Pharma and Pharmacy: Innovative Patient Engagement Strategies

Larry Dobrow [00:00:10] Welcome. We’re glad to have one of the late afternoon panels, because we know everybody’s here. We know everybody’s a little bit punchy. Fortunately, we have a terrific topic. No one’s going to be running out to the bar right away. So I’d like to thank Beth Zemkoski from Alcon and Brett Barker from NuCara Pharmacy for joining me. We’re going to be talking about agility for point of care marketers, a dialog between pharma and pharmacy. Brett and Beth are going to talk a little bit about the differing approaches that their organizations are taking to refine their pharmacy and pharmaceutical companies as vital points of care. Both NuCara and Alcon are working to become indispensable patient resources. So while pharmacy and pharma have obvious differences, our panelists are each big believers in agility and patient-centered innovation. Creating stronger and more proactive relationships in service to patients is at the center of what both of them do. So Brett and Beth, welcome.

Beth Zemkoski [00:01:03] Thank you.

Larry Dobrow [00:01:05] Brett, we’re going to start with you. Nucara career started has remained headquartered in small rural towns where pharmacies are obviously very important to care, but they’re also in danger. They’re under threat. You’ve also maintained the focus on elderly people. You know, you moved into Austin, obviously, but new roots inform your brand identity clearly as well as the way you innovate. Can you share some of the challenges that you face, given everything that you’ve taken that the company has taken on? How have you addressed keeping patient engagement high in areas and populations that have geographical and physical obstacles to care? What are the stakes?

Brett Barker [00:01:45] Yeah. So thanks for having us today. And our company, like was mentioned, started in Conrad, Iowa, the first pharmacy we just had our 40th anniversary started in the 1970s. And Conrad is a population of about 1200 or 1500 people. And so really, that small town community pharmacy backbone and culture still exists in our organization, but we’ve since really grown and transformed. And so our company leadership, back up almost 15 years ago really, took a look around. And they said the health care system has a huge need. We have a massive generation that is going to need a ton of health care services. Health care costs are skyrocketing and the baby boom generation is different from those before. They really do not want to be in a facility. They don’t want to go to nursing homes. And so how can we as a company build our organization to help our patients and our communities stay active and independent as long as possible? And the lowest cost of care setting. So the lowest cost is obvious in a home. And then there’s assisted living and then long term care. So there is a progression. But as much as we can provide services around those patients in our communities, to allow them to stay as independent as possible is really how we were built. So, across our organization we had community pharmacy, obviously. You heard this morning a really good panel about the industry, and I think they did a great job kind of teeing us up for this discussion. But since then, we’ve added home medical equipment and specialty pharmacy and the long term care pharmacy and a bunch of different divisions. We mentioned Austin, that’s compounding an infusion. So how can patients get infused drugs in their home so they’re not having to travel, or we have infusion suites. They can come to the pharmacy instead of maybe having to go to a medical center that may be 90 miles away. To really help, help with their care and, and all of that. And so some other things, you you mentioned the elderly population, obviously that really is around them, but it’s not just the elderly. And then, in our rural areas, we’ve also tried to really be innovative in how we serve them. So [00:03:43]there’s a lot of pressures on the industry right now. We want to elevate the practice of our pharmacists. And so we were really a driver behind what’s called technician product verification, which means pharmacy technicians in the state of Iowa can verify the product that’s filled for that prescription, so the pharmacists can be spending their time doing clinical tasks. Because for the last 20 years, pharmacists have been graduating with a doctorate level pharmacy degree. Our technicians in our state are all certified, and they have been for decades as well. And so the education of our of our workforce has increased. So, as much as we can have everybody practice at the top of their capabilities, it helps us take better care of our patients. [37.7s] And then also we’ve used  telepharmacy. We were a leader in that. So those those [00:04:26]towns that can’t support in today’s economic model, a full time pharmacist on site, we can have pharmacy technicians providing the service–filling the prescriptions, working with the patients–and the pharmacists is still doing all the same things. We’re verifying doing quality improvements. We’re counseling the patients. We’re talking to them, having a good dialog, using telepharmacy. So those are some of the ways that we’ve tried to be innovative, and to maintain or add services into our communities. [27.7s] And another thing I’ll point out too, is [00:04:56]we think about all of them as patients. And we had that discussion because one of my crusades was getting the word customer out of all of our materials, out of our policies, because it really defines your mindset. I mean, we’re a health care destination. These are our patients [12.4s] . Could there be somebody that comes in and just buy some Tylenol off the shelf and doesn’t talk to a pharmacist, and is more of a customer? Sure. But that’s not our mission and our vision. So that’s our patients.

