In the Pharmacy

As pharmacists’ roles expand to near provider status, new opportunities for partnerships open up for pharma.

Over the years, pharmacists’ duties have been expanding, but recent legislative acts and regulations are providing the stimulus for an even more robust role. Pharmacists are becoming full partners of healthcare teams as a result of the Affordable Care Act, the HITECH Act, and state regulations that allow them to perform as part of a patient’s healthcare team. CMS’s Medicare Part D Star Ratings program is also compelling pharmacists to engage more with patients in order to be recognized as a high-quality pharmacy that can increase patient compliance and reduce costs for payers.

As pharmacists move toward providing more medication management, vaccinations, counseling, and patient education, this presents the opportunity for pharma to partner with a new set of white coats who are becoming increasingly important in patient care.

According to a Strategy& report, pharmacies embracing this new role will represent an important potential ally to pharmaceutical companies. As pharmacy chains deploy compliance programs and more complex disease management protocols, pharmaceutical companies stand to gain a great deal from improved adherence, as well as diagnostic services provided at the pharmacy. For example, there are more than 6 million undiagnosed diabetics in the United States, and pharmaceutical companies have launched massive efforts to promote testing, Strategy& reports. Pharmacies could aid both parties, gaining valuable clients and helping patients avoid complications as a result of early detection. Pharmacies and retail clinics will likely become essential alternatives for making specialty drugs part of a broader disease management effort, the report predicts, and both CVS and Walgreens are moving in this direction.

Due to the growing functions of counseling and medication management, there are more healthcare discussions happening at the pharmacy today that used to occur at the physician’s office, or not at all.

“The role of pharmacists in healthcare has been increasing year over year because of several reasons," says Christopher Dowd, executive VP, market and product development at PSKW. “One reason is the site of care is shifting from the doctors’ offices to other places, including clinics located in the pharmacies, such as CVS Minute Clinics and Kroger’s Little Clinics."

This provides a new channel for pharma to provide consumers with education, information, and adherence tools.

“In the new healthcare environment, the role of the pharmacist is expanding, taking on an even greater role as trusted patient advisor and consultant," says Harry Musumeci, VP, retail business development, Adheris Health. “They are being called upon to counsel not only on prescription medications dispensed by them, but also on immunizations, health screenings, chronic disease management, medication therapy management and more."

Mr. Musumeci believes that pharma manufacturers can help pharmacists in their burgeoning role by providing patient education materials on their brands directly to pharmacists that help them engage in more productive patient dialogues and by creating more personalized patient medication educational materials that can be delivered to patients by pharmacists and pharmacy staff at the point of dispensing.

Pharma as a Pharmacist Ally

Pharma has been providing educational and branded material to pharmacists for decades, but now the emphasis is on providing material and support that the pharmacist can pass along to patient customers at the pharmacy counter. Through digital programs, couponing, and compliance tools, the industry can help bring more tools to the pharmacists’ fingertips to aid in providing better care for their customers.

For example, for the past 30 years, AmerisourceBergen has supported independent pharmacies with its Good Neighbor Pharmacy program, which provides continuing education, disease state training, regulatory guidance, business development courses, and marketing tools. Good Neighbor Pharmacy, which is AmerisourceBergen’s solution to help independent community pharmacies compete with larger retail chain pharmacies, is always looking for ways to stay ahead of the curve and help pharmacists adapt quickly to changes to optimize the quality of patient care.

According to Scott Robinson, VP of Good Neighbor Pharmacy, there are more than 3,100 owner operated Good Neighbor Pharmacy locations across the United States.

“We focus on providing them marketing tools, online websites customized with their store name and location, as well as social media tools and refill mobile apps for customers," he says.

Working through Good Neighbor Pharmacy, pharmaceutical companies sponsor or provide some of this education and training.

Besides training and digital tools, many pharma companies are supporting financial patient assistance programs or PAPs. It is important to get pharmacists onboard with using the PAP as well as to create a process that is easy for them to administer, as they are front and center of the first financial conversation the patient will have about their prescribed treatment.

“The pharmacist really has to handle the financial conversation more than anyone else because the physician doesn’t talk about the cost of drug, the nurse and healthcare staff don’t talk about it, and the insurance companies certainly don’t talk about it, so it comes to the pharmacist counter," Mr. Dowd says.

“Pharmacists will be able to tell by the patient reaction if the treatment is too expensive and they are about to walk away from it," he says. “Therefore, when the pharmacist identifies a financial barrier, the ability to readily access financial programs at the point of patient care will enhance patient compliance."

