the winner would be big tobacco if we got awards.

Felicity

We handed out PSMs for this we had it you know that the the the secretary and the minister got went over to the you know the US award packaging thing yeah because you know we've done all these great things we can't be seen to step away from it because this is our badge of honour. Well but what if your badge is getting rusty you know the genuine modern policy you need to constantly evaluate and be prepared to say it was right at the time but it's not right now. You've got to keep looking forward because as you always used to say to me in uh pricing you know we did the F1 F2 split we start price disclosure everyone puts in you know a combination item because combination items are exempt so then we go after combination items then they do a separate combination item so it's not referenced policy whack a mole is the game. You both have to evolve I've always admired the industry for evolving you know in price and policy but government has to evolve too and so the great irony right now is that maybe the policy people should talk to the TAAD people who just constantly look at how do I ratchet this price down again.

Paul

I'm going to evolve again and I wish they'd stopped doing it quite so much and teach people to say this is what I had but this is where I need to go to and what's illegal tobacco illegal vapes it is everywhere it's true of vaccines it's true of illegal tobacco where where we're just not or ex excise we're not capable of having a just a mean conversation about it publicly I assume one is going on within government about both of these issues but are they both sort of in denial about it and looking looking the other way I don't I don't know the vaccine reticence might it look it it it might be worsened in the short term by a Royal Commission but helped in the long term because people don't trust people have lost trust and and it doesn't need 50% of people to lose trust and there's five percent of people to lose trust which I think is kind of where it's at and and that can have a big issue on things like herd immunity particularly childhood vaccination which Australia has not been doing great on for quite a long for quite a while now where we've dropped below I think it's 95% you meant you meant to be at and we're at I think we're at at around 90 now.

Felicity

Yeah and that we've been we've been behind VG for a decade now.

Paul

Like and we're probably paying for this we pay mostly for their vaccines there.

Felicity

But we do we have we have a real real problem with that and you're right it it does create distrust for a little while but it also allows you know information like this like updated information to be put there and discussed. And you know it's also the the problem I have with vaccine policy in Australia at the moment too is that we made people have a vaccine on the basis of herd immunity to protect those who were immunocompromised which these days is not just from a rare disease it's also because of the medicines that you are taking that require the suppression of your immune system to keep you healthier longer. And yet we're also in that space where if you look at the types of listings we get for vaccines, immunocompromised people between the ages of 18 and 65 are usually the last to get access to a vaccine because we don't do the clinical trials in it and then we don't allow the subsidy in it. So the great irony right now is that most people who are immunocompromised would walk out tomorrow and get that vaccine because they are terrified of ending up in hospital whereas you and I who are healthy sort of go, I'll do it because it's the right thing to do.

Paul

Yeah. Let's go on to phrase of the week which is evidence-based decision making we've often had claims in this system that it's based on evidence-based decision making I think it would be better to describe the system as evidence-ish based decision making or selective evidence-based decision making. No better example than the price cut demanded of the MS therapies where there is absolutely no evidence that a 50% price reduction is warranted but one is being demanded. So I don't know if there's a better way to describe it but I know it's a ridiculous phrase alongside value of innovation, PBAC independence, all of these terms that are complete misrepresentations of the facts what we have is a system of contested economic models that are heavily manipulated on both sides on the way in and on the way through and then presented the outcomes are presented in these things like public summary documents as if they're sort of as if they're the gospel truth and that the people who make them are infallible. So to me it's one of these phrases that needs to be challenged like PBS independence value all of these things they need to be challenged because they become scripture and they just repeated over and over and over and over again and then people just start to believe it. And for the minister all of the issues that you're dealing with have nothing to do with evidence-based decision making or evidence. No? They are manipulation writ large what do we always say lies lice and damn statistics. Yeah and unfortunately evidence is used to make certain claims and assertions about this system when in fact and the MS medicines just like the catch up statutory price reductions is a classic example. The Minister is in a situation where a bomb's been dropped on a city and they're now going through and saying well which buildings are worth saving that's kind of the evidence based decision making we have is it worth saving this building yeah okay we'll save it but we're gonna save it uh on on subject to certain conditions.

