Fighting for a Seat at the Health Care Table


The keynote address for the fall 2022 Total Pharmacy Solutions Summit looks at where independent pharmacy is and what needs to be done

Kevin Walker, PharmD, RPh, Chief Strategy Officer, RPhAlly, opened the October 22, 2022, Total Pharmacy Solutions with a keynote address that took stock of where independent pharmacy is and what's ahead. Walked noted how often independent pharmacy is left out, citing a $59 million grant in California that community pharmacists were left out of and had to fight to be included. Some positives are also out there, with a move in Idaho from using a pharmacy benefit manager for state employees to a program that preferred independent pharmacies and saved the state money.

Addressing what independent pharmacy brings to the table, Walker said, "Sometimes we are pushed away from community pharmacy, because of thoughts of it not being clinical. But I'm here to admit and to tell you that I truly feel that patient care and clinical care happens in these locations. It doesn't only happen there, but I feel like it is the most impactful location for it to occur. Prevention is everything. Having a holistic partner in your care is everything. Having someone that has time for you is everything. And that's what we're providing."

William Mulderry: Hello and welcome to today's Total Pharmacy Solution Summit. Today's theme, “Extending Care, Expanding Revenue” captures the general intent of today's content. My name is Bill Mulderry. I'm a publisher of Drug Topics magazine and the Total Pharmacy website which is hosting today's meetings. Community pharmacists played such an integral role in making the adjustments to provide care during the pandemic and have taken on an expanded presence. Today's sessions aim to educate and inspire ways to expand the strategies and services offered to make your pharmacies more successful.

A few housekeeping items to help you navigate today's meeting platform. For submitting questions and expanding your video screen, click on the ‘Ask a Question’ button to submit questions. You can type your questions right into that environment and then make sure you hit submit before you leave that environment because that will actually put it into our dashboards. We'll get to as many questions today as we can.

For each session, I'll be introducing the speaker and I'll give you an idea of the Q&A setup for that particular session. I'll be curating the questions, so we'll get to as many as we can. We'll follow up with all questions post-meeting, if we don't get to them live during the session. I think that's all of the housekeeping issues. We can work to get into today's first session.

I'd also like to acknowledge our sponsors: Prescryptive who will be providing a session with Paige Clark; Liberty Software, who's supporting today's sessions; Advasur, who is also a sponsor; and PRS. We thank them very much for their support of today's content and distributing today's content. We've got a really good group on the line.

With that, let me introduce the first topic area and that would be Kevin Walker. Dr. Kevin Walker is going to give this morning's keynote presentation. He's a PharmD and the Chief Strategy Officer of RPhAlly. He feels blessed to be a pharmacist. He specialized in pharmacy care setting diversity, from the hospital to the health tech world and from the independent pharmacy to Native health outreach. One constant with Kevin has been his passion to elevate patient care through the melding of clinical and business expertise, genuine relationship building, and technology. At RPhAlly, Dr. Walker works each day to support the profession he loves and bring awareness to the immense current and future value of pharmacists and pharmacy technicians to every facet of health care. With that, I'd like to turn it over to Dr. Walker for this morning's keynote. Thanks, Kevin.

Kevin Walker: Thanks so much for that Bill, really appreciate it. Good morning, everyone. It's an absolute honor to be speaking with you. I'm really grateful to Drug Topics® and the sponsors. The entire team is doing a ton of work behind the scenes and lots of things for our profession, very grateful there.

It is really wonderful to see all your cheery faces early in the day. I'm over on the West Coast. I actually can't see anyone. So right now, you guys could literally be in your Mickey Mouse pajamas. I don't blame you. I'm still over here thinking maybe I should have worn a suit, but when I woke up that wasn't true. I was just thinking ‘how much water can I put on my face?’ and ‘can my eyes look a little less puffy in the morning?’ but regardless, I'm glad you're here. I'm really thankful to be a pharmacist.

So let's jump into a really important question right off the bat. Why'd you register? Why did you join this morning? More importantly, who did you ultimately join this summit for? I'll give you a few seconds to think about it. If you can, you can type it in the chat if you feel comfortable.

It is highly likely you aren't here for me. I take zero offense to that. I just pray this morning that something that comes from my mouth will resonate with you. Maybe it's going to be this: you aren't here for me. I do believe each of you are here for your family, your team, your patients, and your community, the people you guys all care about the most. You guys are all out there, just like I am, trying to find ways to continue serving each of them. It is not easy, but you keep pushing.