Larry Dobrow [00:05:19] How is that mission going? More people taking to it. Is that something which requires some training or maybe even a different philosophical mindset?

Brett Barker [00:05:26] Yeah, I think really well, you know, that’s something as a company, it’s in all of our documents now. We have our mission vision on the wall. We change those out to say patient. And so maybe you’ll hear ‘customer’ from time to time, but I mean, it’s really that’s our mindset. We’re a health care company. And so yeah, it really the terminology can make a difference to your whole organization as well.

Larry Dobrow [00:05:49] Beth, obviously I work on slightly different type of company. But you’re in a unique position, I think, in your role, because you connect all brands to patients and very agile team. Can you give us a little background on how agility and breadth have given you a unique view into an approach to patient engagement? As you’ve developed some of these patient centered solutions, what have been the biggest surprises and what have been some of your learnings? What have been some of the misses?

Beth Zemkoski [00:06:16] Yeah, thanks. You know, [00:06:18]one of the first questions I get a lot of times is where does market access fit? Does it fit with the reimbursement team? Does it fit with brand marketing? Does it belong in patient services? And the answer I always give is, ‘yes’. No matter what, you have a situation where the patient has an access question at the practice and then they head to the pharmacy and you have access to affordability and then fulfillment. And so from my position, I have this opportunity to look at it truly from a customer-centric point of view, right where it’s agnostic of a brand. Because at the end of the day, access is, regardless of any brand, the same platform. And so if you can teach a patient and empower them initially to understand how to gain access, what questions to ask at the pharmacy, what information to provide to the provider, then that next time they have a different disease state, they have a different medication, they’re more likely to be adherent and actually not have patient abandonment. [73.1s] So that’s kind of an overall picture from that perspective. [00:07:38]We’ve done a lot of neat things, being able to be agile by thinking about patient affordability programs and building them as a portfolio in multiple disease states, not necessarily that every product has to have the same kind of platform, but if you build it on the back end, you’re able to be agile and switch and change and really take advantage of some of those bigger brand budgets to help support some of your lower brand budgets. [33.5s]

Larry Dobrow [00:08:12] You know, it’s funny you bring that up, in terms of, you know, being a big and well-regarded and successful company, how hard is it to keep that agility, you know, driven throughout the company? Is it something which is is it an everyday task? Is it something which you have to drive into people’s heads repeatedly?

Beth Zemkoski [00:08:31] I joke I’ve had three managers as of last year, so I highly recommend, if you’re going to be agile you just switch management every every three months, four months. But it really did allow to to bring the team up to speed. And so, I think part of that is showing the value of what you can do, and it only needs 1 or 2 brands to start coordinating together. And then that that obviously goes through the grapevine and you’re able to sell it in to the other brands.

Larry Dobrow [00:09:05] Actually, Beth, you touched on our next question a little bit in your last answer about, we’ll talk a little bit about how the common ground is patient access. Both of you, I think, have grown innovative approaches almost as a requirement to the context in which you operate. It’s obviously different how you’ve come to them. But at the same time, there are challenges and solutions you each independently come to that solve for patient barriers and contexts. Tell me a little bit about what some of those patient challenges are, that you’ve already addressed them a little bit. And maybe can each of you share one way that you’re working across both live and digital touchpoints to better engage patients? I know we could talk about MyAlcon Glaucoma. We could talk about anything else.

Brett Barker [00:09:46] Sure. [00:09:47]One of the big things in the industry is really adherence. And we heard earlier from several panelists some of the barriers to adherence, and there are a lot of them. And so people talk a lot about technology and AI and different delivery models of mail order. But really there’s a huge human element to what we do in pharmacy that you can’t replace through a mailbox and you can’t replace with a computer. It’s really coming down to patient behaviors and trying to assess those. There’s first fill medication abandonment statistics that are just mind blowing. The number of patients who will take the time and spend the money to go see a physician or nurse practitioner, or what may be, to be evaluated and then not come to the pharmacy to pick it up. And so trying to get around that, figuring out why didn’t they come? Did they not realize a prescription was sent? You know, maybe it blurred past them or maybe they were worried about cost or they have a transportation issue. What it may be. [54.1s] And then continuing on the therapy. So a lot of times, like we heard on the stroke panel earlier, patients may start a therapy. They may have a side effect and not tell anybody or they may have a cost issue and not tell anybody. So those patient behaviors are really big. And then there’s just reminders and adherence aids. And so [00:10:58]what we try to do is be nimble with that because everybody is totally different on what works. So we have the mobile app and the text message reminders and things like that we can set up to help the patients digitally. We have different adherence programs we can enroll them in, and some of the payers actually will pay for that because they know how important it is. So they’ll pay our staff to really stay on adherence for these patients. And then we do compliance aids and compliance packaging. So we’ll package them up into blister cards. And so when it’s their morning breakfast dose they can punch it out. And it helps them remember, ‘did I take that did I not take that?’ And we’ve had a lot of patients even though that sounds simple, and it’s time consuming for us to be honest, it’s a challenging service just from a workflow standpoint. But we’ve had a lot of patients say if it weren’t for that, I’d be in a nursing home. [46.9s] And hearing stuff like that really makes it worthwhile to continue to do that, because as much as we can do, really helps their quality of life and their, their longevity and all of that. So those are some of the ways we’re trying to work on those adherence type things with patients.

