Interview with ICER CEO Sarah Emond

Curious about the forces driving healthcare pricing and access? Join us for an enlightening conversation with Sarah Emond, President and CEO of the Institute for Clinical and Economic Review (ICER). Sarah's upbringing in a family passionate about policy and social justice laid the foundation for her impactful career in health policy. We explore her educational journey from Smith College to Brandeis University’s Heller School, and how her professional experiences in clinical research and biopharmaceutical consulting shaped her path to ICER.

Unravel the complex world of health technology assessment (HTA) in the US as Sarah breaks down the challenges and opportunities within a fragmented healthcare system. ICER's pivotal role in evaluating new medical technologies is discussed in depth, including its interactions with international agencies like the UK's NICE. Sarah sheds light on ICER's evolution from a small initiative within Mass General Hospital to a powerful voice in global HTA practices, emphasizing the importance of fair pricing, patient access, and sustainable innovation funding.

Equity in healthcare takes center stage as Sarah introduces ICER’s updated value assessment framework. Learn about new tools like the clinical trial diversity rating and the Health Improvement Distribution Index (HIDI) designed to promote representation of diverse populations in clinical trials. We also tackle the high costs and value-based pricing of innovative treatments, including gene and cell therapies, and the necessity of evolving payment systems to ensure continuous innovation. Tune in to gain a comprehensive understanding of the pressing challenges and future directions in healthcare pricing, equity, and access.

Host David E. Williams is president of healthcare strategy consulting firm Health Business Group. Produced by Dafna Williams.

Transcript

0:00:01 - David Williams
How much better are new treatments than what's already available? What's a fair price for gene therapy and how can insurance coverage encourage the best patient outcomes? Those are great questions, but who can answer them? Hi everyone, I'm David Williams, President of Strategy Consulting Firm Health Business Group and host of the Health Biz Podcast, a weekly show where I interview top healthcare leaders about their lives and careers. My guest today is Sarah Emond. She's President and CEO of ICER, the Institute for Clinical and Economic Review, an independent source of clinical evidence review. If you like this show, please subscribe and leave a review. Sarah, welcome to the Health Biz Podcast. 

0:00:48 - Sarah Emond
Oh, it's my pleasure. David, Thanks so much for having me. 

0:00:51 - David Williams
So we've got these tough questions that are on everybody's minds. But maybe, as a warm-up, we'll talk about some of the things that have preceded you addressing these topics and maybe start way back with your background, your upbringing. What was your childhood like? Any childhood influences that have stuck with you? 

0:01:07 - Sarah Emond
I love this question. Thanks for starting there. I was recently reflecting on this because I think when you assume a new role, like I have taking over as president and CEO just this past January, you think a lot about all of the choices you make that sort of get you to that point and you feel a lot of gratitude for all of the influences you've had. And I thought so much about my parents. And I grew up locally in Boston, in Braintree, last stop on the red line, and was surprised to learn as I got older that my experience around the dinner table was not typical of a lot of families. Where we were talking about policy was what we were doing. I didn't know that. I didn't know that's what we like. 

At the time I was like cool, like we're talking about current events, we're talking about why certain decisions are made, we're talking about the consequences of decisions that made the role of government, the role of business. 

These were very typical conversations at dinner, even from a pretty young age, and my parents really found you know their voice through the 60s and 70s and through what was happening at that time whether it was voting rights, civil rights and the Vietnam War and they loved to tell us me and my two brothers about the experience of that time and what it meant for policy change and what it meant for social justice. 

And again, a word I didn't really know or understand and then only, in reflecting back, realized that's what we were doing, like we were having dinnertime conversations about social justice. So my parents were really big influences in helping me realize that that was a contribution that I could make in a career, because I make this joke all the time when you're really interested in biology and health and you're 15, you think there's five things you can do with that. Right, you can be a doctor, a nurse, a veterinarian, a dentist or maybe a physical therapist or like whatever it is. I was like, wow, health policy is a doctor, a nurse, a veterinarian, a dentist or maybe a physical therapist or whatever it is. I was like, wow, health policy is a career which I also didn't figure out until I was in my late 20s, but the foundation for that definitely came from my parents. 

