Hey, guys. Welcome to the podcast. My guest today is Todd Weinstrat, senior director of field medicine, and we talk about managed care MSL's past, present, and future. Awesome discussion. Really insightful. Don't forget to follow us on YouTube and Instagram and LinkedIn, of course. So thanks for joining me. Welcome to MSL talk with Tom Caravella, a podcast specifically designed for MSLs and all things field medical. Hey, Todd. Thanks for joining me. How are you doing today, buddy?
Very well, Tom. Thanks for having me. A really important topic we're gonna discuss today. I'm so excited, man. This I have to tell you, this is one of these topics that just keeps coming up, and Yeah. I don't think people really have a full grasp or understanding of the managed care, managed market side of the industry and how it all comes together and why it's so important. So thank you so much for joining me.
And, not to jump into it, but let's jump into it because I'm really excited to hear your take. Yeah. Let's let's start. I think the best place for us to start is with a historical perspective. You know, what is managed care, managed markets, access? What does all this mean? How does it all come together, and why is it so important? Well, Tom, I I gotta take you back a number of decades.
I've had over 20 years of experience, 22 now, in the in medical affairs and leadership positions and another 10 or so in clinical practice, and this position's been developing since the eighties. So broadly defined, managed markets, managed access is anybody that pays the bills.
So that can go from your traditional health plans like the Aetna's of the world that been bought by CVS recently, you know, Cigna, all those plans you know and love that take care of your insurance needs, your health care needs, but it also defines a lot other customers. It could be the PBMs like CVS. It can be the federal system, so Medicaid, Medicare, the DOD, VA.
It can also go incorporate into, other type customers such as oncology networks that look at value, group purchasing organizations that use their bulk to purchase drugs at a lower price. All these different customers really encompass what we call today managed markets or managed access in the US. Got you. Before we go further, I mean, I just jumped right into it. I apologize. But I know you have an amazing background in in managed care.
You also have 20 plus years of experience in medical affairs leadership. So give us a quick overview of who you are and where you're from Sure. And what you do. So we jumped right past that. We're gonna get back into managed care, but we kinda jumped right past the intro. So so, so I apologize for that. Just go for it. At all.
So so, essentially, I started my career as a clinician in pediatrics neonatology and got involved with health outcomes and health economics, what we consider now h e n o r, nowadays what we call, and got so interested in that I brought it from the clinical setting, the academic setting into industry. And actually was one of the first managed care MSLs in industry. It was the late nineties when we started this at a particular company, and it's grown over the years.
So my background encompasses clinical experience, academic experience, but also coupled with a deep knowledge of HUR and a deep knowledge of the managed market customer. I was a customer for a number of years and had my own company in the area and transferred over into industry because I thought I could do more good with more people. And so it's been a slow development. We actually started what you would consider a managed care MSL a little bit in the early nineties. We said, wow.
There's other customers out there other than key opinion leaders, other than prescribers, other than a hospital, you know, pharmacist. And we really felt that it was important to expand in the areas because they dictated therapy. They Right. Facilitated therapy. It's all about 2 things, Tom, here. It's about your drug gets used in the right patient at the right time because there is a need and the prescriber sees that need. That's the clinical acceptance. But, also, there's access.
So if you have both, the drug gets to the right patient at the right time. But if you don't have the access, you can't write the drug. If you're a prescriber, you tend not to use it. So you need both to really have that balance. And that's what we discovered back in the nineties, when we started this long journey, which has been a fabulous journey, by the way, since the middle nineties or so.
Yeah. And I know there's so much to unpack when we when we talk about this because there's, you know, formularies and there's government programs and there's so there's so much that the pharmaceutical company needs to take into consideration when they're in the process process of commercializing a drug. Absolutely. So can you talk about that a little bit as far as what are the areas that they need to focus on? So for example, there's health plans and there's the government, then there's PBMs.
And can you break that down a little bit? Yeah. Absolutely. And and every one of these segments, Tom, is unique. So you have to have the experience. So any MSL that's a managed care MSL should really have experience in 1 or more of these areas as a customer Mhmm. Before they go into the industry because they can be able to guide their industry colleagues and be collaborative and work together with account directors and quality management individuals to really provide the best value to that plan.