Felicity

Yeah we're gonna we're gonna redo it with plaster board this 12th century building we'll just plaster it it it is important and I think it's not it's only the evidence that they decide and so it's starting to go through it. It's selective evidence based decision making. So when you're in court what is and isn't admissible so we know when you put in a um an affidavit and then the the two sides argue about what of your admi uh evidence will or won't be allowed in but at least there's a robust discussion by both sides. We're in a system where certainly patients we're nowhere but there's selective evidence.

Paul

You don't have a spot on the PBS website. No we don't you know and then you know they're not gonna change that now because it's that would be an admission.

Felicity

Yeah they'd have to sort of suddenly it'll it'll be in you know uh evolution 2.9 That's right that in six months' time they'll quietly they'll use it no they'll use the nurse prescriber thing is opportunity to upgrade you know that's where it's gonna happen.

Paul

Yes you're you're actually you're actually right on that.

Felicity

But it is an important thing. So you know if if if Minister Butler is in charge of an evidence based program all of his programs are nominally evidence-based or a vibe or or a political commitment we're we we get that but the evidence here is quite clear which is you are not taking all of the evidence into account and so when you're selectively choosing your evidence this is where PBAC because it's not subject to any challenge because you can't take it to ART and I also because it's not a decision-making body it's only an advisory body it's actually the delegates who are failing because what the delegate is supposed to be taking is all the evidence not just PBAC's advice that was at the She'll be right mate or um the the ill one that says oh have I got a pricing deal for you in the end the delegate has to sit there going am I really pushing the system too far? Is this really a risk to patients? Should I be considering something else faster? I mean it's like this um the Zolodex thing you know and the the the discussions that are going on about you know the is there going to be an alternative available with you know AstraZeneca's putting forward that that bigger listing well when is that being considered shouldn't that be a matter of urgency? Why is the delegate saying well that can wait we can deal with all these things there's not a problem here so I I'm with you on that it's it's their evidence.

Paul

Yeah it's their it's their evidence this is one-sided it's not like this is a contested by an independent umpire no it's the the fact is that the government sets the rules administers the rules via uh advisory committees who aren't independent I mean this is the craziness I I don't I don't know evidence based decision making by an independent sounds great but it's not evidence based and they're not independent.

Felicity

No and multiple PBAC chairs have said on the public record I am not independent.

Paul

Yeah but if you say it people look at you like you've got some kind of problem no I know and and it's like well they don't administer themselves they have no money they don't you know they don't have decision making authority it's like the minister could sack them all tomorrow.

Felicity

They're advisory they take the information given to them from the department.

Paul

Let me let me ask this question. Do you reckon they feel independent to ignore what the minister said about MS medicines? Do you reckon they feel independent to do that to just ignore it?

Felicity

Well I note that the No way Well I hope not but I note that the current chair was also the chair at the time when uh former minister Hunt directed MSAC to say on this gene therapy I or this cancer treatment I want it fixed.

Paul

Yeah and the uh PSD we have from that one shows how well they take this I don't I see I don't know that I don't know why we have this mindset and this is really prevalent in New Zealand you know we can't have politicians involved in decision making it's still weird it's weird and and you know I rush like it makes no sense to me like well then why are we electing governments? Why don't we just have this sort of this you know autocracy and just rule our lives oh we've had that in the past and guess what didn't go so well for most people it's like we need our elected representatives to impose because I you know I I mentioned talk today about community expectation these advisory committees have never had a discussion about community expectation because they know what the community expects like we know what they expect we know what's in their interest what they should expect is what we tell them to expect if we didn't have a minister doing if we if we did not have that minister going up walking up to the press gallery and and answering that question which I'm still guessing was like you know what I why don't you ask him about MSM they would have just carried on oblivious and this is the way this is the way now I've seen it done all sorts of ways via the media directly I've been in cars when ministers have called the PBAC chair and said what can you what can you tell me about this this medicine? I'm getting a bit of pressure about it. That is the minister exerting their influence over the committee and I've also seen a committee repudiate a minister's attempt at influence and they all lost their jobs.