0:03:14 - David Williams
Got it All right Now. That sounds pretty good. If you just added in touch football, it would sound like John F Kennedy's upbringing. You could be president. 

0:03:22 - Sarah Emond
You have just made my parents day by having that reference Very good, very good. 

So education Smith College how'd you choose there? You know it was funny. I wanted to stay close-ish to home, right? So it's about two hours from home, so it was far enough away that I wasn't supposed to come home all the time, but I could still come home and do laundry at a pretty periodic basis, which I did. But also because they had a tremendous science program. So I knew I wanted to be at a smaller university or college, didn't want to go to a big college, big university, but I didn't want to sacrifice being able to really dive into the science. I knew I was going to be a biology major, which I was, and I was so impressed with the facilities they had. The campus was beautiful, the people were so kind and it was really attractive to me to be at an institution that was focused on women's education and that was a part of the attraction, and so actually it was an easy yes, once they said yes to me, to pick Smith. 

0:04:26 - David Williams
Excellent, and did you work for a while after that before going to the Heller School? 

0:04:30 - Sarah Emond
I did so glad that I did Worked for about a decade before I went to graduate school, kind of made my way through doing some clinical research at Beth Israel, then found my way to doing some consulting for biopharmaceutical companies and actually working at a biopharmaceutical companies and actually working at a biopharmaceutical company and then realized there was this whole part of how health policy fits into this broader ecosystem that I didn't have the right tools and words to describe or know how to influence the policy. I could observe that it was like oh, that's interesting how we're making decisions now, but how should we be making decisions? How does evidence play a role in thinking about these trade-offs that are made when we make tough policy decisions? And that's when I knew that graduate school was going to be the next step for me and I was so pleased to have found the program at the Heller School at Brandeis and it's their Masters of Public Policy program and it was actually part of the very first class. 

So, they just started introducing and contemplating the program and that was also really fun. That fed the sort of entrepreneurial side of me. I was like, oh cool, we're like the guinea pigs and like we can give feedback on, like, which courses are working or what we might be interested in. And so then I started at the Heller School in the fall of 2007. 

0:05:46 - David Williams
I think one of the companies you'd worked for before that I saw on your LinkedIn Feinstein Keen, I remember. Actually I hadn't thought about them in a while, but I remember meeting the founders after I left Boston Consulting Group, which is in the early 2000s. They gave me some advice on setting up my own consulting practice. 

0:06:02 - Sarah Emond
That timing is sort of perfect. I joined Feinstein in the early 2000s and Marsha Keene, peter Feinstein, had built this really impressive practice advising everything from small stage you know, pre-revenue, as we like to say biopharmaceutical companies up to big pharmaceutical companies, about their investor relations, their public relations, about their investor relations, their public relations, even some marketing communications and they had just sold it to Ogle VPR, so a much bigger firm, and I remember being there and I hadn't known the pre-merger days, so that was also a really interesting experience. 

Divorced from learning about the business, was what it's like to be in an acquisition, which is something I think many of us have gone through if you're long enough in your career, and the challenges and opportunities that that presents, and the lessons. But I learned a lot from Feinstein and deep gratitude for the time I spent there. 

0:07:00 - David Williams
Let's talk about ICER. I have to say, the name sounds at the same time cool, like ice, but also ominous in a way. What is ICER? 

0:07:11 - Sarah Emond
ICER is our answer in our hilariously American healthcare system, to how we think about using evidence to drive decisions about pricing and access in the healthcare system. So we're organized as a 501c3 nonprofit. We are funded the majority of our funding comes from independent foundations so we can keep our independence. We're nonpartisan, we have no skin in this game, and no one has to do a darn thing, we say, which is also really interesting. We don't have any regulatory authority, but no one has to do a darn thing, we say, which is also really interesting. We don't have any regulatory authority, but we produce information to help decision makers know when prices match the benefits that patients receive and when they don't, and with an emphasis on prescription drugs. 

