The 'Dispatched' Podcast - Series 5. Ep.29

The opportunities available in the pending negotiation of new industry agreements and the selective discrimination against some patients and patient groups by an outdated and unaccountable institution.

Transcript

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Paul 0:10

Hello and welcome to the Dispatched Podcast Week in Review. My name is Paul Cross. I'm delighted to be joined by my co-host, Felicity McNeil, PSM, Chair of Better Access Australia, amongst many other things. How are you, Felicity?

Felicity 0:21

Oh good thanks, Paul. It's been a big bored week.

Paul 0:23

So Board as in B-O-A-R-D.

Felicity 0:27

That is correct.

Paul 0:28

Not B-O-R-E-D.

Felicity 0:30

No, for those who work in the the sector with your um financials, your audits, whether it's in government or private sector or ASX, it all comes to fruition at one point. It's that you and I were talking about how do you decide how many boards to sit on? Because it looks like you can do, you know, I've got 20 days or a month up, this is easy. It's not when the critical reporting periods, particularly the fiscal, come in and you're you're spending hours and hours on it. So I think I'm a little bit um I'm all numbered up.

Paul 0:59

Yes. Yeah. Uh interesting, isn't it? It's um I've done a series this week on just you know what's the opportunity here in these agreement negotiations. And I've tried to sort of just get encourage maybe people to think a little bit differently about it. Obviously the first one was biosimilars. I don't think there's any surprise in that. This is something that we've got wrong for a very long time. And I I would argue that for the uh research-based sector, you can't decouple your failure to achieve reform in the areas you want with the failure on biosimilar reform.

Felicity 1:40

Yeah, look, you know, we've been at Better Access arguing for fairly dramatic change on the way biosimilars are both prescribed and uh priced. Yeah. To to expand the indications. We've spoken to many companies over the years just saying get a universal listing and and expand and and take the market that way and and and let's get those price volume things happening. I don't think price disclosure is a solution. We have better access, I think it's a dead duck. Uh, and there's much better way to price medicines in the future because that reliance on our older policies and assuming they work into the into the future it is part of what um cripples the system. So it's I'm with you because you know I'm I'm helping patients right now who whose children are being put through absolute trauma to access biologics that are now, you know, a tenth of the price that they were, but still children must suffer irreparable damage before they're allowed to have access to this $150 or $250 a month medicine versus what used to be $1,300, $1,500 and the side effects of that. It's become a pricing issue that has been captured by an original good idea that hasn't evolved and adapted, and it it's a problem. So, like I said, I love the fact that is it Amgen is getting a broader indication. And there is no excuse for the PBAC and the government to not give them that, given that they have given clinical clinician discretion to prescribe F1 medicines uh for cancer treatment, uh, and clinical discretion to prescribe certain medications in other rare disease areas in F1 and F2 medicines. If we're accepting that, then let's have a grown-up conversation about biosimilars. It can be a great um opportunity, and I won't I won't say savings, it's a great opportunity to deliver the better access to the standard of care therapies that we were promised when we originally made these restrictions really tight.

Paul 3:52

If it's just about savings, there's really no point for patients. I mean there's no benefit. No. It's just about savings to government. There's got to be it's got to be a link to broader access. That's the promise of patent exploration. Yes. I mean it shouldn't be, but but it is in this system that that lower prices driven by competition enables you to uh widen access and that just hasn't happened. And in fact, there's still a thousand items for these this group of BD MARDs, and as you write this say, as we basically just decided on PDL1s to build trust or premise an outcome on trust because of because of long clinical experience with those drugs. Well, the experience with these drugs, one of which has been off patent for twelve years, one is has been off-patent and had biosimilars for longer than it had exclusivity on the PBS.

Felicity 4:47

Yeah, I mean it's a bit like uh talking about the Finn review and the the DLP ones last week. Uh Infiximab, which is is the drug that we're talking about, is cheaper today than the highest cost of a statin when we listed those when we were spending 1.1 billion a year on statins, and there were some of those statins that were the had a dispense priced maximum quantity uh of over $135. $150, $180. So can we just have a grown-up conversation, please, about you know, we can talk about the the science of, you know uh the growth and rates, you know, $150 in 2006 is $230, $250 now. We're not having those conversations, and that's why we've pushed, and you saw in our letters to ministers and uh to industry and to to individual company leaders, we at Batter Access Australia will not discuss the S-word savings. Um we won't discuss the acronym HTA until we actually get the fundamental principles right, which is the broader access and redefining what that means on the PBS. Because as soon as you walk into a room and discuss, have we got a deal for you with the department? We as patients have already lost.

Paul 6:11

Yes. Uh number two was AI.

Felicity 6:15

Your favourite.

Paul 6:16

Um, with emails this week, remarkable. I know, I know. It's uh I I had a great chat with the BI team uh this week uh just about the patient buddy tool they've developed. Uh that was really interesting conversation. And I think well I believe that if if AI can work effectively in one area of the evaluation process, it can work in others. I think it's a huge opportunity to democratize uh HTA and to make it more accessible for more people because at the moment, well, the submission, the major submission or whatever it's called now, category whatever, is over $250,000. That's evidence of the problem. We've made this so extraordinarily expensive. Apparently, Taylor Swift is doing these evaluations.

Felicity 7:12

And and even worse than that, so you think that that's supposed to be a cost recovery and it doesn't actually fully meet the cost of running the PBAC. Well because there's just too much.