So health plans are health plans. Okay. But but but they're not the way they used to be in the eighties. Used to be health plans were HMOs, PPOs, that is, you know, health management organization, where they took care of your care. And what they were trying to do, and they did for the most part, was maintain quality or increase quality by reducing costs. Mhmm. So procedures, just episodes of care, drug costs.
They want to get that down so they could have a better treatment outcome for their patient at less cost, but that's evolved. So now a health plan can be considered, a health plan that it's an insurance plan. It has a specialty pharmacy within it and maybe have pharmacies like CVS, Aetna, the huge mega merger recently in the last couple years. So a health plan is not the way we defined it in the eighties, Tom. Now it's just all encompassing and all services put in together.
But that nevertheless, there are traditional PBMs as a pharmacy benefit managers Mhmm. That help guide therapy, that help reduce cost, but there's also just been a just an incredible change in advent and evolution in what we call a hospital. You know, recently, we we we started, recently within the last 10 to 15 years, the advent of the hospital system being, again, all encompassing, cradle to grave. You go there for everything, outpatient, inpatient, medications.
And now we've seen the domination in that market evolve into what we call integrated delivery networks. One of the famous ones, the largest ones is Kaiser that everyone knows. Geisinger in Pennsylvania, Mercy Health Systems throughout the United States, and AdventHealth System. So they have a approach to the patient. It's holistic. They want to provide all their services. But where industry has to change and has, luckily, is how do we deliver value to those systems and their new systems?
So who do we even meet in the systems to affect that change or deliver that value proposition statement? So not only have the systems changed, Tom, but who we talk to. Like, you never would have thought 20 years ago you're talking to a quality manager in a hospital. Right. Like, oh, I'm talking to medical director. I'm talking to pharmacy director. We're good. Now you have the health economics person. You have the quality.
You have maybe their nurse manager that does episodes of care if you're doing cardiovascular therapy experiences. So it's the the landscape is incredibly changed. And not to even mention, not to get into, Tom, the different prescribers now. You don't just have physicians. You have nurse practitioners. You have PAs. You know, you have really high functioning advanced clinicians that you have to work with because, remember, it's all about clinical acceptance.
It's all about access, whether you're prelaunch, peri launch, or post launch in your life cycle management. You have to start thinking early about those things, probably in phase 2. Mhmm. Mhmm. So okay. Let me let me go back a second.
So managed care, as I'm hearing it from you, has to do with the management of care for the patient and how companies the continuum the whole continuum of care in the spectrum of services is trying to be more cost effective in the way that they administer care to patients without disrupting quality. So in the managed care world, there's that's really the culmination of what exists in managed care.
But we're also talking about access, and we're talking about inclusion and why it's so important for pharmaceutical companies to make sure that their products and drugs and, you know, devices and and are available. So it's about availability. So can you talk a little bit about that piece of it? And I would even add, Tom, you made a a good point there. It's not just about drugs. It's about procedures. It's about test. It's about molecular diagnostics.
So we have managed care MSLs now that are working in companies in transplant, for instance, with liquid biopsies, believe it or not, tell t cell mapping. So the strategies we always thought that were you know, the scientific part of it is now evolving as a real need in a pharmaceutical company to cover. So not only do you have customers, but you have different therapeutics, gene therapies, for instance. Yeah. So some if you take a look at managed care, you can really use the word payer.
Mhmm. Okay. If you kinda put that into your head, okay, payer. Everything we're talking about today involves a payer, whoever pays the bills. When you think about that, it makes it kind of easier to talk about, okay, definitely have to have access. So we have to have that prescriber saying this drug is good for my patient. I think it's gonna work very well. And then we also have to have the other side of it.
When that physician or that nurse practitioner that or that, PA makes that decision, they wanna use drug a in this patient, it has to be available. It has to be easily available because it's all about the patient journey. Patients, prescribers, they get very discouraged when there's any roadblocks in the road for them getting that drug. It's very hard to deliver a drug to a patient. Everybody thinks, oh my goodness. The hardest part of getting a drug to a patient is having it approved.
No. It's not. It's after it's approved and that prescriber writes a prescription, some of the hardest part of that patient journey is that spectrum right there, that area between when they ride it and when they get it in their body. So access is extremely important to allow for appropriate use of a drug. Yeah. You have to have both. It's like a little teeter totter.