Let's talk about some of the things we're pushing against. Just recently, I was made aware of a $59 million grant funding for test-to-treat facilities in the state of California. Guess who was left on the sidelines, guess who had to ask and apply to be invited to the game? Community pharmacies. CPT codes came out this year, titled remote therapeutic monitoring, and currently focused on musculoskeletal and respiratory conditions. They should have just called it ‘one of the things pharmacists are best at,’ but we're talking about CMS. Once again, guess who is left out, needed to go through loopholes to be able to bill for it and even to participate? That's community pharmacy.

I went to the federal website to see all the available test-and-treat locations in my area, if it's been highly touted as location to go, if you want to find out where you can go to get help with COVID-19. I live just north of the second largest city in the state of Washington. I gave a 200-mile radius and the results were absolutely laughable. In the area closest to me when I was looking for a pharmacy to go to, it was a Walgreen’s over 2 hours away. All of you in this audience, I can guarantee you if I need service that I'm not going there. You can also guarantee that all of my pharmacy owner contacts have looked into it, just like all of you. They want to do what's best for their community. But the reimbursements were terrible and the risks being absorbed, along with the lack of lab integration, outweighed all of the benefits for them.

I received a screenshot just yesterday from a pharmacist filling a prescription, once again for a loss. It immediately brought back memories of me and my little pharmacy in Washington eating those exact same costs and thinking ‘how is this serving patients?’ How is this making your community better by putting us under the strain? But these are things you all know and you live with every day.

Let's get on to something a little bit different because I don't want you to depressed and defeated this morning. I want you motivated and honestly a little fiery. We're being left out blatantly and strategically. Our patients are being misled and deprived of services that our pharmacy teams are offering and services they will not get from anyone else in health care.

So, a little more lighthearted here, with professional football, I'm a Seahawks fan. Regardless of what you think about those Seahawks, when I think about things that really just light me up, get me a little hot under the collar, talk to me about devaluing pharmacy or the Hawks being at the goal line and throwing an interception to lose the Super Bowl against the Patriots. Honestly, since you guys are all here and I have a relatively captive audience, I still feel the pain deep in my heart from that loss. It is a very real pain for me and I got to get it off my chest at least once a year. So, thank you so much for allowing me a little bit of catharsis here, but back to us.

Before we clench our fists and shake our heads, which is completely understandable, let's talk about how ridiculous these barriers really are and how we have hurdled them over and over again. Think about your own locations for a moment and think about 2 specific things that were thrown at you that you had to overcome. Once again, just to get you a little bit involved, get the blood flowing a little bit this morning, actually think about it with me. If you're comfortable, share that one in the chat too.

Study after study shows that utilization of pharmacists in chronic disease management shows, even when accumulated in several different scenarios, results in improved speed and likelihood of reaching goals for patients. Yet, we still see these studies being conducted and we still see limitations held over our profession that has displayed incredible innovation, adaptability, and a willingness to serve, even in the face of crisis.

I know we might not want to, but let's go back to spring of 2020 for just a few moments. You can close your eyes with me and you can think about that time, what was happening. Let's lay it out. Everything is shutting down. People are panicking. Toilet paper has disappeared from the face of the earth. I'm hoping I get at least like 1 or 2 smirks or courtesy laughs even though I can't see your faces. I'm hoping it's there, but back to the pandemic. Who remained open and took on the full weight of outpatient care? Pharmacy did. Who had to help triage when hospitals were being overrun? Pharmacies did. Who did patients lean on to provide stability in health care and guidance during societal turmoil? Once again, that's us, that's pharmacies. Now let's flip that over. Who had to fight to be utilized as vaccine centers because they didn't think we'd be efficient enough? Who had to once again fight to be infusion centers, because they didn't think we had the capabilities? Even today, who has to fight to be oral treatment centers?

I laugh, not because it's funny, but because it's painful. It's painful as a professional that values each and every one of you and what you're bringing to your communities, and then seeing what the outside industry leaders are doing to those same communities. Overcoming obstacles and barriers to serve has become part of our identity. We're gritty. We’re willing to pivot and to discover things, do new things, and always focused on what our community uniquely needs. One pharmacy and another pharmacy, they're not mirrors of each other. That's not true in some large-scale settings, because that's what they are. They're just one carbon copy after the next and you wonder why the satisfaction levels are so low there. It's because we uniquely cater to the needs of those folks that we serve. But we have to fight for everything. We have to market everything. We have to prove everything and that is often multiple times.