Paul 7:24

Well, you know, I also said we should get rid of PSDs. Yes. We should just get rid of them. Uh and because they don't there's no utility in them, it's just a vanity exercise. And I think that's all tied up in the issue. So I would hope that in this negotiation there is a conversation about AI. The last time I heard the discussion of utilizing AI in this process, it was all governance frameworks. Well, where's the current governance framework for this system? Right. So why do we need why do we need a governance framework for for for that, but not for the the one that we have? That makes absolutely no sense to me. Uh and a potential pilot in 18 or 24 months. I mean, that's just complete lunacy in my mind. So we just need to do it. I know companies are using AI to prepare their submissions. We need an open and honest conversation about it. And to me, it behooves the industry to proactively raise this because democratising this process, and I'll get to that when we get to opportunity five, is just a huge way to change the conversation.

Felicity 8:28

Yeah, and look, I support you on the concept that AI is the opportunity to crack the system open. Again, because I'm anti that word, uh perpetuating HTA. I think one of the things that because that has become a dogma, because that was, you know, we are the world's country, the first country in the world to do this, so we're so cool. And so we're like so wedded to that acronym. One of the things that has to go is HTA.

Paul 8:57

Yes.

Felicity 8:57

Now I know it has to be replaced by something else, but it's time to let go, peeps. It's time to actually say, if we can use this, what are all we're doing is trying to find a common point of view on the value of a new health intervention.

Paul 9:12

Yeah, we used to say that a lot. We were the first in the world to do it. It's like boasting about killing someone.

Felicity 9:16

Yeah, well, unfortunately, I think I probably did say that a few times and the estimates. Uh I did.

Paul 9:21

But they sort of dropped that line a little bit, haven't they, in the last couple of years?

Felicity 9:24

Yeah, well, there's so many other things that we're boasting about. About how long it takes, we're so proud. It's just like it's a weird thing.

Paul 9:31

It's a weird thing to be proud of, isn't it? We introduced economic modelling in terms of valuing health technologies that we've got to do.

Felicity 9:40

Let me tell you how to do this. We did.

Paul 9:43

So, yeah, I think that's a huge opportunity. Um, and in that in that realm, opportunity free is to deliver on the repeated claims of patient centricity. The idea that an industry group would share the stage with health department officials to brief patient and other stakeholder, non-government organizations, on HTA reform and the agreement negotiations is literally too stupid for words. I mean, it is there is no world in which that is a good idea.

Felicity 10:14

Well, there's someone who uh as a patient group and who's actually had a call from the deputy chair telling me that although I'm a patient group, I'm not allowed to participate, um, has sat in on some of these things in the past.

Paul 10:26

Yes, that actually happened to you, didn't you?

Felicity 10:27

It did actually happen to me that yes, um the deputy chair, Joe Watson, yeah, actually rang me and said, I appreciate that you are a patient group, but basically we're finding an excuse not to have you there. Yeah. I mean just Even though I represented patients. Um yes.

Paul 10:41

We've done more speaking out on patients publicly in the last three months, certainly than it's been reported in the last three months than anyone else.

Felicity 10:48

Yeah, spent a lot of time up at uh with but you know, but but the issue is there, which was we we won't. It's a it's a everyone was allowed to apply, but we will choose who's allowed in the room on a on a Zoom to to contribute, because heaven forbid you might, you know, overwhelm the other patients with what your knowledge of the system. Yeah, and and I I really am, I'm saying it publicly because people need to understand that's how manipulative the system is that where the can the consumer, the the lead consumer at the deputy chair, who you know obviously I had worked with and employed, did that, knowing that I would respectfully go, okay, look, I'll I'll I'll let it slide. Um but yeah. So when when we go to that issue about patient centricity, I sat on that one where I've watched the department say, we're going to tell you how this process works. Over to you, insert name of uh industry group. You tell us, and the introductions are always this is what the industry wanted, this is what the industry wanted. We're doing this because the industry wanted it. They literally blamed um of Australia for their agreement for insisting that everything we were doing is because industry asked for it and laying the blame at their feet.

Paul 11:59

I presume the industry understands that that invitation has intent. They're tying you to the process and the outcome.

Felicity 12:06

Yes.

Paul 12:07

From that point forward, that's it. You're done. You're cooked.

Felicity 12:10

And we're expecting you to tell patients, to join us telling patients in saying, look, we know you think you think it's your PBS, but this is this is about the grown-ups, okay? This is about the grown-ups discussing pricing of the medicines. And the moment you participate in that, the moment you uh weaponize and legitimise what the the department and the government are doing, you're in you're in trouble.

Paul 12:34

Yeah, well, you that that's it. You at that point you're quizzing. Well, then we have to come out against you as much as we're coming out against the So the what you need to do is to understand that you need to sit on the sit you you and the department need to sit down and hear from patients about what their expectation of the outcome is. Surely that's the thing, surely, and and we'll get to um uh the opportunity number five, because it's related to that, the uh the idea of changing the conversation. But we need to have an honest conversation about and there's been no better example. You know, I was on that panel in Sydney about 18 months ago where the the patient groups were talking about, oh we had to, you know, we got the report and they gave us a couple of weeks and we had to all sort of and they didn't understand that do you understand that is just a vile situation that you've that you've been put in? That they've thrown this to you at the last minute and given you a few weeks over Christmas and New Year to put together a response. Do you understand how wrong that is? And that the proper response to that is to say, no, we're not one, we're not working to your timeline, and why why we why are you giving us this now?

Felicity 13:41

Well, and that's it. Remember the National Medicines Policy Review, and they did that to us. And um, you know, I love Nicole Cooper because she joined with us at Better Access to just call out and say, sorry, you're giving us you guys have been doing this for how long, you delayed it for how many years, and now you're giving us two weeks to respond to something that meanwhile we're also responding to PVSE, we're responding to everything else in the health system. Have respect for our time.

Paul 14:04

It's so messed up.

Felicity 14:05

And yeah, I'll give um I think it what was then? I can't remember whether it was Greg Hunt or whether it was uh Mark Butler at that stage, but it would have been Hunt at that point. All or kiddos to um ministers every time we've written and chucked a wobbly and said, sorry, this is not about patience. You've got to give us more time. You take all this time, they would at least react to it after after we went to the state.