Larry Dobrow [00:12:02] That’s the same question for you.

Beth Zemkoski [00:12:04] Yeah. So I’ll go back to this concept of across brands. And [00:12:09]I’ll give you an example. We have a chronic medication. It’s asymptomatic disease. So already you’ve got patients that are abandoning their script because they don’t feel anything. And so can we provide them with communication at the point of the practice via text message, whatever that may be? And what are those messages going to be? And then, as they go to the pharmacy and they go to pick up their prescription, what are the questions they can ask? You’re you’ve got a Medicare patient and throughout the calendar year that journeys a look different. They’re going to pay their deductible. Then they’re going to go to $25 copay. And then they’re going to go to 20% co-insurance. And so there’s confusion around all of that. So them understanding what they’re doing and asking those questions, can they change it from a 30 to 90 day script? Those are all really great tactics to empower the patient. [63.3s] But when you’re looking at other aspects, right. Affordability beyond access, but affordability, [00:13:20]your chronic product–there’s an adherence aspect to that. So you build a hub and you can put a lot of money into a hub. And there’ll be aspects of education, reminders, text messages, affordability and so forth. But then you have another brand who is an acute product. That journey looks different, but that patient’s the same patient. And so what aspects of that hub can that acute product utilize. So ultimately, with your vendors suppliers and and talking together and working through things, our acute product was actually able to take advantage of that first contact. So instead of activating a copay card and calling a calling a recording to then go through the mechanism of everything, they were actually able to talk to a live operator. And what we saw was a drastic increase in activation and claims just from that one point. So that’s really that taking advantage across products, same patient, different disease states, different needs, but their journey is the same. [73.9s] And what’s great about that is if you think about the practice, a lot of times we go into the practice one company, multiple products. We’ve got a program for this product A, a program for this product b. And you’ve got one sole technician taking every single pharmacy call back that needs an access, a PA, a step therapy. And they’re going, okay, which number do I call? So you keep it simple. You have one number that can then triage to a multitude of programs. And you’re able to satisfy that need both at the practice and at the patient pharmacy level.

Larry Dobrow [00:15:14] You know, you know. Both of you brought up over the course of that last answer the notion of simplicity. Is simplicity underrated in both of your jobs? I this system is so incredibly complicated and there are so many different factors, multiple brands, everything else. How do you ensure that you build that simplicity in to everything that you do, your communications, the actual point of care, everything else?

Brett Barker [00:15:40] Oh, that’s absolutely a challenge I think in pharmacy. And one of the challenges we have, and [00:15:44]I tell our vendors, this is when you have to have a browser open with 12 different dashboards, you’re checking all day long for every little platform you’re using. It makes it really difficult. So there is a lot of disjointed things in the pharmacy space from a software standpoint. And so I tell them, the more you can bring everything and even if you do it 90% the best I’d rather have one touchpoint than a whole bunch of different ones and the same thing for the patient. [24.2s] I mean, we want them to experience as seamless as it can be on their end as well. And then there’s just a lot of misunderstanding. And I always often wonder, what do people do that don’t have somebody with a health care background to advocate for them? Because our system is so disjointed. And that’s one thing. I think [00:16:27]pharmacy can really fill a gap, because we’re one of the components that has a better picture of everything going on than other points in the health care system. Because your primary care should be your quarterback. They should be hearing from specialists, but they may not know the patient behaviors. And sometimes they may assume I gave them a prescription. They’re filling it. I mean, we know which prescribers are sending what and can watch for some of those problems and kind of be that point that that understands the information. And, we’re the place that sees the patient the most. We see patients, on average, there’s different statistics, but about 12 times more a year in the pharmacy than in the physician’s office. [38.8s] So it’s it’s a huge point that if you’re working on behaviors, we can really help with that because we see the patient a lot more and can follow up rather than somebody going every 6 to 12 months to the clinic. It’s harder for them to to really move the needle on some behaviors because they don’t have as many frequent touch points. And another thing we’re working on is [00:17:26]a lot of states have different programs trying to train pharmacy technicians as community health workers. And part of that is giving them a better understanding of the ecosystem in the community that’s not even just health care. It’s maybe it’s a rent issue and then they’re having transportation problems and just having a better idea to help the patient navigate some of those, social determinants of health. So the community health worker thing is new, but I do see a lot of positive things for that to help simplify it for the patient who may not understand how to navigate the system. [29.8s]

