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Post by nylefty on Jun 14, 2019 23:22:57 GMT -5
Are there any other medical clinics that sell drugs directly to their patients? I can't think of any. Since it would be lucrative for a clinic to sell directly to patients, I have to believe that some rule or regulation that prohibits it. My understanding is that the CVS Health umbrella has both pharmacies and clinics, so I assume they do. Kaiser also has both clinics and pharmacies, but I doubt that Vdex has the capital to open its own pharmacies anytime soon. It can't sell drugs directly to patients if it doesn't have pharmacy licences in the states where it operates, but it could strike a deal with a mail order pharmacy like Eagle. |
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Post by ktim on Jun 14, 2019 23:46:30 GMT -5
I believe you are correct that the pharmacies are part of the for-profit kaiser provider system rather than the non-profit entity. |
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Post by longliner on Jun 15, 2019 0:34:30 GMT -5
Mannkind had a window for grass roots growth such as Vdex can offer.
Vdex has done a fantastic service to both diabetics and Mannkind share holders.
Mannkind management needs to focus on expontial growth that only a BP can offer due to patent life.
Ideally BP will see the value Vdex brings and use their clinics in their forward growth model. JMHO
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Post by matt on Jun 15, 2019 6:58:12 GMT -5
Clinics selling drugs directly to patients is not a problem at all. Historically, most physicians would stock medicines and give them directly to the patient as part of the office visit. That only ended because the breadth of drugs available to prescribe exploded in the 1960's and 1970's which meant that physicians had to stock too many medications and that is when retail pharmacies really started to grow, but the practice has never gone away. ExpressScripts got started not by doing mail order drugs, but by repackaging bulk drugs (which come in containers of up to 5,000 pills) into small bottles containing 30 pills and then selling those smaller containers to physician offices. My wife had a practice in a rural area outside Chicago where the closest pharmacy was a 15 mile drive so she used to stock the ten or so most commonly prescribed drugs for short-term used (antibiotics for example) and patients could either pay her or else she would write them a script to fill elsewhere. About half of the patients appreciated the convenience and filled on the spot. Dispensing to your own patients does not require a pharmacy license; if you have a license to prescribe then you have a license to dispense.
The challenge with a VDEX/MNKD partnership is the difficulty of forming a binding contract that is equally restrictive. VDEX may want exclusivity in that MNKD will not support a competitor with the same business model, but VDEX cannot promise that they will only prescribe Afrezza insulin because the physicians working in the clinics are legally obligated to act in the best interest of the patient and Afrezza is simply not always the best drug for every patient. Even if VDEX and MNKD signed such a contract, it would likely be legally unenforceable as contrary to public policy. If money also changes hands, such as with cross-investment, that is an invitation to an unwanted OIG or state attorney general's investigation.
There is also an issue with "tying" prohibitions under federal anti-trust law where a party uses a patented product to enforce purchasing of some other good or service that is not patentable. What VDEX has is a method of doing business which is easy for any licensed physician to copy and they could not use an exclusive relationship with the manufacturer of a patented drug to create more clinics without running afoul of the law. Best case, VDEX could franchise their concept and brand name to physicians that wanted to open an independent clinic. MNKD could assist that effort, just like other pharma companies often assist start-up practices to build goodwill, but there is a fine line between marketing promotion and bribery. It usually turns on the question of whether MNKD is fishing for future sales that may happen because of the goodwill generated by their actions or whether they have locked a physician into a restrictive relationship that will definitely produce future sales.