While physicians, patients, and pharmacies often cite co-pay assistance programs as a positive tool to assist with the affordability of a patient’s medications, others may not endorse these programs as they may alter access to drug products that are not preferred on the patients’ drug formularies, says Andy Szczotka, VP of clinical services, Emdeon.

“While there may be varied opinions about pharma supported financial assistance programs, data show that use of co-pay assistance programs improves patient adherence to drug therapy," he says.

Additionally, when the co-pay assistance programs are embedded into the pharmacy workflow and enable the pharmacist to interact with the patient who has been properly identified for these programs, data have shown these patients refill their prescriptions more frequently — up to two to three more prescription refills per year — and stay on therapy longer than patients who are not offered these programs, he adds.

“The solution is to empower pharmacists at the point of care to apply these co-pay assistance programs to patients that would most likely benefit to improve patient outcome by aligning the right patient, with the right coupon offer, at the right time," Mr. Szczotka says. “In this manner, real-time, point-of-care pharmacist empowerment for appropriate co-pay coupon use would minimize the current barrier."

Another significant element of the expanding role of the pharmacists is counseling patients on any questions or issues they are having with their medication. This may be the most difficult duty to fulfill, however, as in a large pharmacy, the pharmacist has 200 to 400 prescriptions a day to fill as well, Mr. Dowd says. “The challenge with this additional responsibility is how can the pharmacist counsel and also keep his or her productivity high. This is a big barrier because pharmacists are torn between wanting to be a part of the healthcare discussion and servicing the patient and getting all the prescriptions filled each day."

Despite the time challenge, large chain pharmacies are implementing programs that focus on patients with chronic conditions. For example, CVS has developed the CVS Pharmacy Advisor program, where pharmacists reach out directly to member patients with certain chronic conditions who haven’t been taking their medication.

According to a CVS release, the program helps CVS/Caremark plan members with chronic conditions achieve better health outcomes by promoting improved medication adherence and closing gaps in care. Through the program, CVS Health engages members who are diagnosed with chronic conditions face-to-face when they choose to fill prescriptions at CVS/pharmacy or by phone when members choose mail service pharmacy, allowing them to intervene directly with patients and communicate with their physicians in real time. In addition to improving medication adherence, the program also directs members with chronic conditions to existing disease management programs where they can obtain additional support.

Research published in Health Affairs about the Pharmacy Advisor program for diabetes showed that contacts by pharmacists with patients and their doctors increased both patient medication adherence rates and physician initiation of prescriptions, thereby improving care for diabetes patients and resulting in savings for payers.

In the world of acquiring and retaining patients, this type of intervention becomes vitally important, says Rob Blazek, RPh, VP of Network Strategies at Leverage Point Media —Rx EDGE, and a registered pharmacist.

“We need to create pharmacists who are better educators, better communicators, and better equipped to talk to patients," he says. “This is currently not happening enough."

The challenge — and the opportunity — lies in how well the pharmacy company intersects its brand communications with patient needs. To successfully facilitate these types of disease management programs, companies need to provide unbranded tools and focus on the broader educational value of disease management.

“Pharma companies tend to be more focused on a specific condition or brand and for the major retail pharmacy entities, a holistic approach involving education, one-on-one contact, and behavior modification advice is preferred," Mr. Blazek says.

Pharma companies can also consider sponsoring commercially available programs that enable the pharmacist to communicate directly to both current and potential patients.

“In my view, the most significant action pharma can take is to develop tools that help pharmacists have conversations with patients," he says. “As pharmacists become increasingly viewed as true healthcare providers, they will need not only information about a brand but also information about how to conduct an ‘office visit’ and how to interview patients."

To make pharmacists more effective in their patient counseling role, it is important for pharma companies to help them adopt a more personalized, customized approach to engaging with patients.

“It is important to arm pharmacists with ways to determine which patients will benefit most from counseling as well as what information will be most receptively received," Mr. Musumeci says.

Similarly, patients need help to cut through the clutter of information provided to them. The current state of patient communication is fractured, resulting in uncoordinated, redundant messages that are inefficient and less likely to drive desired behaviors.

“We need to move to a more patient-centric environment where, rather than treating everyone the same; it’s critical to understand, identify and address their unique preferences and motivators," he says. “Using behavioral insights to identify the type and frequency of communication most appropriate for different patient segments and helping the pharmacist understand and act upon those individualized patient scenarios are keys to success."