This is an important input into the conversation about how we pay for sometimes extremely innovative and life-changing therapies, but in a way that's sustainable for the whole healthcare system, and so those who watch this space may be familiar that other countries do this as a government function. So if you are a single payer healthcare system, like the UK National Health Service, you have an entire government agency that asks pretty much the same questions we do what kind of benefit does this new drug bring? What kind of price are you charging for it and do those things align and what are we getting for the spend in terms of health gains for patients? And yet, you know, no one's expecting us to have any sort of government agency doing this anytime soon, because we don't have a single-payer system. We have so many different budgets and perspectives and incentives that we exist sort of outside that system, producing this information in a way that we hope is driving everyone towards using evidence for more sustainable access for patients at the end of the day, so you talk about other countries. 

0:09:14 - David Williams
your single payer system, like the UK, and their equivalent there is called NICE, and I don't know whether NICE is nicer. I think ICER is nicer than NICE. I'm not sure. But today you have a challenge to make your influence felt in the US. Are you influential with those agencies in the countries that have the single payer? 

0:09:33 - Sarah Emond
Well, I think what I would say is that we're part of the international community, so this is known as health technology assessment. So we participate in health technology assessment, international HTAI, where we share best practices about evolving methods, how to do stakeholder engagement. Recently lots of conversations about the role of AI in HTA. So it's really important to us and we value being part of the international community. We learn a lot from them. I would say part of the international community, we learn a lot from them. I would say Many of these HTA agencies have been around much longer than ICER has, but where there is some learning from us to them is that a lot of the technologies that we review we do first because companies are introducing them to the US market before they're introducing them to the UK, Europe, et cetera, and so if it's on a specific technology, there may be opportunities for those organizations to see what we did. How do we design the model? How did we think about the evidence as it informs their own decisions about how to go about a technology assessment? 

0:10:45 - David Williams
decisions about how to go about a technology assessment. It's interesting and of course in that answer you're hinting at. One of the other sides of the debate over single payer versus not is that if there is an innovation, it is introduced here. There's a question of whether it's cost effective, but there's less of a question about whether we're going to get it first and whether it will exist here or not. 

0:11:03 - Sarah Emond
You know, and I think this tension is real and okay to name we often think of this as a balance, right. So we want fair prices so we can have sort of an affordable, sustainable healthcare system. But we want fair access because, you know, at the end of the day, making it hard for patients to get access to things that might benefit them isn't really the social goal that we have about our healthcare system. And then we want enough revenue out of that bargain to fund the next round of innovation that we all want. And so we are often talking about the balance of those three things so that we can think about the price that's high enough to incentivize the next round of innovation. That we want, but not so high, is to make health insurance premiums go up and unaffordable and make it really difficult for people or even employers to offer health insurance. Right. 

So, like that balance, it's like we don't shy away from saying like it's okay to talk about the trade-offs that happen when you have the, when you're holding those three things at the same time. And it's not to say we should have a single payer healthcare system, it's to say we can have the system that we do, but we can do a lot better by patients. If we're very honest about how we're using evidence to think about pricing and that we're okay maybe calling it out when there's an overreach on pricing on the manufacturer's side, and we're also okay calling it out on the payer or the pharmacy benefit manager side when they're making it really hard for patients to get access to something that might be really high value, it's okay to have those conversations out loud in service to better access for patients in a more sustainable way. 

0:12:51 - David Williams
Sarah, how did you decide to join ICER in the first place? 

0:12:55 - Sarah Emond
I said yes to an informational interview that I will, to this day, be so grateful that I said yes to that. If you can believe it, my classmate at Heller's father's neighbor was Wendy Everett who's a? 

name that many of your listeners might know. She ran knee high for years. She's a respected nonprofit leader in the healthcare space and I had known of Wendy because I had been in the biotech space. I had never had the chance to meet her. She very graciously offered to spend some time with me as I was finishing graduate school, thinking about my next move, and she said my good friend, steve Pearson, is looking for a founding executive director for this group he just started, called ICER. Can I give him your resume? And I said yes, please, Wendy, by all means, please pass along my resume. And then Steve and I sat down for a conversation and completely hit it off. I loved what he was trying to build. I loved what his vision was for a more just healthcare system and thankfully, you know, he said yes when I said please hire me, I'd love to come on board. And I was the second person that he hired as he was building ICER. 