Paul 14:26

It's indefensible. That's why.

Felicity 14:28

Yeah, but it's also a point of why having the the ministers engaged and uncomfortable, which you've been reporting on it and we've been talking about for weeks, is so important because in the end they are the ones that stop the exclusion of patients and stop the disproportionality of the, like I said, you can't have a seat at the table. It's only when ministers intervene.

Paul 14:51

And it's this one area of government, it's this one. Yeah, no. It's just this one that that even it's the one area of the health bureaucracy that somehow treats patient groups like the like it's serfdom. And it's just and unfortunately, I think there is an element of a cultural outcome where this approach has insinuated itself into patient expectations.

Felicity 15:18

Yes, it has.

Paul 15:19

And we're just glad to be asked and we're glad to be involved. And the idea that uh look, the two industry associations were invited to share the stage. I know one said no. Yeah. And you straight away to say, not doing that. Why would we do what? Why would we do that? You know, we can speak to patients whenever we want to, but I'm not gonna share a stage with you. And I don't know what the other one decided. I think I know, but but but let's wait and see because there's no world in which that is a good idea. So there's got to be some discipline and there's got to be some expectation and there's got to be demands around no. The first point is to ask patients for if you guys to sit in the audience and say, Patents, what do you want to get out of this? And if they say we want HTA reform as misguided as that is, uh so be it.

Felicity 16:10

Take them a bat and ball and go.

Paul 16:11

So so be it. But we just got to ask them what's what is their expectation? Because we know in the system that we're constantly asking patients to do something or to make a contribution and they're constantly being ignored. Yeah. And you know, with l talking to the BI team about patient buddy, it was really interesting because they said some of the feedback they got was that you know, patient organizations are having to devote res human resources to sitting down with patients and putting together their input, and that obviously takes that takes hours. So now this AI platform is enabling that to be done really, really quickly, opening up the process. More people can make contributions more quickly and in a timely way, and it's re- enabling patient organizations to devote time to other things. That is the gift of AI. It is. That is the opportunity, and so we have to embrace it that the opportunity here is to democratize the process.

Felicity 17:08

And so, but the the problem we have, which is why we want the legislation changed, is that transforms and makes it easier for those of us in the community to participate. But if it's actually not going to be genuinely considered and a genuine input, what well that is the challenge.

Paul 17:28

I'm really glad you spoke about your experience with the deputy chair. Because I can remember you telling me that, and I was absolutely outraged.

Felicity 17:35

Well, you thought I should, you know, tap my bat and ball and swing at it.

Paul 17:37

Yeah, yeah, yeah. My my my view is that there's a legal avenue to resolve those sorts of things. And but that goes to the cultural problems. Like, what hope do you have? When they're basically picking and choosing who's allowed to represent patients, the ones the ones we like, basically the ones who just sit there and don't kick up and don't know anything. And we'll get to path dependence in a minute, but that's that's the critical component is that oh, you might call my BS in front of everyone. And I don't want that, it's a power play. Yeah. And that there's like, oh, how many red flags? I mean, this is Kremlin level red flag. Because this is not the Mari Antoinette let the meat cake, even though she never actually said that. Um that's the myth.

Felicity 18:20

She's like me, gluten-free.

Paul 18:22

That's that's the myth. Uh that she said though she did not. She's one of the most besmirched people in human history. I answered on him. Um but um unfairly. Yeah, unfairly. Um but that's just so outrageous. That is so outrageous. It's like Soviet red flag over the Kremlin alarm alarm bells. So we we can't let that happen. Opportunity for scope create. I use the aviation example is when you're off track to get on track, you've got to overcorrect. People because history is not a great asset of of this sort of area. You and I have it and we carry that as emotional baggage most of the time. Uh but the PBAC never used to do what it does now. And you know I'm a great advocate for the PBPA, not because the PBPA or the pharmaceutical benefits pricing authority. So people so people know the PBAC would make a recommendation, it had very little on pricing. It would then go to the PBPA, which had the industry on it, the industry department, the health department, and independent chair and consumer. And that's where Joe Watson started.

SPEAKER_01 19:40

Joe Watson, yeah.

Paul 19:41

Uh in 2002, we appointed her to the PvPA. The 2002, everyone. Yes. Just so you're clear 24 years ago. Uh so so on that leave. It would it would then go to the PvPA and the PVPA would effectively negotiate the price. And a lot of times the minister would favour the PvPA advice because it was it would clear a roadblock. PVPA PBAC hated the PVPA.

Felicity 20:11

I am aware of that.

Paul 20:13

Absolutely hated it. Because they had this idea of, you know, they this sort of system ideological purity. But a lot of the time, and there's this great cabinet submission released a couple of years ago where the minister said, well, there was disagreement between the two committees, but the PvPA's job is to set the price. And so I'm taking their advice. And then it was abolished under the red tape reduction reforms because it had stopped kind of functioning because the ing industry downgraded its participation. Once the MACEO stopped going, that sent the signal that we don't really care about this.

Felicity 20:44

Well, as I said to you when I inherited it, it wouldn't actually accept recommendation. You weren't allowed to recommend anything to them. They it was for noting. Yeah, which was important to make a decision.

Paul 20:55

So the old factor F program, so the old factor F program, there were plenty of manufacturing, there's still a few manufacturing facilities in Australia that were the factor F. That was factor F of the pricing principles. There was ABCDEF, and factor F was are you invested in manufacturing and clinical research? Well, then we're gonna give you a price bump. And so that was abolished, and the PBAC just subsumed the role of pricing, and it's become sort of the pricing committee, not the clinical advisory committee. And so its scope has been allowed to creep. Ministers and officials have allowed to do it, in some ways unlawfully, in my view, and its advice is treated as though it's sort of it's sort of a uh you know, uh a papal fiat. And but there's no accountability.