Beth Zemkoski [00:17:57] I think you bring up a good point. You see the patient more than the physician a lot of times. And so you get diagnosed, we finally get the patient to the pharmacy.  We’ve had our messaging. They get the first fill. And then where does the adherence take place? Three months later, they’re at the doctor’s office again. And and their measurements aren’t right. And they’re like, ‘are you taking your medicine?’ ‘Well, yeah, I’m taking it.’ Well, I’ve been on a diet and I ate a salad January 1st. So I mean, it’s perspective, right? ‘Yeah. I took it. Sure.’ They don’t have that feedback. And so I think from that perspective, on the pharmacy side, it’d be great if we [00:18:41]could provide that information back to the physician’s office so they we can close that loop with the patient’s script journey. [7.5s]

Brett Barker [00:18:50] Yeah. And I think on that point, if I were using my crystal ball and we’re sitting here hopefully five, ten years from now, [00:18:56]I would hope that pharmacies are able to see things like lab data and diagnoses and some of the things out of the medical record and that your prescribers are able to see the fill histories [9.0s] and things. Because [00:19:07]that data is there. [0.7s] We just as a society and a health care system need to pass it back and forth. Because [00:19:12]that would help everybody do our jobs better if we if we weren’t flying blind as much. [4.9s] Because, to that point there, there are times that we’ve had patients come in and I’d be like, why are they doubling the dose when they haven’t filled the other 1 in 3 months? And you call the physician and they’re like, well, they told me they’re taking. And I’m like, not from us. So so you can dig into and figure out is the patient getting it elsewhere? Are they not taking it? And they’re assuming they’re taking it because then they double the dose and the patient starts taking it. And now they have problems.

Beth Zemkoski [00:19:38] Well, and then that’s a prime example of the first dose titration that we saw earlier during the day. And the ability from point of care messaging to be able to trigger off those different types of aspects. [00:19:52]So how could we trigger, if the patient hasn’t filled in 45 days? And we can allow not only communicating to the patient, which I think we can do it from an industry perspective, but then communicating back to the physician so that they can also nudge and utilizing some of those advancements. [21.5s]

Larry Dobrow [00:20:15] That unification of the patient experiences across touchpoints, it’s going to be done through communication. There’s going to be strategies. How how are we going to get this right? How are we going to better enable patients in the ways that we have to rely on? So I wasn’t phrased very well.

Beth Zemkoski [00:20:35] I’ll let you go first.

Brett Barker [00:20:37] Yeah. Repeat that.

Larry Dobrow [00:20:39] The, you know, the opportunity for pharmaceutical companies and marketers to either unify patient experiences across touchpoints, or better enable patients in the ways that we have now to rely on them.

Brett Barker [00:20:53] Yeah, I think [00:20:54]there’s several things in our space that we need as the health care system has a huge problem around medication misuse and adherence and those things, but yet they’re still looking at pharmacy as just the product based service. So they’re paying for the pills in the bottle, but they’re not thinking about all the clinical things that need to happen. And that could happen if pharmacies are reimbursed differently. So we really need to make that transition as a health care system. [26.8s] And one thing that different states are working on is actually transitioning the regulatory model around pharmacy from what’s called Bright line, which means the state tells you exactly how you do things, when you do things, it’s very scripted and it really puts you in a box to what’s called ‘standard of care’, which is how every other health care provider has been regulated in this country. So that transition and states like Idaho and others have been happening. There’s legislation in many state capitals to keep moving that forward and what that’ll do is kind of take the regulatory handcuffs off of pharmacy. And then when that happens, then the payers come along because then they’ll see because vaccines are one thing. [00:22:01]When I graduated pharmacy school, it was more unlikely that a payer through the pharmacy benefit was going to pay us to do a vaccine. And we were doing more cash services, and now it’s flipped. I mean, every payer is going to pay pharmacies to vaccinate. So I think once you’re able to do the service and there’s a value there, it can be done well and can be done at a good cost, you can get payers to come along. And I think when that happens it really, because of the accessibility of pharmacy, there’s a lot of simple things that can be taken care of in the pharmacy that then don’t have to take up the time at the urgent cares or at the clinics and let them focus on the more complicated things that they need to dive into. And I think it helps us use all of our health care resources better. [40.5s]