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Post by rtmd on Jun 15, 2019 7:07:22 GMT -5
I doubt the clinics sell drugs directly to the patients. The clinic doctor writes a prescription which the patient then takes to the pharmacy of their choice to get filled. The patient doesn't necessarily have to get the script filled at CVS. I'm not sure what you mean when you focus on the word 'directly'. The VDEX proposal says: "MannKind agrees that it will refrain from selling Afrezza directly to any medical provider or practice, or to any entity that also owns all or part of, or controls, or is under common control, with any medical practice in any of the “abandoned states.” It seems to me that would include CVS, Merck, and others. CVS, for instance, owns and controls medical practices in so-called abandoned states. Perhaps that is not what VDEX intends, but it seems to me how that proposal can be interpreted. Even now, Mannkind does not sell afrezza "to any medical provider or practice." They don't sell directly to "CVS, Merck, and others." They sell to distributors who, in turn, sell to pharmacies, hospitals, nursing homes, etc. VDEX's proposal doesn't make sense since the agreement still wouldn't restrict the distributors from selling to those entities. |
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Post by mnkdfann on Jun 15, 2019 9:00:58 GMT -5
I'm not sure what you mean when you focus on the word 'directly'. The VDEX proposal says: "MannKind agrees that it will refrain from selling Afrezza directly to any medical provider or practice, or to any entity that also owns all or part of, or controls, or is under common control, with any medical practice in any of the “abandoned states.”It seems to me that would include CVS, Merck, and others. CVS, for instance, owns and controls medical practices in so-called abandoned states. Perhaps that is not what VDEX intends, but it seems to me how that proposal can be interpreted. Even now, Mannkind does not sell afrezza "to any medical provider or practice." They don't sell directly to "CVS, Merck, and others." They sell to distributors who, in turn, sell to pharmacies, hospitals, nursing homes, etc. VDEX's proposal doesn't make sense since the agreement still wouldn't restrict the distributors from selling to those entities. That is something I don't know, i.e., who is / are the distributors Mannkind currently sells to. Do you know? Is there a list available to us? But, in any case, CVS Health includes CVS Caremark (the prescription benefit management subsidiary of CVS Health), and Caremark DOES deal direct with pharmaceutical companies (at least some of them). So a reading of the bold lettering suggests Mannkind could not deal directly with Caremark (and like entities) going forward. That seems to be asking a lot. But I'm not a lawyer, I may misunderstand. |
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Post by nylefty on Jun 15, 2019 9:30:17 GMT -5
Matt said: " Dispensing to your own patients does not require a pharmacy license; if you have a license to prescribe then you have a license to dispense."
Actually, the states have various restrictions or prohibitions when it comes to doctors selling prescription drugs. Here in New York State physicians are "Limited to dispensing no more than 72-hour supply except for specific circumstance." In Massachusetts "Physicians may only dispense samples." In New Jersey "Physician shall not dispense more than a 7-day supply of drugs or medicines to any patient." In Montana "Physician dispensing not allowed except in very limited circumstances." In Ohio "Payment for covered drugs limited to drugs dispensed by a registered pharmacist." www.mymatrixx.com/wp-content/uploads/2017/04/Physician-Dispensing-Limitations-as-of-March-2017.pdf |
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Post by scottmnkd on Jun 15, 2019 10:31:17 GMT -5
I've read through most of the posts and still don't see a compelling reason for an agreement. @sports I agree that we need more exposure. On the surface, everything may sound copasetic, but we don't know how well run or well funded the VDex venture would be? Exclusive rights to sell is my sticking point. Mannkind signing up with an untested business model could be disastrous. If I were VDex, I would have proposed something much less restrictive to bolster VDex - not start a new business.
The letter to shareholders and proposal took an aggressive and threatening stance trying to force the hand of Mannkind management to sign up. I would not go into business with anyone under those circumstances. If it starts out bad, it'll likely to continue in the same direction.
So, it seems to me that if VDex and Mannkind sticks to their core businesses they will naturally take care of the other. i.e. business partners without a formal agreement.
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Post by sportsrancho on Jun 15, 2019 11:00:31 GMT -5
Maybe you would want to start a list of questions..
What does well-funded mean?
How long is this going to take? What are the goals in each state?
What does the distributorship amount to?
I’m not asking these questions per say they’re just examples ...
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Post by mytakeonit on Jun 15, 2019 14:05:54 GMT -5
I don't believe that MNKD has a problem with VDEX opening clinics all over the world, but they sure shouldn't allow any exclusive rights to do so. Other clinics should also be able to prescribe and dispense Afrezza as they see fit. BTW, the VA here does prescribe and dispense drugs in house. Not sure if they are doing so with Afrezza. I'll ask next time I see my VA doc.