Felicity 21:48

But I think I I disagree with you in that they've allowed the PBSC to take over. They actually just made a conscious decision to do that. Well the department's really made a conscious decision to go get them to recommend something high. harder and tighter and then every time a company comes out, oh look, we can't PBSC said this before. So you know the department and the Minister have l really forgotten what it is to um what admin law is and the obligations of what you do and don't take into account and the exercising of judgment. And you can he's easily mount a case that they're actually not exercising their powers correctly because they are saying if PBAC says this, that's all I can do. I cannot take anything else into account, which is a complete failure under administrative law. You must actually take if you want to choose to say I I considered all of that, but I'm just going to listen to PBSC, then have the courage to say that's what you're doing. But they pretend that there is some legal or obligation and it's not PBS is just a vibe.

Paul 22:46

This is a very recent thing. It is not it's a very it's a very recent thing.

Felicity 22:50

It's a it's a only in the last decade. And I want to remind you know I I've worked for multiple health ministers and one of the great strengths of uh Minister Roxan Nicola Roxan was in all the powers that she delegated and everything she did she was very clear she said price is mine.

Paul 23:10

Yes.

Felicity 23:10

Price is mine. The last minister to do that she was very very clear that anything we did we could negotiate all sorts of things but she wanted to know what pricing outcomes we were achieving and how we were setting things before we actually listed. And it wasn't because she didn't trust us she said that's what I was elected for. That this is my thing to get the medicines on the PBS. It's why we had the issue with special patient contributions because she said price is mine and I don't like this. I want to change things and like that's good. You're my minister that's what you want to do that's what we do. So everything that went to PBPA we weren't allowed to action any of those outcomes for listings until we had told her this is what we've agreed and everything and this is what the companies and the the community said.

Paul 23:56

Well the end game of what's happened in recent years is Mark Butler having to intervene every other week. Yes just the because the PBAC does something a bit nutty or off piste patients run the risk and so he has to say okay I'm just making it clear to everyone that this is the outcome I want I mean it was a bit like the Prime Minister on the 730 report last night when he finally admitted that it that it was a mistake to go on the podcast. Prime Minister all your female colleagues said it was fine. Yeah everyone likes to talk about big things he obviously went on he went on a safe platform bagged out the Jewish state yeah hit behind the um the Israeli admonition yeah yeah bagged out my other country and then this one then obviously lined up a question on this which is exactly what Minister Butler did on the MS therapies when he walked up to the press gallery and played the got one question.

Felicity 24:52

But I think he had to because I mean we all know that the only reason he's he's done this is obviously what's been going on with the Sydney swans in Melbourne and all the investigations there. Oh my goodness he had the temerity to call out saying that the swans needed to do more on this and that's what actually caused this people hang on a minute you you you you're part of that culture you said oh it was all just joking it's all good it's all fine this is what we as women have been saying since that podcast took place and you know I was one of the early actual full readers of it not just about Kali but about the the Japanese Prime Minister about his wife all these things that were being said. And it went to culture and standards and leadership and it failed on all of them. And now we're looking at what's going on with the AFL and there is just no place for the Prime Minister to tell anybody about what is or isn't appropriate behaviour because the type of joking that he was doing is what leads to the moments where these five men are now under investigation and have been banned by their club.

Paul 25:52

The carpenters apparently yeah they are carpenters I uh I'm you know I don't want to dig too deep on that but for people who don't know this is this is you know I've been struggling with this all week as a mad AFL fan who's someone very much on the inside of the AFL world or has been for quite a long time less so now but this is I don't understand this at all. Okay so for people who don't know that hotel is right across the road from the MCG. It's literally a five minute walk to the MCG from there. So it sort of makes sense for the team to stay there but it sort of doesn't because at the end of the game the bar in that hotel has got a thousand people in it. Now there probably only a thousand people had that game last week because it was sort of a dead rubber a bit like that game last night so what generally happens is the team the team hires one of the conference rooms there and pre-game and postgame they prepare in that room post game they'll come back and they'll eat dinner as a team because of course there's 30 players there but there's 20 staff all the physio the coaches all the support crews you know the the president the board there they're all there so it's a pretty big representation what I really don't understand and it was Adam Simpson the great former West Coast coach premiership winning coach who said on SEN yesterday Finally Finally Finally this is a team that travels every other week you know my team hasn't traveled out of Melbourne for eight weeks Carlton I have a love we get the best lawyers as well we definitely would have got your guy off this week but but but do they do this every time they travel because normally is it you know they go you know yeah they are buzzing I just thought I even found it was weird that the coach was wandering around Bridge Road which is across the road from the MCG also in Richmond not the nicest part of Melbourne Bridge Road you know a lot of the underbelly series is filmed in Bridge Road I think or set in Bridge Road but mean complaints but but uh you know it's not wandering around there at one o'clock Monday morning I just think that's just weird to me. And you know there's hell to pay now and you know I've always had a lot of well I don't have a lot of respect for Sydney Swans but oh you you have no respecting for grudge grudging respect but I really feel sorry for the fans but anyway it's just that whole thing is just so odd to me it's just was everything about it is completely wrong and the fact that they weren't the 18 and 19 year olds it was three of their best players involved.