Felicity

And and I I understand why you use the nomenclature influence and I think it comes about because we've got to this dystopia of where people think PBAC is independent and think it's its own being yet the reality is it's very heavily entrenched with the department and what the department wants. And so a minister doesn't a minister doesn't actually need to influence because we all need to take two steps back under law. This is an advisory committee. Yeah it's advice they give advice and the minister can question it he can ask for different things you know under the law he can say I'd like you to give me an opinion on this I'd like you to reconsider this I'd like you to take what you know I've now been told this what do you think they are advisory no minister when I was the delegate was required to take my advice no on policy on issues if there's certain things and like I said and if I said I'm making this decision they can't tell me not to make that decision they cannot interfere to tell the decision you tell them you tell them and they note it. But that's not advisory like that's when I'm a delegate but if I'm giving if the minister says to me hey I'm thinking about you know starting a new programme on XYZ what do you think? I'm advisory and so I I don't want to also disrespect the minister which is he's being absolutely fair and reasonable and saying I want you to take this you are my advisors and this is what I'm taking into account. So give me the advice knowing what I think about this issue already. And so we need to empower the minister by make not making it look like he has to intervene and influence we need to say to him he is the actual head of the PPS and these guys are advisory to him and they need to just total power on pricing.

Paul

What he's trying to do is to avoid having to do it at the end. You can see that right he says on you know I've always argued because Mark Mark Butler is at his point now where he's in his fifth year as minister and he's starting to be a problem for the institution because he knows what they're doing. After a couple of years ministers start to recognise the little games and and the tricks but they also get they so so so because he's not part of the institution. He sits above it you know he's transiting through this institution. Yeah and the institution is ossified in the sense that it's incredibly intransigent and they're just waiting for him to they get the the new minister and they get to go back to year zero and start all over again. And so he's is at that point now where he can see it. And he's probably getting very irritated but but I but I think the system works best when there is tension between the person who ultimately holds power and those that advise him. I've always thought that because I I I work for a minister who was incredibly fed up with them and I worked for one who kind of saw themselves as an extension of it and eventually the institution got hold of that minister and you sort of lose control and uh I I think there's a there's a few signs that I see where the minister's going oh why am I having to do this now I know we we're going a bit over time but I said to someone this week the best person I ever worked with in minister's office was an ex-FAS from the health department because she could I compare it out Patsy from absolutely fabulous so an incredibly gorgeous looking woman who makes champagne an app yes absolutely brilliant human being who could sniff everything out sort of what they what the bureaucracy was up to. What a force what a force because games are played let's be under there's no be under no illusion games are played but he's at that point now where he's starting to understand how to he he can play the game too. The op ed last week he did with I don't know what just Got through. That happens, right? We all have our moments. That's right. I got I got no issue with that. We shouldn't worry too much about it. Um but the the stuff he did this week was I I thought it was very uh very you know, it was really good. I was really impressed with it. Going up to the press gallery. He could have just phoned it in. But he actually went up there and he took like two questions. It was it was so it's it's smart policy.

Felicity

I guess the thing that I reflect on is that this part of the the system, compared to say the NDIS, where you have strong militant participants and providers, like they are organized, they are constant, they are there. And some of the most ambitious reforms in the budget outside CGT were about reforms that this minister wants to make to the NDIS.

Paul

Yeah, and he's in trouble on that.

Felicity

And here's the thing that is the biggest game in town for him at the moment. And meanwhile, the department is starting a fight with another group of people, and he's like, some of whom are actually on the NDIS because of the permanent disability from MS and going, What are you doing?

Paul

Yeah, this is multiple sclerosis. What are you doing?