But, that's mytakeonit
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Post by rtmd on Jun 15, 2019 14:22:31 GMT -5
Even now, Mannkind does not sell afrezza "to any medical provider or practice." They don't sell directly to "CVS, Merck, and others." They sell to distributors who, in turn, sell to pharmacies, hospitals, nursing homes, etc. VDEX's proposal doesn't make sense since the agreement still wouldn't restrict the distributors from selling to those entities. That is something I don't know, i.e., who is / are the distributors Mannkind currently sells to. Do you know? Is there a list available to us? But, in any case, CVS Health includes CVS Caremark (the prescription benefit management subsidiary of CVS Health), and Caremark DOES deal direct with pharmaceutical companies (at least some of them). So a reading of the bold lettering suggests Mannkind could not deal directly with Caremark (and like entities) going forward. That seems to be asking a lot. But I'm not a lawyer, I may misunderstand. I don't exactly know who distributes for Mannkind but the quarterly report said, "As of March 31, 2019 and December 31, 2018, the Company had three wholesale distributors representing approximately 99% and 89% of gross accounts receivable, respectively." The big three are McKesson, AmerisourceBergen, and Cardinal Health and I imagine those are the ones referred to. Like I said, I know of no pharmaceutical company that sells their product directly through a medical clinic. The patient can get samples at the clinic but to purchase the product they must get a prescription which they take to a pharmacy. |
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Post by robbmo on Jun 15, 2019 17:42:43 GMT -5
That is something I don't know, i.e., who is / are the distributors Mannkind currently sells to. Do you know? Is there a list available to us? But, in any case, CVS Health includes CVS Caremark (the prescription benefit management subsidiary of CVS Health), and Caremark DOES deal direct with pharmaceutical companies (at least some of them). So a reading of the bold lettering suggests Mannkind could not deal directly with Caremark (and like entities) going forward. That seems to be asking a lot. But I'm not a lawyer, I may misunderstand. I don't exactly know who distributes for Mannkind but the quarterly report said, "As of March 31, 2019 and December 31, 2018, the Company had three wholesale distributors representing approximately 99% and 89% of gross accounts receivable, respectively." The big three are McKesson, AmerisourceBergen, and Cardinal Health and I imagine those are the ones referred to. Like I said, I know of no pharmaceutical company that sells their product directly through a medical clinic. The patient can get samples at the clinic but to purchase the product they must get a prescription which they take to a pharmacy. The agreement states that Mannkind may not sell to any entitiy that has any ownership/control of any medical practice in any of the "abandoned states." So, they would not be able to sell to any distributor that has any ownership/control of any medical practice in any of the abandoned states. I believe this would preclude sales to most any major distributor as everyone has their finger in everything nowadays. |
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Post by mnkdfann on Jun 15, 2019 17:47:45 GMT -5
The agreement states that Mannkind may not sell to any entitiy that has any ownership/control of any medical practice in any of the "abandoned states." So, they would not be able to sell to any distributor that has any ownership/control of any medical practice in any of the abandoned states. I believe this would preclude sales to most any major distributor as everyone has their finger in everything nowadays. Thanks, that is essentially the point I keep trying (perhaps poorly) to make. |
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Post by robbmo on Jun 15, 2019 17:52:37 GMT -5
The agreement states that Mannkind may not sell to any entitiy that has any ownership/control of any medical practice in any of the "abandoned states." So, they would not be able to sell to any distributor that has any ownership/control of any medical practice in any of the abandoned states. I believe this would preclude sales to most any major distributor as everyone has their finger in everything nowadays. Thanks, that is essentially the point I keep trying (perhaps poorly) to make. Lol, thanks. :-) Here are my other thoughts if you are interested: mnkd.proboards.com/post/181012/thread |
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Post by mnkdfann on Jun 15, 2019 18:12:35 GMT -5
Thanks, I saw that. I made your point about taking over distribution in more than just abandoned states myself yesterday. Great minds think alike. Lol.  |
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