They both have to be even, because if you get one and don't have the other, your patient's not gonna get the right drug at the right time. Okay. So now that leads us to the MSL side of the equation. So let's just assume for a second that, we have access, availability, formulary inclusion, and things are available. On the commercial side, you have sales folks that are out there promoting the use of a product drug proceed whatever. Yep. Then you have MSLs.
And MSLs who are non promotional, fair and balanced, unsolicited, developing relationships with KOLs. So let's talk about how does the MSL fit into the managed care world? What are managed care MSLs, managed markets MSLs, medical outcomes liaisons, health outcomes? Right. Let's break that down because there's this nomenclature that I think a lot of people don't understand, and it's a little confusing. So I wanna hear your take on how the MSL fits into the managed care world.
Yeah. Well, first of all, in in our highly regulated environment, everything has to be done compliantly and legally appropriate. So whoever you interact with has to be right to the letter done the right way. Mhmm. Now what's interesting in the payer world in the payer MSL world, you have a little bit more latitude because you can work with who we call account directors or account managers that work with the account on the business side.
So you are a partner joined at the hip where it's compliantly and, legally appropriate to work together to provide value to that plan, to that integrated delivery system. So I wanna make sure everyone understands that the medical person is not in isolation. They're a part of a collaborative team that works very closely together, because we need each other. We need the the business part of the the equation because we need to understand what the the barriers are here.
If outcomes research and outcomes contracting comes up, we have to be able to to address the endpoints. Whereas, they need us to go in-depth, whatever depth possible, to describe the value proposition of that drug or that procedure or that lab test. Mhmm. So what we find is that you have a highly trained individual that wants to be a payer MSL.
The the names are subtle difference, and sometimes you involve a a a field payer MSL and more health economics research, and maybe they have that as a part of their job. Mhmm. Nevertheless, even if they don't have it as part of their job, they have to understand deep knowledge of how health economics affects the value proposition of a drug and how to communicate that. Sure. You have to have the business you have to have the business environment overview, Tom.
You gotta know who you're going to see. You gotta know their business model. You can't walk into a Department of Defense, military treatment facility and not know how the military works and how drugs are utilized to preserve force preparedness. You have to know the terms. You have to know the nomenclature. So you have to have to know a lot about the landscape, lot about h and r, and certainly about your drug and how it fits in to the armamentarium.
So it's all about finding the fit of the drug, supporting it with the value proposition, and you have to be aligned with your internal medical directors. Your therapeutic MSLs, you might get a physician in a, that's a specialist in, let's say, multiple sclerosis in a plan, and they wanna go a little bit deeper into it. Traditionally, therapeutic MSLs are those those partners that do that, whereas payer MSLs tend to stay a little bit more on the surface there, and they're more broad than deep.
They they're usually transfranchised. So you have to be very nimble, and you have to have experience in different therapeutic areas, Tom, because you're gonna, as a company, have you know, if you're a bigger company, you might have 10 therapeutic areas. You might cover that much Wow. As a payer MSL. So you have to know the environment. You have to know H and R. You have to know value proposition. You have to work collaboratively.
But then on top of that, you have to be really, have a general understanding of the therapeutic areas and where your product fits. That's really important. So you could be an MSL, be a PhD, a PharmD, an MD, a nurse practitioner. The degree doesn't matter. What matters is your experience and your dedication to that, promotion of the value proposition. That's really what makes a great payer MSL today.
So would you say the main difference between a therapeutic MSL and a managed care MSL is the customer base, the client base of who they're going to be calling on? Absolutely. Different client. Now that doesn't that doesn't mean that I haven't called on KOLs, a physician, because an MSL and I might be collaborating. Maybe that m maybe that physician is on the p and t committee, of a particular health plan.
We wanna make sure that they have all the data they need and and and talked about in a in an appropriate manner. So we may collaborate. But in general, you're right. The payer MSL has the payer customers, and the therapeutic MSL has our traditional prescribers Mhmm. Our traditional thought leaders, you know, our academic thought leaders. But net nevertheless, we do crossover and collaborate quite frequently, actually, more than people would think.