Felicity 28:30

Yeah and again this is why I have zero respect for the Prime Minister on this because he played into the the culture that leads to that slippage and I have no respect for his female colleagues who were either were they bullied by the men in the Labour Party to actually say nothing to see here. It's all good. It's just a bit of lighthearted fun. The reason they're apologising now is because they have said there's nothing to see here for five or six weeks then something like this has happened and Australia's having a grown-up conversation which is we can all have fun but it must be with respect and how far do things go when you're you're suppressing and you're making light of of what the Prime Minister did. If he can get away with you know saying you know dodgy rude jokes about a head of state in another country then what can we get away with? Because what is the culture that we tolerate and I I've been so upset by you know particularly Minister Plebisek who used to be a very staunch um advocate for women's rights and respect and culture and you know even Catherine King Minister King all these women just suddenly went nothing to see here and now they they're all stuck because you breed what you saw which is you've condoned this kind of behaviour that the edges of it for the last six so who who's right who's it was just so weird that he did that in the first place and I'm glad he I wish he'd never done it.

Paul 29:56

The fact that the fact that because it was beneath him was but no it's beneath the office. It's beneath the office uh it's not the set of madmen you know what does he think he's Don Draper I was bad enough that he's sitting there in the black t-shirt now Andy Burnham is doing that now walking around in these black t-shirts what are you trying to you trying to have Oasis or something what's going on I'll buy your black t-shirt what are you doing it's so I'm glad he did it. I just wish it was a long time ago we've got many things to sort out in this country we don't need the Prime Minister to be playing into jokes about famous women or the leaders of other countries particularly the the Japanese Prime Minister who's the first female leader of that country it's um it's got well well having worked in Japan over many years and it's a country that ideally love fair to say it's not the most most progressive exactly on on women. It's a big deal it's a really big deal and I just think she she is owed a bit more respect than that as all women are and we've seen with the whole Sydney Swans thing this week which if you're an AFL person you're completely devastated by uh you know the Swans you know we're we've got a really not not a great we haven't had a great a great go at the women's game uh we started a little bit late and then the AFL has done everything it could to try and destroy it.

Felicity 31:25

Yeah they've sort of got it a bit better this year with double headers which has been absolutely fantastic getting more people you know I was a big supporter of Carlton AFLW a financial supporter at at the start and there was just such a great buzz about it absolutely loved it I took you to a couple of games made a bit of a faux pas at the Carlton Collingwood game but we won't go into that that would be because I the Collinwood player kicked an absolute ripper and I forgot where I was sitting and because I'm a D supporter we just support both sides and play it and I I said oh brilliant goal everyone went quiet when I realized I was surrounded by Colton supported doing but anyway so it was a faux pas. I'm glad he uh has expressed regret he should have done it a long time ago it's beneath the office you and I both old fashioned on this and so yes but anyway we've gone a little we have got a little bit but I just want to finish one final thing on the AFL W because that the did this is tough. Like you you are this is a co-ed sport today it's a fully co-ed sport. I don't talk AFL or AFLW I talk AFL one team. Yes it should just be O It's just one team and so I do support the men's and the women's teams playing on the same day because it is one team and I think the moment for me to that yeah it is and it's just I I I've written to my own team because they give me my membership for AFL and then they say hey do you want to add on the the W team for thing I'm like no no I'd just like to buy one membership one team I I think that's also part of this this con this construct.

Paul 33:01

So when we're having you know some really difficult conversations this week about how far Australia has or hasn't come in respect of how it respects women and treats women uh equally that's for me another really good example of like every little bit matters and um to everyone involved in this thing it's well I don't know why I mean I I can't believe I'm praising the BBC but when it comes to the Premier League they don't differentiate. No they will just say Liverpool, Arsenal Manchester United and then you click on the story and you've you work out oh it's the women's team or or the men the men's team. Yeah I completely agree with you when someone comes on one of the Carlton AFLW players comes on I don't know why we need to say AFLW it's obvious that they're a woman like we haven't quite you know we we sort of you know lost our minds there for a couple of years on this stuff but but it's obvious yeah and I don't think it's that I don't know why we need to differentiate in that way. The fact is that um people talk about the need for the the women's comp to be commercially successful. Well okay well let's apply that capitalist ethic across the AFL which is basically a socialist enterprise. So for people who don't know we're going down the football rabbit hole but it's important because if you if to understand the AFL you've got to understand that everything is split 18 ways and about to be 19 ways so if you're Collingwood or Carlton some of the biggest sellers or West Coast or the dare I say the Swans some of the biggest sellers of merchandise you don't get all that it's split evenly amongst the clubs. Yeah because the AFL owns all of the the brands which is something that Carlton fought all those years ago and we were punished for it but the GWS is not profitable. The GWS will never be profitable. Yeah it is never going to deliver a viable return and so the AFL supports it means that the big game it wants a national game. So the big the big money clubs like West Coast Collywood Carlton etc they are essentially propping up the GWS and other clubs that are never going to be profitable and that includes some Melbourne clubs. Yep so I don't know why we have to treat the women's game like it's some sort of it has to be a sort of a profitable enterprise I mean what we've got to do is what the AFL has done in things like the areas like the Gold Coast where it's built the sport over many many many years. It's made some terrible missteps on AFLW when it was originally eight teams because most of the comp didn't want to didn't want a women's team. Yeah but Melbourne was the original yeah yeah it was you Bulldogs car Carlton Colin and and then all the other clubs went oh geez our sponsors are demanding that we have to support we need some token women yeah and so they all decided to pile in and so that the the foundation teams were just devastated because they grew the comp too quickly. Because you don't have the the we don't have the talent yet and so that is starting to come through now you've got the great North Melbourne team which hasn't been beaten in two years. Yeah they rock yeah I know but Carlton are coming through I'm very confident this year because we made a prelim last year and I think I think we've got good coach we've got good players we've got all these Irish players are absolutely amazing. So I just think all of this is in the same genre it's been a really really important couple of weeks and period for us as a country country to to reflect on the these issues and I'm like I said I'm glad the Prime Minister said what he did last night but all his colleagues that said oh nothing to see here I think they need to be questioned so you are wrong you are wrong and we live in a country where the Prime Minister's behaviour can't be called out doesn't make any sense but anyway we digress very important very important issue it was an important issue and I think it also because we we are in a sector that is predominantly female.