According to Dick Domann, VP of pharmacy services at TrialCard, pharma needs to seize the opportunity to initiate programs that increase adherence, reduce abandonment, and provide education at the point of sale, so the pharmacist or the pharmacy technician in charge has tools available when questions come in from patients. Another time saver for the pharmacist can be realized in the packaging of drugs they dispense, something the pharmaceutical company could be redesigning to expedite dispensing.

“One solution that pharma can begin with is to design packaging that allows the pharmacist to use his or her time to counsel effectively rather than be burdened by activities — pour, count, lick, and stick — which can be handled by today’s advanced technology," Mr. Domann says.

An article appearing in the Los Angeles Register in April of this year outlined the preliminary results of a three-year, $12 million study conducted at USC that brings pharmacists into safety-net clinics. Although the study does not include retail pharmacist interaction, so far, it seems clear that the healthcare system can benefit from pharmacists’ expanding roles. According to the news report, almost nine of 10 patients who had out-of-control blood pressure saw their readings drop below hypertension levels and remain there within 45 days of working with the pharmacy teams. Similarly, diabetes patients whose blood sugar levels had been too high were twice as likely to have them under control within six months if they worked with a pharmacist team. In the program’s first 11 months, pharmacists corrected 19,696 medication problems among 1,993 patients, an astonishing 9.9 medication problems per patient. Study coordinators project a 25% decrease in hospitalizations for the estimated 6,000 patients in the project.

Reports like these illustrate how partnerships and tools that encourage and assist the pharmacist with engaging patients in their chosen treatment regimen benefits all parties and results in improved health outcomes.

“One of the most common healthcare interactions is the interaction between the pharmacist and the patient," Mr. Szczotka says. “Often overlooked, the pharmacist plays a vital role in the delivery of healthcare to the patient. As the pharmacy profession continues to evolve to a more direct patient care function and role, pharma can support retail pharmacies through the provision of programs that directly assist in ensuring improved patient care and outcomes."

Fast Fact – Every $1 invested in clinical pharmacy services can save about $10 in healthcare spending, as patients better understand how to manage their illnesses and avoid further or more expensive treatment. Source: U.S. Public Health Service

“The excitement in the pharmacy field centers on providing a different level of care and increasing patient adherence through in-store programs."
Scott Robinson / Good Neighbor Pharmacy

“In the new healthcare environment, the role of the pharmacist is expanding, taking on an even greater role as trusted patient advisor and consultant."
Harry Musumeci / Adheris Health

“Pharma needs to seize the opportunity to initiate programs that increase adherence, reduce abandonment, and provide education at the point of sale."
Dick Domann / TrialCard

“The role of pharmacists in healthcare has been increasing year over year, providing a new channel for pharma to provide consumers with education, information, and adherence tools."
Chris Dowd / PSKW

“We need pharmacists who are better educators, better communicators, and better equipped to talk to patients."
Rob Blazek, RPh / Leverage Point Media — Rx EDGE

“Pharmacists need tools at the point of care to apply co-pay assistance programs to patient prescriptions."
Andy Szczotka / Emdeon

Pharmacists’ Role Depends on State Regulations

Flu shots and vaccinations: Pharmacists in all 50 states are allowed to administer flu shots to adults, however, regulations differ as to what kind of training is required, whether children can be vaccinated and whether residents need a prescription or referral from their physicians.

According to CDC, in 1999, only 22 states allowed pharmacists to immunize adults against the flu. As of 2007, the number had risen to 46 states and as of June 2009, after the H1N1 flu outbreak, all 50 states allowed pharmacists to administer flu shots to adults.

According to American Pharmacists Association, during the 2010–2011 flu season, about 20 million flu shots were administered at pharmacies. According to a recent TIME Healthland report, some states are pushing for legislation that lowers the age at which children can receive flu and other childhood diseases vaccinations at retail centers. For instance, in Indiana, a new state law allows pharmacists to administer vaccines to kids over the age of 11 without a prescription. Pennsylvania legislators are considering a change that would allow pharmacists to administer vaccines to children 7 and older, instead of 18 and older.

Drug management: 47 states and the District of Columbia allow pharmacists to interact with physicians for collaborative drug therapy management. The extent of authority, which varies by state, may include initiating MTM, ordering and interpreting lab tests, and discontinuing or modifying drug therapy, reports the American Pharmacists Association.

Advanced Practice Pharmacist: California enacted a law in January 2014 that allows a special class of advanced practice pharmacists to enter collaborative agreements with physicians to start, change, or discontinue medications, and help manage chronic diseases.