0:14:11 - David Williams
Very nice. Now you mentioned that you'd been reflecting on your background and so on. As you've taken over a new role, which is just in January, how did your role evolve over the time frame up until then and then what's the latest? 

0:14:26 - Sarah Emond
change. Well, it was really fun joining as the third person back in 2009, because we were decidedly an experiment at the time. Can we do something like HTA in a US healthcare system and what does it look like to do that without having any government authority, regulatory authority? So we focused a lot on methods and how to do it right, and we made mistakes and we tried things that didn't work. We focused a lot on stakeholder engagement. We said, everybody, come on over, let's have a day long meeting talking about a particular technology, but let's also talk about, like how we're doing this deliberation, like how we're applying our methods, how we're looking at the evidence. What is it the decision makers need in order to make decisions in a more evidence-based way? And so I think in the early days, we had a lot of humility about how we were doing this, because we didn't know the right way to do it in the American system. And then, over the years, we just started getting better at it and we learned from our mistakes and we had some wins. We were attracting more funding, we were attracting more people and cool people who thought that it would be fun to sort of work on this idea. 

Right, it was really, in the early days, this idea of using evidence to help make decisions, and I particularly liked it. So my role when I started was chief operating officer and that just meant I did everything except the actual evidence reviews in the early days. So we, you know, for the very first part of when we were when I joined ICER we were actually a research institute within the Mass General Hospital and that was a really good place for us as we were doing this experimentation, because we had really nice support for payroll and all of these other things that we didn't have to worry about. But it became apparent at one point that we needed to become an independent nonprofit and so the early days we were figuring things out. I would say that spinning out and establishing a 501c3 from scratch was such an experience that I don't necessarily want to do again. However, I don't regret going through it and what we learned about actually filing the 501c3, how to find healthcare benefits, how to set up an accounting system all of those really in the weeds things that you do from an operational perspective. 

I do make the joke that when we spun out, we got some office space at one state street right near downtown crossing and we basically picked it because they already had furniture and so I yeah, so I equate it to like your very first apartment after college, like you actually don't care how nice it is, you're just really glad it's yours and we. 

I remember setting up the printers and the IP phones and Googling it to figure out how to do it and then being so grateful that my husband, who's an IT professional, worked across the street and could come over at lunchtime to help us out. So just to give you a sense of what it was like in the early days we were pretty scrappy and really bootstrapped, like trying to get this thing going that is not just donated furniture and a staff of about 35 people, both in Boston and a few across the country, who do this work with us. And we've just been really grateful for the evolution of our impact over that time and my role has gone from worrying about the IP phones and whether or not the network switch is working to now having the great privilege of taking what Steve had built Steve Pearson, our founder and build that to its next generation. So I'm really excited for that opportunity. 

0:18:42 - David Williams
Terrific to ICER when a certain assessment has come out that says what a drug is worth, which is usually something less than what the pharma company is putting it out for, and then that leads to various, I won't say controversy, but some of the tension that you described before. But I'd like to talk about some of the other, maybe broader initiatives that you're working on now and I noticed, if you don't mind, what is this concept of health equity in HTA and health technology assessment? What are the issues there and how do you address them? 

0:19:10 - Sarah Emond
You know, one of the things about the methods that underpin health technology assessment is that, like everything, we've gone through a real moment of review over the last four or five years to see where some of those methods might have been developed or thought about in a way that was reflecting a fair amount of privilege, whether it was white privilege, class privilege, whatever it might be. 