Let's think about this. When we have worked together, we're absolutely amazing at all 3 of those things I mentioned. Here's some quick examples. Our profession coming together can include some things that are already being covered by individual employers looking at pharmacists as a solution. Everything we provided during the pandemic is part of that provider recognition in several states and growing is a big part of that. Pricing gag order removals, as part of that state changes, we're seeing the PBMs and hopefully someday exciting news from the FTC of what they're trying to do inside of the space. I'm not personally holding my breath, but I do want to switch over to 1 opportunity that I'm going to highlight that I think shows a lot of gumption. This is why I'm going to highlight it. Because I believe that when we get knocked down and then we get back up with a mission in our eyes. I think it's captivating, not just captivating to our peers, but to all of those that we're providing mentorship to, to the next generation of pharmacy. It's all the individuals that are on our team that we're caring for and to our community, recognizing that those guys don't give up and they find a way to make things work because they're bright and brilliant human beings.

There's a team in Idaho looking to push a vertically integrated PBM out of the state employee health plan and substitute it with a transparent pricing proposal that directly favors independent pharmacies through preferred decreased co-pays and leverages them as true health hubs. There's a level of integration of care that I've heard from one payor after the next that needs to be brought all together.

In Idaho, this will likely save the state around $10 million for their 130,000 covered lives. Not a huge number of individuals, but enough to definitely make a dent. We all know the quality of service will be improved astronomically by pushing folks over toward independent pharmacies. When have we heard that last? Pushing over to independent pharmacies? It's something that never happens. These are the kind of moments in revenue generation that we have to be able to cultivate, to get behind, to unite with, in order to have employers recognize ‘where are their employees getting the best service?’ and where are they actually finding abilities to reduce overall health care spending and costs.

In these cases, we're not only serving our patients and communities. I've been told by several pharmacy owner colleagues, that we're also serving our profession, because, let's be honest, we're in a really tough spot for a lot of individuals. We went through a very difficult spot outside of our profession. Knowing that there is an option for all those that are burned out and that it's available by working in independent pharmacies is something special.

Everyone has been wrong for years. I'll admit that's me included. Because I think one thing that happens in training in academia, nothing against our colleagues there, but sometimes we are pushed away from community pharmacy because of thoughts of it not being clinical. I'm here to admit and to tell you, that I truly feel patient care and clinical care happens in these locations. It doesn't only happen there, but I feel like it is the most impactful location for it to occur. Prevention is everything. Having a holistic partner in your care is everything. Having someone that has time for you is everything and that's what we're providing.

So I'm thankful, especially with the current market practices and the stated shifts by players to close stores. They're buying up stores and they're closing them down as quickly as they buy them, looking to close down hundreds more stores, maybe 1000s over the next 5 to 10 years with a shift toward mail order and centralized pharmacy. Anyone on this call, the reason that you are here is not for any of those things. The necessity to stay employed by a location that values your knowledge, your health, and your patient's health is available if these individuals transition to independent pharmacy. I feel like that's something when we're looking at revenue shifts that has to be recognized. There's the ability to utilize these individuals and these bodies and payment models.

With this all being said, I've been asked ‘why try to fight? why try to fight the uphill battle, Kevin?’ by trying to push for improved working conditions for pharmacy teams in these retail giants. This question honestly, it comes with a little extra zeal for my community pharmacy colleagues. I completely understand, but here's my answer. I care about our profession. Regardless of employer, I believe every employer should be held to the same patient safety and clinical quality standards and the same working condition standards for our profession. I'm going to be frank. I will bet on independent pharmacies winning that race every single time. Whenever we see the other team playing by different rules, we need to hold them accountable. Our communities deserve it.

That said, I also believe we need to distinguish ourselves. Let's examine the opportunities to advance our profession and provide even more service. You guys will get even more training throughout the rest of the day, through CEs and so many other pieces. I'll just set the scene a little bit here. Around 90%- 93% of the population lives within a few miles of pharmacy. I'm a rural guy out in the country. I might be in that 7%, but still the closest health care provider and the most successful ones, for me as a young man and even now as a father, is pharmacy.

The other brutal thing is this. If we want to go see a physician, if we want a doctor's visit, physician wait times across the country are moving toward a month plus. I can't even imagine the stress for those individuals that need to get in, need to be seen, feel like there's immediate need. Guess where they're turning to? The physician shortage is projected to be around 130,000 providers by around 2035, with a majority of those being primary care. I wonder who could fill that gap?

Hospital costs keep going up, astronomically. I've been part of hospital systems for about a decade, seen what's happening behind the scenes and their charges, seen the reasons behind that. I'm not here to argue any of those things, but with an example, like a UTI. Treatments for a UTI inside of the ER can be around $2000, that the individual patient is owing, that the payer and the employee/employer is taking on board. We can do those same kinds of services inside the pharmacy, led by a pharmacist, that costs less than $100.

What can we do? What can we do now? What opportunities are out there that I know you're going to dive even deeper into? I'm just going to brush over them really quickly so you can think about a few of them, the ones you're honestly passionate about and feel like your community needs.

So leveraging collaborative practice agreements and incident-to-billing for things like remote patient monitoring and chronic care management, in some states, direct billing opportunities are available. Knowing those CPT codes, knowing how to bill, knowing the clinical side of things is a massive opportunity and I know that there are several technology vendors out there trying to make it easier for our profession to recognize those opportunities and take advantage of them.

Another one where technology is involved is point-of-care testing. We’ve seen that the CLIA-waived labs inside of community pharmacies over the last 5 years have basically doubled. We know there's opportunity inside of there, but even doubling, it's still somewhere around 30%.

Cash opportunities, these ones I think are cash opportunities today. My hope, my mission, my fight is to make them billable opportunities inside of an insurance and or payer setting. Advocacy, diabetes, other chronic disease management, prescribing, geriatrics, functional medicine, herbalism, pediatrics, honestly, the list just keeps going on and on and on. I see that those needs in the communities are significant, I see that there are patients out there that are willing to pay for these services and more of them than you may initially think. I feel like we've been programmed that the value that we offer always has to be free other than the product.

Now is a great time for us to make that shift, to make that mindset change, for us to recognize that our clinical services, especially the in-depth detailing we're doing, add significant value to our communities. Those new billable opportunities through payers and employer contracting and leveraging those, partnering with technology companies that are willing to help you make it easier, big benefit. Uniting together to be able to recognize a standard that can be delivered across our very unique settings inside of independent community pharmacy is extremely powerful. The question is when will we have time to do these things? I'll respond this way: adoption curves. When you have new technology, strategies, or business, those can also be used as business survival curves. I heard a recent talk where a pharmacy owner told his staff this, and I think it's pretty perfect for the current state of pharmacy, “be comfortable with change, because what we do, what we have been doing, and how we're doing it will be different next year,” not might be different, it will be. We know that those changes are coming. We know that those shifts are coming.

COVID-19 vaccines are down and even if RSV and flu season are as severe as some are predicting, revenue will need to come from somewhere. Obviously, you guys all know that I'm biased and jaded toward patient service and that's the biggest push that I personally have as an individual practitioner and what I really believe in. But I also believe that we have to fully harness our profession. Regarding a lot of those clinical services and technology that's there to help you quickly implement some of these things, be prepared for the anticipated need and educational gaps. It makes it less of a burden for your staff to be able to take this on.

I often say something along these lines and I say it on LinkedIn quite often. I want you to know that. When I say to reimagine health care is to reimagine pharmacy, I'm not blowing smoke. I've seen it happen where pharmacy is integrated into a system, and it takes a massive burden off that system. It takes away from the risk profiles for patients. It uplifts clinical service to places that we've never seen it happen for. We know our communities. We know how to serve them unlike any other profession. We are great at fighting to serve them the right way. Seven-minute appointments, you get in and your doctor's looking at a screen. Your provider is barely paying attention to patients. They're not cutting it.

Everyone is clamoring for more provider time and holistic approaches to medicine. Just imagine if we all gave up the fight and let the mail order, vertically integrated, “profits over people” companies win. Imagine us not uniting and advancing our profession together. How much worse would this disconnected pharmacy space be for our patients? Society needs to understand that we are not exchanging 1 location to count by 5s for another. We're not looking at some pill pushers versus other pill pushers, just at a different address. We're exchanging facilities that use pizza pacifiers and ‘do you want shots with that fast food’ mentalities to serve members of their community, providing care that no other profession comes close to.

We are here. Pharmacy is here, to often go above and beyond in the community. I'd love for you guys to tell me some time about the things that you have done, that oftentimes we don't even think about as being above and beyond, we just think ‘that's my duty, that's my service to my community’ to do it. You don't see other professions getting called in the middle of the night and coming into the store to be able to put something together for a patient, to deliver something to a patient, or coming away from a vacation to make sure a patient or their family member is taken care of. Answering calls and worries and concerns at all hours of the night because they can't reach anyone else, that's us. Now, we have to go above and beyond for our profession too.

For everyone in this virtual room, my parting words are to get up with a mission in your eyes, to have the confidence to band together and push ourselves across the line, to do that. Regardless of the specific revenue and clinical service strategy, we have to do these things. We have to be united as a profession. We don't have any time left for silos. We have to keep advancing care to be able to distinguish the expertise, safety, quality, and attention to patient detail that uniquely we provide. Finally and most importantly, we have to keep fighting to be able to serve our patients. Thank you so much for your time and I look forward to any questions.

Mulderry: Thank you, Kevin. Appreciate it. Thanks for that perspective. I had 1 question come through regarding some specifics on the types of services that you're targeting coming out of the pandemic. Things that you're recommending or implementing within your own practice, or things that you're consulting with, to increase the presence, footprint, and revenue for the pharmacy?

Walker: So things that I'm looking at right now really revolve around all those things that I've highlighted that we're doing at RPhAlly. Trying to allow for those opportunities to be educated upon, to take advantage of them and utilize the members of the team that are literally doing that every day that's how they're paying the bills and keeping the lights on. Things that I'm specifically interested in for door openers are really things like remote patient monitoring and chronic care management that we're seeing as an opportunity right now, oftentimes, an incident-to-billing inside of Medicare. Another interesting space right now is technology, coming in with wearable technology and how we can harness that and offer services related to it. And pharmacogenomics, finding a way to make sure that our profession is staying at the cutting edge of what it means to treat and provide treatment of care. Those are ones that I'm particularly interested in. Do I feel like those are the greatest profit centers? I feel like it's so unique to your individual community that you're dealing with, in your patient population, that I wouldn't like to make a broad stroke statement on those things. I do feel like those are other opportunities that are out there. As some of my colleagues have said, we get the people in the door to be able to serve them and now we have to give them the service for them to be able to take advantage of.

Mulderry: Very good. Another just came over. How does independent pharmacy get paid for these kinds of services? Any insights? You talked a little bit about direct communication with payers or employers. Any other advice that you've seen working for getting reimbursed for those special services?

Walker: A lot of those services like the reimbursement for point of care testing is already there and established. Many of you probably already have seen that. Inside of the incident-to-billing models, those relationships were just absolutely integral for us to establish with providers. Have a CPA in place. As the CMS guidelines are currently written, they don't allow us do that billing that some states are allowing us to directly do. Being able to harness some of the software that's out there that allows for those billable opportunities to come right across your screen and be evident is a major benefit.

The other thing is making sure that you're involved with your primary care practices, so that you can do some of those things, including that remote patient monitoring and chronic care management. Several of my colleagues, that's what they're building their businesses off of, just doing that. Inside the independent space, I think those are some ways.

The other piece is finding those cash-based models. It's funny. I live in a community that doesn't have cash. Interestingly, when it comes to some of the services they're paying for and getting some perspective on what insurance really is, the amount that's coming out of their pocket already is pretty significant. Being able to study the plans in your area and see what they are paying out of pocket and see what you can offer is a really interesting way to go about that. As individuals are signing up for their benefits or their plans, being able to help those individuals find what's going to work out best for them and their long-term health, I think is another big push for us.

Mulderry: Very good. In terms of advocacy, another good question just came in. What actions are our professional pharmacy organizations doing to advocate for the profession? Are there some insights that you can give? I know that you're working as an advocate but are there other sources that you would point to?

Walker: I do think it's an interesting juncture right now, Bill. I've never seen it in my career that dissatisfaction was there. Right now, when we're seeing documentaries, trying to be put together, seeing pizzas not working, being out there, and being a hashtag recognized across kind of the entire nation. Those types of things that I'm getting behind, my colleagues are getting behind to support our profession, I think are interesting advocacy components. Others that I'm seeing are interesting coming from the transparent PBM space. Even when I say the word PBM in a setting like this, I get nervous that there's going be tomatoes thrown. But there is a big difference, right? There's a big difference between transparent PBMs and what they mean for independent pharmacies and some other PBM systems and what they mean for independent pharmacy. There are opportunities to be able to advocate for our profession, by finding ways for us to be reincorporated to the table. Like that example from Idaho, it's a really big one. For us to be able to say, ‘we're going to push our employers in our area to recognize the value that independent pharmacy is offering and then be able to redistribute wealth coming back our direction.’

Mulderry: Very good. Thanks so much, Kevin. We appreciate your insights.

Walker: Awesome, thank you guys so much. Have a good one.

Fall 2022: Extending Care, Expanding Revenue
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