Felicity 36:53

75% female so the respect for women in this sector is actually a lot stronger. So your lived experience for many women is not the lived experience of women working in other areas of Australia. And I think it's always important for us to understand where we have um respect and how we can model that and and give that back to the rest of the community or equally if you're not getting it then you should say something.

Paul 37:14

Yeah we don't always live up to the standard we want for ourselves and we just have to acknowledge that. Yeah okay sometimes you know we're all we're we all make mistakes. Obviously what's happened this week is an absolute disastrous mistake and it's devastating it's really devastating and devastating for the victims. Yes you know I don't particularly care that much about the players to be honest but I I care about the victims and I care about the fans and I care about the competition and I care about the country and we just have to get better at those things. We really do. We do and that we it's got to start at the stop at the top and the Prime Minister made a dreadful mistake going on that podcast going on it was a mistake. The fact no one's in his office said you know at this point and she knows she's come out whatever her name is and said they knew exactly what they were getting into. Of course they did they thought they were going to be too cool for school yeah the whole black t-shirt oh he's trying out for the Smiths I mean it's just like what are you brand PM 60 year old man to wear a shirt and a tie um okay back on we'll get back on piste opportunity five this is this is uh the easiest thing to get right this is a absolutely easy thing and it's path dependence power dependence really is how it should be described this is the idea that the the reality is that the agreement negotiations are not really a negotiation it's you've got like the government who has total control over everything that the industry wants okay so so I I believe that there's a need to just understand that that you've got to go into this process with a really defensive mindset. You're not the pharmacy guild negotiating the community pharmacy agreement okay you're the pharmaceutical industry negotiating what is essentially a pricing agreement and caution some caution is required and asking questions you know I think you can even ask well what's the relationship here the part it's part theoretically it's called path dependence but I call power dependence because it's easier for people to understand. The more friction you have in the relationship and the more contact points you have with government you're increasing your dependence on them. And so this goes to the patient discussion it goes to the AI discussion. Okay so maybe us going into a room kicking everyone else out or sharing a stage with them to present to stakeholders actually increases our dependence on them. And so maybe what we need to do is to think about another way. Should we have fewer inclusions in these agreements make them simpler give us more freedom to operate and function reduce our dependence on them should we do what the government does transact our policy objectives for individual products encourage companies to do that. Say no more often and that more and more companies are saying no we see that with the GLP ones where actually it's completely flipped.

Felicity 40:04

Yeah they have the power they have the power right so don't concede the power they don't need government they don't need government they're happy to help government but they don't need them because normally you when you have a medicine you need the PBS these guys don't change the conversation so what are the examples of where it it has happened because it's in products companies have power sometimes.

Paul 40:24

Yeah government transacts its policy objectives where it has power like in highly competitive therapeutic areas where it has the power but in policy there aren't many examples. The bilateral with the US was the example and it's the example I always point to because it's the only one and I happen to be very close to it. But the conversation changed because the the Australian government needed the industry in that situation. So the dependent relationship switched so I think the the opportunity here is rather than just going into the same old mode of okay well let's just go into a room lock the door sign the NDA and the government's just going to sit there and give you absolutely nothing because if you make a mistake as I pointed out this morning if you make a mistake in these negotiations there's no coming back there's no coming back. If we saw that with the catch-ups because the the because you're totally dependent on an entity that doesn't want to give you give give you anything.

Felicity 41:16

And then the pathway for prioritization thanks for that one guys so so I just think it's important to have a conversation.

Paul 41:23

Do you want to spend the next five years engaged in processes with government that aren't going to deliver? Or do you want to play a little bit hard to get do you want to reduce your dependence so think about it that way. The more inclusions you have in this agreement you're increasing your dependence on an entity that doesn't fundamentally doesn't want to give you anything. The less inclusions you have you're reducing your dependence and you have more freedom. Introduce more people into the conversation get other people to make the case and see what happens.

Felicity 41:53

I think it's a point and I think you've said over the years unless you do the work. So the the reason the the guild isn't just successful because of their strength and their linkages with the community it's the huge amount of work they put into policy and programme development. So they are ahead of the department most of the time on thinking about what's next in their in their 10 year horizons. The department tends to think about the 10 year costing horizons of medicines not the actual policy evolution. So if you're not going to be doing that and actually have that genuine model then you've often said then why would you even enter an agreement to say you do what you're doing, let us know and we'll we'll tell you whether we agree or disagree but what is the basis of your agreements? What what have you ever actually achieved out of them like I said other than delaying access ironically and you've pointed out that this um review of the process I'm gonna have to say it HDA process for five years you you locked also patients out as well because you said this is all we're doing on the PBS for the next five years. This is it.

Paul 43:03

This is it path dependence.

Felicity 43:05

So um look I I do agree that you have to know your strength and your position and if you don't have a 10 year plan and an evolution and a readiness and haven't been actually socializing all of that for the previous five years in the broader community so it's a no-brainer then yeah you are that you need to minimize your exposure to the system and I I agree with you on that one and I think if you people don't understand just how hard the guild works for that always remind people in 2010 they and the PSA was talking were talking to me about how they were working with state governments on immunization that was non NIP in community pharmacy and how they could help. They built that moment they built the evidence they built the stuff everyone pushed against it COVID came and it was a full switch over and now it is but they had been working on that for five years when they first came to me. They pushed it to the envelope in the the 2015 agreement and where we would start to look at some of these issues and and opportunities and they got their their foot in the door and they kept working at it so by the time COVID hit they were like we are here and we show we've shown you that we are getting more um immunization happening than the GPs because the whole uh primary healthcare system is nobody's showing up to work because a doctor shouldn't see a patient during COVID. Long we're still dealing with that. But what I'm saying is that that was 10 years of work almost 15 to actually build a narrative and a need and an acceptance and you're seeing it again now with um pharmacy prescribing and that's what it takes. It actually takes developing a policy platform and running with it and being consistent with it and putting the evidence in for those periods of time. You can't just rock up now here are our couple of ideas.