We all acknowledge that the way that academic medicine and some of these approaches have been developed have been sort of a reflection of those with education and those with access to the healthcare system and have a particular view, and so we wanted to approach this question of how methods can better reflect the values that are now importantly front and center about addressing health disparities and addressing health equity. And so we ended up having some funding from the Commonwealth Fund to do a stakeholder initiative about two years ago to basically say ask this question what are the methods? Where are their shortcomings? You know what can we do, and our paper that came out a couple of years ago, about a year ago now, basically says like here's the menu of options available to those practitioners of health technology assessment to really reflect things about health equity, and then, in this past, fall. In our recent value assessment framework update we really drilled down to say and here are the things we're going to be addressing now and so a few examples we have a clinical trial diversity rating that we now employ with every review. That rating itself was actually recently published in February and the idea behind it is to say how well did the company do in recruitment in terms of race, ethnicity, gender, age, in reflecting history was in the news because of some conflicting evidence about its efficacy. There was also a lot of pushback. Given how few patients in that trial were Black patients. Given the disproportionate impact of Alzheimer's on the Black community, that seemed like a mismatch. Not really criticizing Biogen here. There's lots of reasons that recruitment is really difficult and yet we can do better. So our clinical trial diversity rating is meant to say how close did the company do get in reflecting the actual diversity of this population in its clinical trial? 

Now we don't use the answer to that question in the actual comparative effectiveness research or in the calculation of the value-based price. It's meant to just be another milestone in our journey of understanding where we can do better. So that's one thing that we're starting to do from the equity lens. The other is a health improvement distribution index. This is to help decision makers know when investing in a therapy may actually have the opportunity to address disparities, if it's something that disproportionately impacts those who've been historically disadvantaged by the healthcare system. So imagine a new treatment for asthma. Because of the prevalence of asthma in the Black community, a payer might decide I'm going to invest in this therapy, maybe even if it's not a value-based price, maybe it's a little bit above the value-based price, but I'm going to do so because it's going to have a disproportionately positive effect potentially on the Black community because of the prevalence of the condition in that community. 

So we put out that HIDI, as we call it, the Health Improvement Distribution Index, with every report now. So again, the decision makers have an input. The final thing I'll mention is that there's often questions about the comparative clinical effectiveness of a therapy in different populations, instead of just the sort of population average that we might get from the clinical trial. So now we will go looking for those data de facto, de novo, every time we do a review to see if they're there. Do we have information on how much better or not this therapy is for communities by race, ethnicity, age? Again, not necessarily to say that this should go into the calculation of a fair price or how we should think about the value-based price, but more to think about are we seeing a place where we might want to invest more money in a particular population because it has the opportunity to address health disparities? 

0:23:59 - David Williams
So in other parts of the economy you're seeing a lot of fairly strong pushback against things that are variously labeled as DEI or ESG. Is there the equivalent of that in healthcare too, or is it more exempt from those forces? 

0:24:14 - Sarah Emond
I don't think we're exempt from anything in terms of sort of the political forces that are questioning the validity of looking at things through a lens of race or ethnicity or socioeconomic status. I don't think anyone's immune from that, whether you're running an organization, so you're just thinking of it from an HR perspective, or you're doing work in a particular area. I think where healthcare is a little bit different is the overwhelming and compelling data that we have about the disproportionate outcomes for certain populations. That is tied to race and ethnicity and sometimes, often, socioeconomic status. That hasn't gone away, whether you call it DEI or IDE or you call it ESG, if you want to use whatever acronym. 

If you're a physician in an emergency room and you see people from a particular community who are basically relying on the emergency room for primary care because they don't have access to primary care otherwise, it's hard to convince anyone in that setting that we don't have an issue right now that is linked to the way that the healthcare system has historically disadvantaged some populations, and so I don't want to get too worried about the alphabet soup. I want to stay focused on how we can continue to think about evidence leading to a more just and sustainable healthcare system. So if you want to change the acronym, go ahead, change the acronym. It doesn't change the fact that we have real challenges as a healthcare system and delivering high quality and affordable care to everyone. And when we do things like ask a question, maybe we shouldn't overpay for this 20th drug for rheumatoid arthritis, because then there's the opportunity for those resources to go to other priorities in the healthcare system. I want to get to a place where it's okay to sort of say that quiet part out loud. 