And so it's very important to have that collaborative nature, but that's one of the big differences. The other big difference is that you're looking more at the value proposition, the total package of the drug. It's like going and when you go into a customer, Tom, it's like going into a bank. You're gonna make a deposit or a withdrawal.
What I mean by that is you're gonna give that customer something of value, kinda put the drug in perspective where where the positives are, where where the data lies, where the unique features are. And if you don't always provide that deposit and you just go in there and you don't provide value, you you're you're reducing your bank account. When that gets to 0, Tom, that customer doesn't wanna see you anymore. You're done. You're done.
And you're done with everything you could do positively for your company, for the patient, for the prescriber, for the health plan. Until you can make another deposit. Absolutely. You have to come with something they need. So that's a little different too. Although, hey, KOLs want value too. They want their MSLs telling them about the newest data, what happened at the meeting they didn't get to be, at, how their drug fits into their armamentarium and their practice.
So Mhmm. It's not so much different. It's just a little different customer and how you have to, utilize that value proposition to dictate the data you're gonna present and how you present it. So let's talk about that for a second. So the customer is is different, and the value proposition is different. So what might that look like? How is the messaging different? Is it more, are the discussions more economic in nature, or they're more presentations?
Like, give me an an understanding of the the day in the life of a managed care MSL versus a therapeutic MSL. One of my one of my colleagues who I consider the grandfather of, payer MSLs once said that as a payer MSL, you are paid for those momentary glimpses of brilliance in front of the customer. What he meant to say was that you have very little time with the customer to get what you need done. They're seeing they're seeing maybe a 100 companies that have 10 drugs apiece.
That's a 1,000 presentations. So we look to be very short, specific, and focused. We rarely get over 30 minutes to talk to someone. Okay. So those hour, 2 hour means, they don't exist anymore. Alright. And what we find is you have to be very focused on a few different areas. You have to be focused on their business model. Mhmm. You have to tell them how their drug fits into their armamentarium, their formulary, their if you're talking about government systems, it's called a preferred drug list.
It's not called a formulary. Military treatment facilities, they have a uniform formula. You have to make the case of why that drug fits where you think it fits, and that involves a little bit of efficacy, a lot of safety, and a lot of comparison on where it fits into the whole scheme of things of what's available, whether it be all generics or a lot of different brands. And that's what you have to do. So you have to do it very focused because you don't have a lot of time.
If they wanted to come back and wanted to give you more time, Tom, great. But you should always plan for a very short presentation. Matter of fact, if you look at some of the kind of in internal studies that were done, for 1 hour of interaction with a customer, it can take up to travel time, prep time, follow-up time afterwards because there's a lot of follow-up. They ask questions. You gotta follow-up. You don't know all the answers. No one can.
It may take almost to a day to a day and a half to prepare for one appointment. Wow. So you may not have that many appointments. And and now going back to the value bank, you may only see somebody, a particular thought leader at a managed care plan, you know, like a a medical care. You may see them 4 times a year at the most, and you have to make your case. And you have to bring back data that's appropriate for them every time you do to build your case, every time you go there.
You may see somebody once, and you may not wanna see them for 6 months because you've made your case. It's gotten on formulary. You wanna, you know, just bring the newest data, and you don't have any new data. So you're not gonna go see them. So it's a lot different than reach frequency model that you would see in sales and even in some areas in MSL. So the metrics don't apply always. It's more of a relationship building.
It's more of a value, and that's how you've had to focus the presentations. They're laser focused. Some some I'll give you an example. Some individuals, especially the DOD, when you go see their, pharmacoeconomic center, they don't want you to say one word about the disease unless it specifically applies to how your drug is being used. They don't want a long 4 or 5 slide presentation on, multiple sclerosis or rheumatoid arthritis, what it is, and why we care. They know that.
They will flag you on, and that will decrease your value. So you have to know your customer. So it's usually where the drug fits and why prove it to me. Awesome. That's great info. So now it makes me think, now that we have an understanding of the historical perspective and what a managed care MSL does, what some of the differences are between managed care MSL and therapeutic MSL.