In essence, pharmacists in California are now recognized as healthcare providers. It gives new authorities to all licensed pharmacists, establishes an Advanced Practice Pharmacist (APP) classification, and gives new authorities to APPs.

According to the American Pharmacists Association, a bill that would recognize pharmacists as healthcare providers was introduced in the House in March 2014 to amend Title XVIII of the Social Security Act to enable patient access to, and coverage for, Medicare Part B services by state-licensed pharmacists in medically underserved communities.

CMS’ Medicare Part D Star Ratings Impact Pharmacists

Medicare Advantage and Part D plans are monitored by CMS through Star Ratings, based on quality measures that encompass medication adherence and patient safety, including prescribing of appropriate therapies. Pharmacies will stand to benefit from contributing to improvement of these types of measures, because if a pharmacy can prove to Medicare that it can provide a level of service and show outcomes of great value to payers in general, other payers may take note and choose them over the competition.

According to Scott Robinson, VP of Good Neighbor Pharmacy, the ratings are the biggest initiative in 10 years to impact pharmacists.

“The star ratings initiative has really reenergized our community pharmacy customer base," Mr. Robinson says. “It is bringing the focus of the pharmacy back to keeping patients on medications. The excitement in the field centers on providing a different level of care and adherence to patients, in the form of in-store medicine synchronization programs, adherence programs, and providing medication therapy management."

Pharmacies do not receive an actual star rating, but their percentage scores — the Electronic Quality Improvement Platform for Plans & Pharmacies (EQuIPP) system tracks a pharmacy’s performance based on data from health plans or PBMs — serve as a point of comparison with other pharmacies, the general EQuIPP average, the organization average, and the state average.

“For the first time in a long time the community pharmacy group — all 30,000 plus pharmacies — has collectively realized this is an opportunity to really show their worth and their value to not only Medicare, but also ultimately to all of payers," Mr. Robinson says.

For more information regarding star ratings, visit ncahc.org or cms.gov.

October is American Pharmacists Month

The Pharmacist Connection

The pharmacist is a key stakeholder in the continuum of care, however to engage these specialists in a meaningful and efficient manner requires overcoming several key challenges.

Overcoming Barriers to Pharmacist/Patient Interactions

Reports show that programs and tools that provide support for pharmacists to engage more with each patient result in better patient outcomes, so why isn’t everyone jumping on the bandwagon? Although the outcome — better patient healthcare — is a win-win for all stakeholders involved, there are several challenges that may hinder implementation. Our experts outline a few of the challenges below.

Pharmacist Time and Reimbursement Constraints

Chris Dowd
Executive VP, Market and Product Development, PSKW

Some retailers do not participate in a lot of pharmacy initiatives because they feel they lack the time. Their priority is keeping pharmacist productivity high, so they can fill as many prescriptions as fast as possible. The combination of CVS and Walgreens makes up 40% of the entire prescription market and a big store could be filling 200 to 400 prescriptions a day. They are torn between wanting to be a part of the healthcare discussion and servicing their patients, while at the same time keeping up with prescription demand.

Scott Robinson
VP, Good Neighbor Pharmacy

These programs are happening across the country. I visit pharmacies every week in every state, but some pharmacists have taken the opportunity to move forward a lot faster than others, and that is likely because of the time and payment restraints. The biggest hurdle is getting pharmacists to change how they do business in terms of focusing more on providing programs on different disease states or more directly interacting with their patients. Another challenge is getting reimbursement for providing these patient care services. That issue has become the big elephant in the room. The industry has been talking forever about getting pharmacists paid adequately for services they provide. Pharmacists may be excited to provide these services — they all want to do more for their patients — but they want to get paid for what they provide.

I think it will be a bit more time before we see that reimbursement come to them, but we need to keep striving for it.

Regulatory Limits and Adverse Event Reporting

Rob Blazek, Rph
VP, Network Strategies, Leverage Point Media — Rx EDGE

From a general regulatory standpoint of course, any materials or resources created by pharma companies that are intended to reach healthcare professionals or patients must contain only content that is consistent with the label. The pharma company must have the clinical research to support providing certain educational elements. This may limit their ability to supply to pharmacists the full spectrum of tools that patients may need to manage their condition. These factors need to be taken into consideration in terms of how far a brand can go in terms of talking about a disease state and treatments. For example, one concern is what would trigger the need for fair balance. In addition to that, state-by-state regulations and applications also play a role. Communications that are acceptable in some states may not be in others. And a barrier to reaching the level of pharmacist-patient interaction could be the actual physical set-up in the pharmacy, for example a place for a more private conversation. This is changing, though. As pharmacies increase their function as providers of healthcare, many are also revamping their physical settings to allow for better patient communication. Another challenge is the fact that right now anyway, there is little interaction occurring between the physician and the pharmacist that would lay the groundwork for more meaningful pharmacist intervention in treatment. This dynamic is also changing. The pharmacy now clearly has an important function throughout the symptom-through-treatment continuum and is a platform for multiple connection points.