0:26:16 - David Williams
Let's talk about some places where there's some very exciting innovation. I'm talking about cell and gene therapies, but also some truly eye-popping prices like nevermind six figures, but could be seven figures. How do we think about those products? We know they're expensive, I think that's a given, but what's the framework for assessing them? 

0:26:36 - Sarah Emond
It will surprise no one to say that we should start by talking about whether or not those prices are value-based. But what may surprise some of your listeners is that in a lot of cases, millions of dollars for these therapies is actually value-based and what we actually have is a payment system that doesn't know how to pay for a lot of value in one price. We have a system that knows how to pay for value over time and we have a system that knows how to pay for value over time and we have a system that knows how to overpay for value over time because you can build it into your budget and it gives you some budget certainty and it can be in the actual actuarial model and it's in your premiums. But if you're presented with the opportunity to spend $2 million on a potentially curative therapy for spinal muscular atrophy, a rare but often fatal neuromuscular condition, if you're a small employer, self-insured, that's actually very challenging. 

0:27:32 - David Williams
Yeah. 

0:27:32 - Sarah Emond
Because your entire drug spend might be $1 million, and then you have something coming. You know you've got a bill coming for two, and so it does have to start, though, with the value based pricing. So while I said you know, we've looked at, probably doesn't sell in gene therapies, and by and large, they're actually priced pretty close to value if you have overreached, and I do want to make sure that we don't get into the space of thinking that rounding up by three or $400,000 is no big deal, because it's still a lot of money. But there are also examples out there of gene therapies that haven't demonstrated clinical benefit and are still trying to command very high prices, and so we need to start by saying is the price value-based right? And in a lot of cases, like I said, those millions of dollars, price tags will be. But then we have to have a conversation about how the payment system needs to evolve. We recently had a white paper that really unpacked the options as they exist now and made some recommendations about some regulatory changes. I mean, we might want to see, or how different payers and purchasers and employers should be thinking about these options so they can be ready for the wave of gene therapies that are coming. 

Because, I will tell you, the thing that keeps me up at night right now is that we're going to be so slow on the payment side in figuring out how to pay for these high value therapies that, yes, are expensive, that the innovation signal back to the venture capitalists and others who are making decisions now about future programs in gene therapies are going to take that money and put it somewhere else, like maybe a GLP-1 program. 

And I'm worried about that because one of the jobs that I had early in my career was at a pharmaceutical company called Genome Therapeutics. It eventually became Osteo Pharmaceuticals. Neither exists anymore. For anyone who wants to try and Google it, good luck. However, genome Therapeutics was one of the private centers sequencing the human genome when I was there and we thought this was science fiction. We thought that maybe in our lifetime we would see that come to fruition in an actual therapy. And here we are we actually have gene editing technology, we have gene therapies, and I will be crushed if we do a bad job on the payment side, so that the innovation signal is weakened and then we don't get the continue wave of science fiction that I think we all want. 

0:30:07 - David Williams
You mentioned. You know, in other countries you've got the HTA agencies that are interacting with the government and part of the government making decisions for them about what's covered and what isn't. We may not have that here, but we have those that are purchasing care employers health plans and how do you think about, I mean, what is ICER's engagement with those purchasers of care? 

0:30:30 - Sarah Emond
I like to say we'll talk to anyone, but you're right that purchasers are in an area where they're increasingly feeling the pressure of higher and higher healthcare premiums, but also the pressure of I want access for my employees. 

I don't want angry phone calls that they can't get the drug that they want, and I want them to have access for the reason of their health and increased productivity. It's good for me as an employer to have a healthy workforce. I think this is an area where we're going to see a lot more action. So, while many employers have relied on benefit consultants and pharmacy benefit managers to give them advice on how to do their pharmacy benefit design, how to manage their pharmacy spend, I think increasingly there's been attention to where there might be some conflicts of interest and some of that advice, and I think that's an okay, healthy conversation to have. 

So some of your listeners are probably familiar with the rebate model, the idea that a manufacturer gives a big discount to a pharmacy benefit manager in exchange for a preferred formula replacement. So you know this is, in one regard, the market working. It's, you know, competition. You get to sort of prefer one over another, but to do that it makes it really hard for patients to get access to the other ones. And so where you see some problems is who's keeping that rebate? Is all of it staying with the ultimate purchaser or the employer? Is some of it being shared by the PBM, because they're the ones doing the negotiating, so it might be very reasonable that they keep a portion. 