Felicity

I don't have time for like why are you doing it? Why are you doing this? I you know, and it it's very rare.

Paul

It's a lot of money. They're saving they'd be on the I mean, now they're on the hook for it, right? That'd be a lot of money.

Felicity

It is, and you can't keep upsetting the community that much. Like the this government has upset a lot of people in the community since the budget. And you want to keep adding to it? I mean, that is the time when you're saying to Secretary Comley, seriously, dude, could you just minimize how many more people are getting angry at us right now? This was avoidable. Why are you doing it?

Paul

It's starting a war on another front. And look, frankly, he never he should never have been put in this position, frankly. Because the people around him should have said, Minister, I a 50% price cut on multiple sclerosis therapies. I'm uh I know we're desperate for ravings, but I think can we pick in like a why don't we take on something a little bit easier, like Middle East peace, the war in Iran? I mean, why would we be doing this? Why would we be doing it? But but obviously Because it's a savings measure. It's a savings measure, and in he's probably dealing with a hundred rolling disasters. So how does this one get to get to the top? But he has been warned over several months that this was a this was an absolute no-go, so now he's having to sort of put his foot on it. But it's just that I I would just be going and again this goes to what's the off what's the culture of that office like? Because people think people don't understand that in the end, this is a pretty small group of human beings in a bunker, dealing with a lot of problems, and some days it's good, most days it's not good.

Felicity

Yeah, and I think it also goes to what I was talking about at the beginning of the podcast, which is when is it henny penny the sky is falling? And so the reason I pointed to, you know, from 2016, and I could have even gone from 2010 with price disclosure and all these medicines that we're gonna delist, and we had to report to Parliament for, you know, every six months for three years to say, guess what? Nothing actually delisted because of price disclosure. Anyway, but that's also the hard part, both for the bureaucracy and for a minister. When is it no longer crying wolf or henny penny? And that's the problem that's coming into. Now we're starting to see that perhaps these calls are now legitimate, and perhaps the department, the PBAC, and the minister need to pay more attention to when someone says from a company, I can't sustain that pricing on the PBS I may have to delist. And I think that is probably also where we've got to is that that constant, yeah, she'll be right, she'll be right. Again, think about the 36.82%, and everyone thought, you know, the world was going to end and we lost one product, which then came back. So you can also understand why the system's gone that they think they can push and push and push. But if these are the moments that we're starting to have now, and it it doesn't look great for the system when you've had a breast cancer treatment that's being removed from Australia and now you've got an MS treatment that's also treatments saying we can't stay if you if you do this to our pricing, then now it's time for everyone to actually pay attention. But I also say to people that doesn't mean that you can all start pretending it's a problem. And I've always said to companies since I've left a department, if you are going to threaten, it has to be real.

Paul

Well, and I I wrote this work that the department will be advising him that of a hundred times this has been threatened, not between 95 and 98 times the company relents. I just think that's a hell of a risk to take in a new world order where it's not MFM, but but but these already listed medicines have been impacted by what's happening mostly in China, it's my understanding.

Felicity

Yeah, no, China's a big picture.

Paul

Yeah, and so we we need to be a bit grown up about that and grown up about the implications.

SPEAKER_00

Right. You got F1 this way again? Yep.

Felicity

Silverstone.

Paul

Oh, yeah, I did see Lewis Hamilton potentially pulling out of the Lego race because he wants to get paid for it.

Felicity

Oh, the man that says that, you know, there should be billionaires and he's worth 888 million.

Paul

So he can give you my at least and he lives in it as a tax exile. Holy money. Alrighty, alrighty. Oh, and uh people who who won't know because I'm gonna have to edit it out because there was a disruption early in the podcast, because I believe I've got an Amazon order waiting for me, which goes to my Amazon addiction.

Felicity

I guess it's a weekly process. We we we need a vote. Should Paul join Costco or not?

Paul

That's right. All right, thanks, Felicity. Thanks, Paul.