Paul 44:54

Well what was the pharmaceutical industry arguing for in 2010 comparator selection reform?

Felicity 45:02

Uh comparator selections they wanted uh managed entries managed entry which you did and no one uses yep correct um they wanted uh lower they wanted to to work on how we what we would do with biosimilus.

Paul 45:17

Yeah I mean it's I think it's a really well made point it's and it's interesting because pharmacy if you look at the department's restructure yeah they've suppl split supply and services but as a result pharmacy's kind of lost its spot a little bit.

Felicity 45:41

Yeah well that was something we uh were going to do in 2014 so it's not a new idea and the only thing that got in the way of that was a change in uh secretary and more importantly when the ANAO decided to come in and review the previous CPA and the receiving area for pharmacy services say we don't want to borrow this this is yours to look after and that everyone agreed that we would have to have to do that and include it in the negotiations. But we had it had long been a thing that this is service and this is PBS. The money that um although an aspect of the PBS is actually negotiated in respect of the the delivery model, the service provision which was an increasing area of interest for the guild and pharmacists in general and particularly the PSA who only really ever wanted to talk about services were like well that's primary care.

Paul 46:35

Yeah.

Felicity 46:35

And if you want to be seen as clinicians let us help you move to being clinicians.

Paul 46:40

I love the fact that they've got a strategic agreement task force they got a lot of there's quite a few task forces in that structure now. I think there's three that I found. Yeah but it's just like oh seriously guys come on uh give it it's a price in agreement.

Felicity 46:56

Yeah it's not it's got a lot in it these days.

Paul 47:00

Hey one of the things we wanted to touch on was both of us really bemoan the fact that individual HTA advisory committee members promote their involvement talk about what they do yet refuse to be accountable for their contribution or to reveal their contribution. And one of them is doing it at a diabetes event this weekend, today or this weekend. Yes. And I'm just appalled by it the fact that they're allowed to sort of freewheel it out there and say whatever they like although I'm I'm dubious about that. But they basically tell us that if well they have formally said that if there is any any revelation of their personal contributions to these advisory committees as discussants, well they'd all resign.

Felicity 47:54

I mean let them resign as far as I'm concerned but the title of the session was Insights into approval of diabetes medications at PBAC Well perhaps you could just release your discussants.

Paul 48:05

Well I'm pretty sure section 135 of the National Health Act might have something to say about that but I just Yeah I'm just completely miffed by this institutional cover-up of individual contributions while they're out there promoting themselves and the contribution they make and using it for professional advantage.

Felicity 48:27

Yeah and it it is really you know let me let you into the secret hardy hole and and I saw it that there was also a diabetes session up in Parliament House earlier this year and uh the chair of MSAC got up and told everyone how it is and that's that yeah that's the issue which is well why won't discuss it you you're happy to trade on it but Robin Ward says you're just all too frightened that someone might come after you. You've literally stood on an international stage and say let me tell you how we do diabetes medicines at PBSE frightened to actually put my name to anything on the actual minutes and to actually say that I led a discussion.

Paul 49:08

Yeah I don't I don't know why we can't know who the discussants are. Obviously a diabetes expert or specialist is going to be a discussant on diabetes and we've got a right to know because they talk well it's cabinet solidarity it's not cabinet. And the thing is cabinet is not a committee of experts no okay so the defense minister or the health minister have no particular expertise in those portfolios. They are representing their portfolios in a formal process around government decision making the people we're constantly told these people are experts on these HCO advisory committees but they don't want to share their expertise with anyone except when it suits them. Yeah. Alan sorry it's just it's completely unacceptable because of course independence as I always say independence is just a euphemism for unaccountability yeah I agree.

Felicity 49:56

Like you said you know what we want yeah we want it legislation changed we want the terms of the PBSC and their subcommittees shortened we've got we've got to get rid of the tenure and we want an appeals process for patients both through the ART and we want the um independent review for companies to be irrespective of the recommendation because PBSC and the department weaponise it by saying yeah we recommend you at like a tenth of the price oh therefore you've got no right of appeal and I don't care whether it's a vaccine or it's a device I don't care whether it's a positive recommendation, a deferral or a rejection I think that companies should be able to challenge it and then the independent review should actually be the advice to the minister not to PBSC to rethink themselves.

Paul 50:39

Yeah well but the this is but this is the thing the argument against ART or or the the the the extension of ART powers to include these HTA advisory committees is evidence of the need. Absolutely why are you arguing against it? Because you and I both know it would change the way they operate yeah because it would it would it would certainly put their advice in a legal framework because their advice is essentially decision making now like a TGA delegate a TGA delegate's decision is appelable to the ART. Yeah yeah is is covered by administrative review so if we treat if we treat the PBAC well if governments who now treat PBACs if it's a decision making body it should be covered by the ART and you and I both know that they probably would like TGA probably wouldn't get to be ART that often but it would change how they make decisions.

Felicity 51:30

It would and even if as you know I've been trying to explain to people about how ART works in the end there is still a delegate which is the assistant secretary or the first assistant or secretary whoever's doing it there is someone in the department who's taking the PBAC advice hopefully applying proper admin law and deciding whether or not to take that advice the moment they accept that the medicine was rejected or the medicine was recommended a caveat that's appellable. Now it should be but the problem is that the ART specifically precludes these sections of the National Health Act and we need to change that federal courts to be able to challenge a decision taken by someone in the department to say yes you know three years on I'm still not making medicines available for children.