Dick Domann
VP, Pharmacy Services, TrialCard

Regulatory requirements must be factored into the decision on what type of programs can be implemented, but there is an understanding that the opportunity to increase a positive outcome at the point of sale should be added into the equation. Dispensing medications is no longer simply a cost issue. Patients have legitimate questions due to confusion caused by ACA, changes in insurance coverage, and more complicated dosing regimens in specialty products.

Also, the industry has gotten used to focusing on the price of the pill, large volume bottles. It will take an investment in time and resources to turn the tide and help make patients understand their increased new role and responsibility in the healthcare process.

Harry Musumeci
VP, Retail Business Development, Adheris Health

There is significant evidence to support the relationship between good healthcare provider-patient dialogue, increased medication adherence, and improved health outcomes. One would think all the key stakeholders would be in favor of and providing programs to encourage pharmacist-patient interaction and discussion. And, in theory they are, but it’s easier said than done. A scenario we routinely encounter is a pharma sponsor wanting to implement a retail pharmacist-patient counseling program for its brand but hindered in doing so because of adverse events (AE) reporting requirements. While most retailers are willing to report AEs and have trained their pharmacy staffs on recognizing, recording, and reporting, brand sponsors want retailers to require their pharmacists to undergo their company- or brand-specific AE training, which is just not operationally feasible.

In the perfect world, we’d have standardized reporting that would be acceptable industrywide. Most of the training modules I have seen tend to be very similar to each other so it’s feasible we may see a universally accepted approach in the not too distant future.

Pharmacist Training: Improving the Patient Dialogue

According, to Rob Blazek, VP of network strategies at Leverage Point Media — Rx EDGE, providing tools to pharmacists that not only increase but also improve the effectiveness of their interactions with patients can greatly impact patient health outcomes. For example, in today’s busy pharmacies, a conversation between the pharmacist and the patient may be too quick to determine what is best for the patient.

For example:

Ms. Pharmacist: “Mr. Jones, you’re pretty late on getting your blood pressure medication filled. Why haven’t you?"

Mr. Patient: “I forgot and I don’t think I want to refill right now, thanks."

Ms. Pharmacist: “OK." However, if the right tools and training were in place, that same conversation could go in a more productive direction.

Ms. Pharmacist: “Mr. Jones, you’re pretty late on getting your blood pressure medication filled. Why haven’t you?"

Mr. Patient: “I forgot."

Ms. Pharmacist: “How is your blood pressure by the way?"

Mr. Patient: “Well I really don’t know"

Ms. Pharmacist: “Do you monitor your blood pressure regularly and do you know what your target is?"

Mr. Patient: “I think it is supposed to be 120 over 80; let me check; I wrote it down somewhere."

Ms. Pharmacist: “We can help you take your blood pressure right here if you’d like. And I’ll get your refill prepared as well."

Or…

Ms. Pharmacist: “Mr. Jones, you’re pretty late on getting your blood pressure medication refilled. Did your doctor change your dosage amount lately because your blood pressure has come down?"

Mr. Patient: “No, I guess I just forgot. I really don’t know if it’s come down or not. I don’t feel any different anyway. I’m fine; no need to refill right now."

Ms. Pharmacist: “Well, it’s important to take blood pressure medication exactly as prescribed unless your doctor has changed something. As far as you not feeling any different, that is to be expected. Keep in mind that blood pressure medicine is for a long-term benefit and will help you be healthier and avoid future heart problems and stroke."

Mr. Patient: “All right, I guess I should go ahead with the refill then."

Ms. Pharmacist: “So let me take a look again at your prescription and we’ll get you the refill you need." In these examples, the pharmacist was able to go a bit deeper because the right information was at hand to allow her to make judgments based on her knowledge of the condition and the medications.

To be most effective, these types of interactions would occur within a face-to-face setting, in the pharmacy. This is preferable because of the opportunity to: