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Keith Loria is a contributing writer to Medical Economics.
How chains are evolving-and how pharmacists will fit in.
It’s no secret that healthcare is in a state of rapid shifts-it has been for a long time, and it shows no sign of slowing in its evolution-and pharmacy is no exception. From independents to big box to large chains to hospitals, every pharmacist is going to feel (and is already feeling) significant changes.
Perhaps the greatest shift in recent years, however, has come from chains. Changes in chains affect not only the pharmacists working in those chains, but show how pharmacy as a whole is evolving.
Pharmacy is continuing its shift away from solely dispensing medications to providing total care of a patient through drug therapy management, active patient engagement, and the ability to expand clinical services like administering flu shots and vaccines. The major chains are expanding the coverage of healthcare services from pharmacy to incorporating retail healthcare clinics into their locations and having pharmacists practice at the top of their licenses, such as strep testing and treatments.
Ramzi Yacoub, chief pharmacy officer at RxSense, a Boston-based healthcare tech company, believes pharmacy chains of the future will be offering more convenience in healthcare by expanding their in-store clinics, partnering with health insurers and health systems and providing a one-stop shop for patient care.
“With the retail chains already having pharmacists on-site and incorporating diagnostic services through clinics, they can provide a multi-disciplined team of clinicians who can manage the patient holistically,” he says.
He also notes patients are shifting how they consume healthcare. They are more educated about the costs of medications and services as a way to save money.
“Patients are comparative shopping for their medications and taking advantage of prescription savings services like SingleCare to save money on their medications,” Yacoub says. “Pharmacists play a vital role in helping patients become consumers of medications, as they are well informed of the cost of medications and less costly alternatives. I think you will see more transparency in pharmacy both demanded by the consumer but also by state and federal requirements, which will result in a more educated consumer.”
Thomas R. Bizzaro, RPh, vice president, health policy and industry relations, at San Francisco-based FDB, which provides drug and medical information, says in the coming years, chains-like independents-will continue to develop and deepen the important role of pharmacists within the value-based care delivery framework, especially as it relates to primary care delivery and identifying and addressing social determinants of health.
“As we have already seen, retail chains will expand pharmacy services beyond medication dispensing by addressing a growing number of basic healthcare needs, enabling pharmacists to practice at the top of their licensure,” he says. “Of course, pharmacists will continue to serve their communities as the most trusted source of medication and drug information.”
Meanwhile, he believes, automation and technicians will manage more of the pharmacy’s dispensing-while pharmacists will become more involved in routine primary care, especially if it supports medication adherence and better outcomes.
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“These changes will elevate not only pharmacists-but also pharmacies-to a larger and more meaningful healthcare delivery role in their communities and in patients’ lives,” Bizzaro says. “In the future, when we talk about the care continuum that includes community physicians, inpatient, and post-acute care, pharmacies also will be included as one of those pillars.”
Alam Hallan RPh, CDE, director of pharmacy at Guelph General Hospital and a registered pharmacist in Ontario, Canada and also the owner of several independent community pharmacies, says the major chain will be a complete health solution with a focus on chronic disease management in 10-20 years.
“We are seeing a lot of these employ nurse practitioners and will continue to see the build on this trend and offer other services, including telehealth,” he says.
Last year, CVS Health completed its acquisition of Aetna, after the health insurer agreed to sell its Medicare prescription drug plan business to WellCare Health Plans. Meanwhile, Walmart has been adding Walmart Health Clinics, offering healthcare services and providing basic healthcare needs.
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As Larry Merlo, the CEO of CVS Health has publicly stated, the “Retailization of Healthcare” will continue to expand and evolve.
“I believe you will continue to see more pharmacies adopting a healthcare model similar to CVS’s,” Yacoub says. “Retailers today are evolving their strategies but, at the end of the day, they are providing a convenient service where customers are the center of care and convenience is top of mind.”
There are many analogs, such as the recent launch of Walmart Health, the Walgreens partnership with Humana specific to Primary Care Services, and the Rite Aid expansion of Rediclinic. This model provides additional convenience to patients receiving health care services in a convenient location-including expanded hours such as nights and weekends.
Alexandra Brown, communications manager for Walgreens, says the company is focused on creating a modern, differentiated retail offering that makes shopping easier and more convenient for its customers, while also providing greater access to pharmacy and healthcare services to become more of a neighborhood health destination.
“Through this approach, and a ‘store-in-store’ model, we’re able to give our patients and customers affordable access to a broad range of important healthcare services, such as diagnostic lab testing, hearing, optical, and dental care-all conveniently located in local Walgreens stores,” she says.
Moving forward, it will be critical for drugstore chains to keep up with the pace of rapidly changing customer expectations. While it’s hard to speculate what this “experience” may look like 10 to 20 years down the road, Brown notes that technology will be a key driver. That’s why Walgreens is digitalizing and innovating for the future by combining its expansive physical store footprint with the latest technology, as well as partnering with leading technology companies such as Microsoft and Verily.
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“With this future focus, we’re working with partners to harness data, analytics, and artificial intelligence to give our customers and patients a unique advantage,” she says, adding that Walgreens it working “to develop more personalized health care experiences across a range of needs, from preventive self-care to chronic disease management.”
Yacoub says it’s likely there will be more mergers in the future, versus roll up of retail pharmacies, as healthcare needs to be delivered more efficiently and conveniently with an omnichannel strategy. Healthcare in general, he says, is evolving and patients are challenged with the friction and the inconveniences even today.
“As an example, you may have to go to one place to get lab work, then to the doctor to get diagnosed, then to the pharmacy to pick up medication,” he says. “This process is likely repetitive if you have a chronic disease. I suspect there will be more consolidation in services to provide a more convenient experience to consumers such as improving the omnichannel experience, expansion of clinical services, and a more efficient local delivery model.”
Hallan says there’s an increased focus right now in lowering the prescription cost, both from a pharmacy’s perspective to increase profit and for the PBMs to lower their costs.
“Naturally this is going to create a system where mergers have to happen in order to grab a larger share of the market so they are able to lower their costs and maintain profitability,” he says. “The market forces are ideal to make these happen.”
Industry-wide, Bizzaro says it’s unlikely that we will see any major activity with mergers in the near term, noting what is more likely to happen is independent local and regional chains will continue to be acquired by major national retailers-which may pose challenges for some communities, since often these acquisitions result in store closings and consolidation.
“If a local pharmacy closes, traveling to another location to access medications may become a challenge for some patients, and some pharmacists may lose their jobs,” he says. “Because pharmacists are central to the communities they serve, it’s important to keep an eye on social determinants of health issues such as transportation challenges that could have an impact on medication adherence when these acquisitions result in store closings.”
Brown notes part of Walgreen’s strategy entails focusing on establishing new partnerships and furthering existing ones with other industry leaders to transform its offering, organization, and infrastructure.
For instance, most recently, Walgreens partnered with brands including Microsoft, FedEx, LabCorp, Birchbox, Kroger, Humana, and Verily to create new healthcare and retail experiences.
The industry has already witnessed how online prescription refills, as well as over-the-counter ordering, have impacted retail pharmacies. Bizzaro notes those services will likely continue to grow in popularity, especially with the increasing popularity of mobile apps that increase access, convenience and adherence.
“Online technologies will have a more meaningful impact in the coming years by providing patients with trusted, objective, and reliable information about their medications, including how and why they need to adhere to their prescribed regimens,” he says. “There is so much misleading and false drug information on the internet, and patients are looking for reliable and authoritative data, especially if they are directed to it by their pharmacist or other trusted healthcare professional.”
For that reason, an increasing number of pharmacies are accessing authoritative sources to provide complete drug and dosing information to their patients that they can access online.
“Ideally, this information should be provided at a fifth- to eighth-grade reading level in multiple languages for maximum comprehension, and to meet patients where they are when it comes to health literacy,” Bizzaro says. “Online technologies also enable video demonstrations of proper medication administration for more complex delivery methods such as inhalers or injectables.”
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Access to this type of information online also allows pharmacies to reduce their complete reliance on paper-based educational materials, which patients may forget about or throw away.
Having customized patient education content available on-demand through desktops or apps, where it can also be integrated with a patient’s digital calendar, can encourage adherence and ensure that patients take their medications correctly.
Yacoub thinks there will continue to be an increase in online consumers of healthcare as well as more telehealth services being utilized, especially in rural areas of the country and where there is a lack of clinicians in a particular segment such as behavioral health.
“The demand for online services will continue to increase as the younger generation accesses healthcare services like they consume products and services today,” he says. “Retailers will need to continue to increase their presence online and allow patients to be consumers of healthcare online, but there will always be a need for a combined brick and mortar strategy along with a mobile presence.”
Hallan notes that with the acquisition of PillPack by Amazon, pharmacy received a lot of focus and a lot of new players. Many are focusing on key areas such as erectile dysfunction and then slowly expanding to other areas.
“But a lot of them are the same basic thing-lowering the cost of prescription medications while satisfying the customer expectations of fast and convenient shipping and good customer service,” he says. “I think a company that is planning to enter this area needs to know that while price is important, they need to have a plan on what they have to offer once prices become a non-competing factor. The customer service differential will always be there but it would be nice to see how they introduce the pharmaceutical expertise in this mix.”
Role of the Pharmacists
In the years ahead, pharmacists will need to continue to evolve in providing their clinical expertise in treating patients and being an integral part of the healthcare team.
“As we are seeing technology advance, and a continued shift to e-Prescribing, the dispensing of medications will be less of a focus for pharmacists,” Yacoub says. “Pharmacists will be providing more medication therapy management (MTM) services and consultations to patients on how to improve their care. As we see more integration of healthcare services, we will see a multi-disciplinary model of a healthcare team to deliver care to patients.”
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In that model, pharmacists will continue to provide their guidance and expertise in medications to deliver the best possible outcomes to patients.
As healthcare moves toward value-based care and retail pharmacies evolve their role within the ecosystem, it’s projected that more pharmacists will be stepping out from behind the counter-with a focus on delivering some components of primary care as non-physician providers.
Bizzaro says services that pharmacists provide will increasingly include the administration of immunizations-already commonplace in most pharmacies-as well as chronic care management, which may include services such as helping patients with diabetes interpret their HbA1c readings and giving them advice on lifestyle changes that will support better outcomes in combination with their drug therapy.
“With the personal touch that pharmacists have always had with patients-one of the key benefits of having so many pharmacists in neighborhoods-they will also help patients overcome social determinants of health challenges and will help connect them to social care agencies to address issues such as transportation, food insecurity and social isolation,” he says. “The pharmacist is ideally suited to address these concerns, considering they often interact with patients more frequently than their physicians do.”
What must also evolve, he notes, is a payment mechanism that recognizes the time and expertise pharmacists will be spending on these important care services that go beyond medication dispensing.
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“Payers already recognize the important ROI pharmacists can bring, especially in a value-based care environment, to improve outcomes, lower healthcare costs, and improve patient satisfaction,” Bizzaro says.
Talha Sattar, founder of NimbleRx, a prescription delivery service, sees fewer brick-and-mortar pharmacies in the years ahead, with a huge uptick in delivery.
“I think the pharmacist is an underutilized resource today and the utilization will increase more towards drug management and counseling, which you are already seeing in CVS, with building basically a physician’s office in-store,” he says. “It will be much more about managing the health and relationships, and less about filling the prescriptions.”
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What Needs to Be Done? Experts Weigh In
In order for retail pharmacies to be fully integrated into the value-based care continuum, there must be greater momentum among regulators and technology companies to achieve true interoperability of systems, including giving pharmacists access to patients’ EHRs.
“More patient information needs to be automatically shared with pharmacists in a standardized format, using interoperable vocabularies like SNOMED, LOINC, RxNorm, and others that can help these healthcare professionals better understand patient conditions and make crucial medication decisions with greater context,” Bizzaro says. “Too often, retail pharmacists are left out of care transition discussions as patients are discharged from hospitals and into long-term care facilities or back to their primary care physicians.”
Involving pharmacists and speaking the same language through standardized, codified information would strengthen care continuity, prevent avoidable readmissions or adverse health events, and ultimately improve outcomes, which benefits all stakeholders.
Hallan believes the move away from dispensing and the technical aspects of operations will continue and maybe in 10 to 20 years would completely defragment itself from it.
“The new responsibilities will focus on the patient care, outcome-oriented care plans, and working closely with the patients to help them accomplish these goals to lower healthcare costs quality of life,” he says. “Artificial intelligence and machine learning would be a key player in in this entire prediction as well. As it becomes more integrated within the healthcare system, its impact may be significant. Whatever happens, one thing is for sure, pharmacy is going to become a high touch health profession.”