Paul 52:17

I'm trying to access the NDIS I have the right of review to the ART. If I'm an immigrant and my visa claim gets rejected I have a right of review I all of these other government areas are covered by it. Yet this one body we treat it as if it's above scrutiny and review. And to me people say oh yeah but you can go to the federal court yeah well who's got the spare millions of dollars lying around to do that the ART is is is specifically around policy making and decisions for government programs. That's why it exists because it's for administrative decisions. And so if if PBAC advice is treated as an administrative decision, which it is for all intent and purposes, then it should be reviewable. And you and I both know that the the argument against it is evidence of the need.

Felicity 53:08

Yes and this is it and you know we really are encouraging pharmaceutical companies and the industry to support us on this one because everyone will try and tell you that oh this is about you and the the department it's not it's actually the moment you allow me as a patient to complain other than writing four million letters to to the minister that he never responds to you empower empowering me empowers you so let me as a patient have the fights let me as a patient say not good enough government not good enough PBOC not good enough delegate your decision is leading to my children suffering irrevocably.

Paul 53:47

Yeah and I have no rights and and we have a a system where these AC advisory committees mark their own homework. Yeah that's just absolute lunacy because we do have independent review under the bilateral with the US has been used three times the last time was 13 years ago it was incredibly critical the PBS and the PBS just ignored it because of course they don't want to admit that they could be wrong and they don't want to validate a review process again why one is needed. Because because the whole outcome process the whole process is just a massive vanity exercise for those people involved.

Felicity 54:18

The the biggest travesty of that one is that I think we talked about in the past was that the company didn't go again. They didn't follow up they didn't come back into the system and say sorry what?

Paul 54:28

I know they had a whinge and went away and that was for a wasn't that like a it's a combination therapy combination like a PPI and a painkiller I think or something wasn't it and they just didn't like it because they didn't like the PPIs but but it's the review is highly critical and then the company just went oh well you know isn't that terrible and then moved on. And then see these reviews don't work so no you've got to well when when we argue for independent review in the bilateral E my theory was that we're just going to swamp the system with reviews but market access people won't do that because they don't want to upset them not be nice to us they might not be nice to us guys if the system is punitive you got much bigger problems than comparators and discount rates. Yeah if you don't if you think that the system punishes you for speaking out and defending your rights it's like the PSDs you know I saw this thing that the industry sent around because the PSDs are problematic they're getting very sloppy we just get rid of them. They don't serve any purpose as I said you know basically no patient has ever said oh now I know I'm dying sooner than I need to because the Kaplan Micerve tells me just get rid of them. Just get rid of them perfect use of AI just to issue plain language one page summaries for people so people know that we don't really value your life that much it's not worth saving for five or six months. So just say it how it is because all those PSDs have all that detail but they got very sloppy so you can well some of them include net prices but unfortunately I wonder if the companies realize that but they've got sloppy in terms of all of the release of that information so companies are increasingly exercising their rights. The problem is not companies exercising their rights no that is never a problem exercising your lawful rights in this country cannot be a problem by definition. The problem is the actual documents themselves because no one looks at them they're like a voyeuristic peep peephole basically for competitors but anyway I could go on all day about that and I won't uh you got Grand Free this weekend haven't you?

Felicity 56:31

Yay very excited album signed on for Williams Carlos looks like he might new rumours about Verstappen's contracts didn't Verstappen he extended it with with Fred Bull didn't there's a rumored that he has been offered a five year contract but will they take away his get out of jail free clause and I don't it's silly season I love it. It's just so nice to have to do you love it.

Paul 56:55

People people always say that to me and they say this Felicity I didn't realise she liked their phone I said she's mad for it. Totally mad for it. Yeah it's all she talks about she talks about doesn't really like cars but likes her f one yeah I don't have any interest in cars whatsoever. I like the strategy you're not gonna buy Chinese EV? Definitely not they've got some weird names I think Chinese EVs are proof that they basically run out of car names or they're using AI to generate brand names sorry that's funny. I drive old fashioned car as you know gas guzzler yeah you do uh but I'm open to sort of you know I think it's you know Cadillac are in Australia now but they're only bringing their EVs yeah so it's about that not the one that someone like me would actually want to drive it's brutal. I know I know it's it's it's it's crazy but you know if all those people drive driving those Chinese EVs yeah note that the cabinet ministers were told do not drive Chinese EVs guys no I have a Tesla solar battery too Tesla and Proud Oh you're one of the We have a solar battery. Yeah did you get the what the subsidy?

Felicity 58:07

Yeah well that has to be one of the worst but I don't have a full size battery.

Paul 58:11

That's got to be one of the worst public policy decisions in the history of Federation giving rich people batteries.

Felicity 58:17

Yeah well we've we argued that it should be means tested. I mean if my healthcare if my access to a $70 script on the PBS is hit by I can only earn eighty six thousand dollars a year why can someone whose family is earning half a million dollars a year get full subsidy on a solar battery that they get anyway.

Paul 58:35

Well you know once the once the government starts subsidizing something you know that you know like that you know that economics doesn't make sense.

Felicity 58:42

Well it doesn't because they've got to tip the scale yeah but we're seeing in all sorts of things like like that you know you know how I feel about um childcare rebates and everything as well too which is when you're earning half a million dollars as a family why are you be is your childcare being subsidized a trillion dollars of debt in this country.

Paul 58:59

Yeah it's a problem very good okay everyone thank you for listening um we've got to get back to the word of the week I think we did your opportunity but yes we've got a bit slackened so you'll yeah yeah but I do have one um but we'll do that do that one next week thanks for listening everyone sorry we recorded on Sunday last week we got some bad feedback about that it's just that was my fault uh so we're back on Friday and this will be out Friday afternoon.

Felicity 59:25

Thanks Fiji thanks Paul