There's probably a lot of MSLs listening to this podcast today that are saying to themselves, well, you know what, Todd? That sounds pretty good to me. So Yep. How do I become a managed care MSL? What skills would you look for if you're hiring a a managed care MSL? I I would, first of all, see if you have customer experience.
So maybe in your past, you've worked at a health plan, or you've worked at a hospital where you've been a part of an integrated delivery network, or you've been a previous DOD, a federal employee. You were actually uniform services, medical services in the in in, in the navy, in the army, in the air force, and, marines, coast guard, public health service. So we're looking, first of all, to see, do you have customer experience? That goes a long way, Tom. Now you might say, well, thanks, Todd.
Well, I don't have that experience. What can I do? Well, okay. It's okay. Because as an MSL, you got all the tools there. You just gotta sharpen them a little bit, certain tools. And so I would say one of the things that we have done in the past that really helped coach people that really have that that burning desire to really wanna work with managed care customers is make sure you have that basic knowledge and applied knowledge in health economics and real world evidence.
You know, know the terminology. Know know how it's, presented in a study. Know what's good, what's bad. You have to do that. And the other thing you do, you can do is preceptorships. And that's that's a really great thing in companies now. It's becoming of age. You know, you wanna be a medical managed care, director, and a managed care MSL, and you don't have customer experience, work with some of your existing medical managed care, your managed care MSLs. Work with them. Ask your boss.
Ask your manager, your coach. Go on a 6 month a stent where you do a little work with them, and you follow-up on things, and you do presentations. You get coaching in that. Because at the end of the day, Tom, we're all one company. We all rely on each other. So I would encourage some of those MSLs to reach out to their role models, to reach out in the area of those those MSLs that are managed care. Work with them. Do many preceptorships.
Get your coach involved, your boss, your manager, to make sure that you get that experience because you can do it. And and I think the last thing that's most important is that you have to sharpen your presentation skills. I don't care who you are. I do it every day. I I record myself routinely every month to 2 months, Tom, and I watch myself. And I have people watch me. And I have a circle of trust, you know, people that will give me good feedback.
You cannot emphasize enough that it has to be sharped, focused, and you have to get the information you need to convince them to influence that very important customer that this drug is worth it and why it's worth it. So those are the areas you can work on even if you are not a managed care MSL.
We've had plenty of individuals, I'm thinking about 2 right now, that have been MSLs, great colleagues that have transferred and made successful transfer into, managed care MSLs, and they're doing a great job. So it all depends on what you need, what you wanted to do. Yeah. Get somebody. Find a preceptor. Find that colleague, that mentor. That's the most important thing.
Yeah. We talk a lot about mentorship on, you know, on this this program and, but, you know, from my side, from a the recruiting standpoint, a lot of times when we're recruiting for positions, we may get the hiring manager might say, we wanna know that this person has has been able to show that they have experience in giving managed care presentations. Sure. Even as a therapeutic MSL, that may be required for certain physicians.
Absolutely. So I think at at minimum, I think it's important to be able to add that to your resume in some way, shape, or form. And what you're saying is the way to do that is to partner with your managed care MSL Absolutely. In order to get that type of experience or do a preceptorship or add to your resume by, you know, educating yourself in, you know, the health economics of things. Which is there are there other ways that they can go out and seek this?
Like, it seems to me, like, in order for you to be a managed care MSO, you really need to understand a lot. Absolutely. You need to understand a lot of business landscape. So, traditionally, what you and I in the medical area would say, well, we don't always go into that. Yeah. You go into it as a managed care MSL. So I would say the other way you can do it, Tom, very, very easily, align yourself with organizations such as AMCP Mhmm. ISBOR that's out there. Go to the meetings.
Get permission from your your coach to go to those meetings for professional development. That goes a long way in introducing you into the environment. You get to hear, what's important to health plans. You get to hear what's important to the government. Go to those meetings. Seek them out. So it is incumbent on you to be a self starter as a managed care MSL. You gotta seek it out. You know, there was a day where we didn't have any managed care MSLs.
We had to forge the way, and part of forging that way is working closely with customers, going to the means they go to, finding out what's important to them, going to a Sembia, which is a huge wonderful meeting in, you know, in the spring in Las Vegas where you have all the movers and shakers of the industry there. You get to learn what's important to them, and you learn about your customers. So you can do it even without a mentor, but you have to have the drive, Tom.