I think there's been a lot of lack of transparency on that. 

That has started to bubble up through the purchaser community going. 

Wait, I'd like to have more of an understanding about where my dollars are going and I will say in our conversations with purchasers, when we talk to them about things like a value-based formulary, leverage ICER's research, to say this is how much we should pay for these medicines. 

Maybe this means broad access in a particular disease area like multiple sclerosis, and we're happy to do that because we're going to pay up to the value-based price. We have heard from purchasers how difficult it's been for them to get traction, trying to get their partners to do that, because that flies in the face of this rebate model. That has been the predominant way that people have thought about discounts, pricing and access, way that people have thought about discounts, pricing and access, and so I think there's lots of opportunities in the purchaser space to be getting everyone to think a little bit beyond the status quo. Whether it's the manufacturer with the list price choice or the PBM with the rebate approach that they're taking, purchases ultimately have the dollars to get everyone in the ecosystem to be more focused on a fair price, fair access paradigm. So we'll continue to talk to interested purchasers and employers who want to maybe disrupt the status quo a little bit. 

0:33:33 - David Williams
My previous guest on the show is Eileen McAnenny, who's running a new employer coalition in Massachusetts focused on some of these things. Just to continue with your discussion about the rebates for a minute. So it's not done as purely as a discount, it's like as an actual rebate gets paid and weirdly, those that are receiving the rebates look at that as a revenue source but they're hesitant to give up. 

0:33:58 - Sarah Emond
Yep, and I'll share a story, without naming the purchaser, that I heard recently where and this is another reason again, some of your listeners might be in the weeds of knowing that the uptake of biosimilars right, so this is basically the generic form of the biologics that have been on the market for a long time has been really slow in a lot of cases, and the market leader there, humira, has been able to maintain a position on a formulary even when it had biosimilar competition. 

And remember the social contract is that when things lose their patent, there's a generic or biosimilar we get lower pricing and society sort of wins after having paid more of a premium during the monopoly pricing period. But Humira has been able to maintain this position. And I heard a purchaser say we really wanted to switch everybody to the biosimilar rebates that they offer us on every other drug in our portfolio and we couldn't make the math work because the rebates that they were getting on the rest of the portfolio, like you said, was revenue that they were expecting to have to offset healthcare costs, whatever other priorities they had as a purchaser. And I will admit that that was one of the moments where I put my head in my hands and I was like and this is why we can't have nice things. 

0:35:22 - David Williams
Yeah, very good, All right. Well, I'm going to ask you what maybe the only easy question of the day, if it is an easy question, and that's whether you've had a chance to read any good books lately anything you would recommend to our listeners? 

0:35:43 - Sarah Emond
definitely reflect the nerdiness of my book choices lately, but some good friends of mine at Tufts, one of whom I have recruited to be back at ICER as Chief Scientific Officer, dan Ollendorf, wrote this excellent book called the Right Price A Value-Based Prescription for Drug Costs, and for anyone who would like to get a sense of what, the sort of how it works now and where there's opportunities for us to evolve to a different approach to thinking about pricing drugs, it's an awesome primer. 

0:36:10 - David Williams
Great Well, Sarah Emond, president and CEO of ICER, I'd like to say thank you so much for joining me today on the Health Biz Podcast. 

0:36:18 - Sarah Emond
It's been such a pleasure. Thank you for having me, David. 

0:36:23 - David Williams
You've been listening to the Health Biz Podcast with me, david Williams, president of Health Business Group. I conduct in-depth interviews with leaders in healthcare, business and policy. If you like what you hear, go ahead and subscribe on your favorite service. While you're at it, go ahead and subscribe on your second and third favorite services as well. There's more good stuff to come and you won't want to miss an episode. If your organization is seeking strategy consulting services in healthcare, check out our website, healthbusinessgroup.com.