How to Make Express Scripts Irrelevant in One Slide
A Sex Pistols fanzine from 1976
Note: This content was originally published on Fresh Paint on July 25; it’s been updated here to integrate the news breaking yesterday that Cigna Group’s Express Scripts sued the US Federal Trade Commission for "defamation", claiming its report demonizes pharmacy benefit managers and asked the court to order the agency to retract it.
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Punk Rock Vision Required
Takeaway: "Anger is an energy", wrote John Lydon (Johnny Rotten), lead singer of the Sex Pistols, in his autobiography, and it's this energy, not the analytics, that needs to get channeled into new strategy stories.
A spokesman for the Pharmaceutical Care Management Association said this to the Wall Street Journal in its coverage of the House Oversight Committee hearing on Big PBMs:
"Too many recent conversations addressing drug costs narrowly focus on PBMs and reflect a one-sided view informed directly by the pharmaceutical industry's blame game. The committee is missing the big picture."
Which is true.
If the committee was really looking at the big picture, it would unpack the interaction between Big PBM and Big EBC (employee benefit consulting), two sectors operating as a 'system of markets', each fueling and feeding the other as a massive feedback loop, sustaining an orbit of "value" that is positioned to customers -- and to the country as a whole -- as "bringing down the cost of prescription medicines to millions of Americans" (quoting the second sentence of CVS Caremark's response letter last week to James Comer, Chairman of the House Committee on Oversight and Accountability, who has accused the leaders of the three largest pharmacy benefit managers of making fraudulent statements during his hearing in July).
And if we're still trying to frame the Big Picture, we (who the "we" is in this story also needs unpacking) would see that "cost" of prescription medicines isn't The Problem in the American Way of Healthcare. The Problem is constructing industrial policy positioned on 'the production of affordable health' as form of market innovation, a new system value where the objective on the roadmap is better EBITDA from the $5 trillion the United States spends ("invests"?) every year on healthcare, a number so large that it's lost all impact as a data point.
But the PCMA’s framing is itself misinformed because it’s 'foundational model' is premised on a zero-sum view of competition in a non-zero-sum game. The jumping-off point is illogical.
Healthcare is an N-sided market: never about just one business or market, but many businesses or markets. Some of them even try to work together to align value across time, space and scale.
But most do not.
Operating with a fragmentary worldview and lacking fluency in systems thinking, we lack the larger vocabulary, and hence the larger capacity, to see and sell better and bigger strategy stories. Which has led the American Way of Healthcare to this point: a $5 trillion economic system at war with itself, stuck in the conceptual past, breeding and feeding inequality, crisis, divisiveness.
So the "narrow conversations" the PCMA spokesperson is alluding to are the ones that recycle themselves in an infinite discursive loop. The same assemblage of words are sustaining structural stalemate for generations. This despite all the expert knowledge and technical potential that $5 trillion/year can buy. David Joyner, Executive Vice President, CVS Health, acknowledged as much last month. With the headline Same Story + New Anecdotes = Old News, he posted this on LinkedIn following the release of the Federal Trade Commission’s report:
"PBMs are part of a complex industry. We do not set the price of a drug. We do not prescribe medicine. But we do have a role in managing the use and distribution of medicine, and the care of people who take medicine. It’s an important role and we’re proud of the work we do. Unfortunately, that is not the story we see about PBMs today or nearly 20 years ago.”
Which is also true.
And also foundationally incorrect.
Reality is hard to know, because of all the hired bullshit, but even without being sure of the validity of the volumes of data from Big PBM, it seems entirely reasonable to think that every now and then, the energy of a whole era comes to a head in a long line flash.
Markets aren't about “efficiency”. They're about power and control.
And what’s been revealed by the latest news hurricane around the Big PBM business model is this throughline: The ability to process the economics of healthcare in the United States is the ability to manage the engine behind the world's largest economy. The big picture everyone involved (and we are all involved) should see is that real innovation in healthcare has almost nothing to do with the humanity-saving potential of all things digital, especially if it's pointed at the past. (For more on this point, listen to the Blue Spoon audio cast Big PBMs and Big Market Power: Who Really Controls the Practice of Medicine in the United States?)
Solving the mad riddle of how to "fix" healthcare anywhere in the world starts by making a narrative turn, using different words to power a Big Strategic Rotation. The goal is to shift the center-of-gravity for competition and creativity.
And that roadmap begins and ends differently, with an intentional reorganization of markets into new economic systems (“ecosystems”), which are then managed as a single organism.
"Anger is an energy", wrote John Lydon (Johnny Rotten), lead singer of the Sex Pistols, in his autobiography, and it's this energy, not the analytics, that needs to get harnessed and channeled in a different direction. When it comes to ‘market access innovation’: “A Punk Rock ethos breaks from the herd of independent minds passing as disruptive. It's about a shift in how to think, not in what to think. It's about using new words to think new thoughts.”
The mind-stretch looks roughly like this:
Broad-Framing is Technique
This content is based on a new technique for big market innovation pioneered by Blue Spoon. Born from fluency in systems thinking, it reflects decades of experience and thought leadership working across pharmaceutical, retail pharmacy, provider, payer and health technology markets.
The central insight behind broad-framing is this:
For the most part, we’re either asking the wrong questions, or our questions are based on the wrong framework.
Strategy at a system level is a rich vein to mine for originality, a unique ‘large language model’ in its own right that can work out new problems and propose new solutions….in one slide.
Our growing portfolio of use cases is available on the Blue Spoon Downloads page.
/ jgs
John G. Singer is Executive Director of Blue Spoon, the global leader in positioning strategy at a system level. For a mind-stretch: john@bluespoonconsulting.com