Yep. And you have that ability to be a self starter. That's what's important. You gotta raise your hand. You know, if you if this is something you really wanna do, you you know, no one's gonna just bring it to you. You have to raise your hand. You have to ask for the like you said, you have to kinda sign up for other You you really do, Tom. You know, I'm pretty good as a coach after 30 something years, but I can't read minds yet. Okay?
So when I do coaching sessions, I ask people and I know it's kind of a somebody will say it's an insulting question, but I think it's an informative question. I go, what do you wanna be when you grow up? Because there's so many people say, you know, Todd, I really wanna do this, and here's what I've done so far. And can you help me? You can you'd be surprised how one question can help identify those individuals that have high potential. So you yeah. You you can't shut your mouth.
No one's gonna toot your horn but you. And You gotta get out there and talk to people in the industry. You gotta talk to people in your company and say, I wanna do this, and I think I'm I'm valuable, and here's why. Here's what I need. You know, you gotta be out there doing it, Tom. We all have to do that, but especially for payer or MSL. You gotta be out there and raise your hand. It's great advice. And it's funny you asked, what do you wanna be when you I always wanted to be a talk show host.
Go figure. Well, you're doing a great job so far, Tom. Are you? So listen. As we wrap up, I you know, let's take a step back a second because, you know, you have 20 plus years of medical affairs leadership experience. You've been responsible for teams as large as 40 people. I don't wanna end this podcast without asking you what advice you might be able to give to MSLs right now. You know, therapeutic MSLs. We talked a lot about managed care MSLs.
But what advice do you have for therapeutic MSLs right now as we're getting through this COVID environment and people are looking to really make an impact, hit their numbers, be top performers, as we move into the second you know, well, you know, what's now gonna become the second part of 2021? Sure. I think the one thing that's kept me going and and a lot of my colleagues I talk with all the time is you gotta maintain relationships.
You do whatever you have to do to maintain these relationships. I don't care if it's this, Zoom Yeah. Or whatever other proprietary source, if it's if it's email, if it's sending journal articles, or or at least the the connection for the reprints, you know, to to your top KOLs is, hey. I saw this interesting. I went to a virtual meeting last week. Whatever you have to do, Tom, to maintain the relationship is what it's all about. And I I don't think it's just in payer MSL world.
I think that's in therapeutic MSL world because it's all about timing, and it's all about the relationship no matter who you are. And I can tell you over this last 20, 30 years, MSLs have only become more important to pharmaceutical firms. And I think where we need to improve, all of us, all of us MSLs in here, is to think what's possible, think out of the box. Who would have thought 20 years ago, Tom, we could have MSLs working in an area for a company that did diagnostic testing?
Yeah. Nobody would have thought that. You don't have any drugs. So what? It's still looked at as a commodity. It's still looked at as a value proposition in in in the managed care environment or even in the therapeutic environment. You know? And so you have to think out of the box. So I would take this time if you have some downtime. Make sure you maintain your relationships, but start thinking more out of the box. Naturally, what's gonna stimulate and keep our industry going.
You know, I I just think therapeutic MSLs are never gonna go away. They're only gonna get more important. I don't think payer MSLs are ever gonna go away. I think they're only gonna get more important. But I think the the more important we are, we have to make sure we're collaborative with everybody. So it's not just customer relationships you gotta maintain. You gotta maintain your internal relationships with all your commercial colleagues.
They're your best source of what's going on in the out you know, what's going on the out the landscape. And more importantly, they they're your best supporters. So make sure you keep those internal relationships going as well. I'm in agreement. Relationships are key. Totally, totally in agreement. And I appreciate this relationship. You're I appreciate it as well. You're the best, man. I I can't thank you enough for coming on. This was really insightful. I learned a lot.
I'm sure a lot of people did. So thanks for taking time. You're gonna have to come back. We're gonna have to have part 2. I I'd love to. I I I just think it's so important. Thanks for identifying this issue and bringing this out because, if people like you don't bring this out, we can't talk about it. We can't get that dialogue going. So thank you as well. Awesome, man. Well, thanks again. We'll talk soon. Have a great rest of your day. Okay. Bye bye. Thank you so much for listening to the show.
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