Beth Zemkoski [00:22:44] It’s complicated, right? You have multiple programs across different divisions and disease states. So how can we actually have a wrapper and umbrella so that it doesn’t matter what brand message is out there or what initiative they’re doing? A patient accidentally calls a number and they know from from the back end that, ‘oh, I need to change and I need to take you to this program or this program.’ So [00:23:11]how can we start thinking about basically that spiderweb of programs so that when a patient calls or when an issue comes up, they’re able to call whatever number and be able to link to where they need to be? I mean, how frustrating is it? I’ve had situations where I’ve called three different numbers for one company, and I still didn’t get through to customer service. So what can we do as industry to start connecting those different programs together? [31.8s] They don’t have to be the same program, but how can we at least link them so that everyone knows what that spiderweb is for that patient journey.

Larry Dobrow [00:23:52] Right? That actually leads very nicely into our last question, you know, rethinking patient journeys in the context of the point of care. What does everybody in this room need to do or think differently about and around patient journeys or reimagining the point of care and its role? You know, what are what some of the advice get diverse places where you will sit that you give to everybody in this room.

Beth Zemkoski [00:24:18] I think I’ve said it multiple times. [00:24:21]Regardless of the brand or disease state, it doesn’t have to be complicated but there are areas of opportunity to be flexible and be agile and be able to utilize different funds. Just by utilizing your your agency partners and the offerings they have. And actually having different agency partners talk to each other. I know that’s like not something we do or talk about, but but if you can build those types of networks amongst agency partners, then you’re indispensable because you’ve created something across multiple brands and and it’s working. [42.6s]

Brett Barker [00:25:06] Right. And I think from, from our standpoint, we’re already touching patients in a lot of different ways. So we have the digital app, we have the website, we’ve got social media. There’s fliers that print out, that go with the prescriptions that we bag stuffers and posters and digital TVs in the pharmacy. And there’s all different ways you can get messaging to patients. And then also, I think a lot of our software vendors are definitely eager to work with folks that are creating content to provide them content through their channels. And for us, [00:25:36]a lot of the messaging, I think, is best at a time that it’s not interrupting the patient. So what I like is, you know, if the patient’s already interacting with us and you can append a little message to them that says, ‘hey, by the way, you know, while you’re talking to us right now about your refill, did you know that you’re eligible for this, or have you looked at this program’ or things that are specific to that patient? And so there’s different ways to do that. Through the IVR system, which is like the touchstone refill system both inbound and outbound. It can call patients and say your prescriptions ready or text them and say it’s your prescriptions ready, or patients can call them in. There’s technology that can append clinical messaging to that. So while they’re interacting with you, you can actually give them pieces of education, which I think is helpful because none of us want to be interrupted in extra time. [47.4s] But if you’re already interacting and it says, hey, it’s flu shot season, did you know, you know, think about these vaccines. It is helpful. So we already do that around Medicare enrollment for plan reviews. We promote vaccines. We promote different services we do internally all that way while the patient’s already interacting with us.

Larry Dobrow [00:26:44] Brett, and one of your previous answers, you said something along the lines of like, in 5 to 10 years, it would be great if we’re at a certain place. Are both of you optimistic? Are we going to get there within that time frame sooner or later? How do you feel?

Brett Barker [00:26:57] Yeah, I’m one that tends to be optimistic about where we are going as an industry. [00:27:02]It’s going to be a very turbulent year. I think there are a lot of pharmacies, unfortunately, that aren’t going to make it through the year. But I think those that are able to navigate the system and really step up and find new services that can generate revenue and really not solely rely on the product and show their value to the healthcare system, I think will have a bright future. Because the healthcare system needs pharmacy. And I think they’re figuring that out, and I think they figure out also you need to pay appropriately and make that transition. So we are in a very transformational time. [30.0s] But I also think where technology’s going, the public expectations, the policyholder expectations, even the expectations of other medical professionals has changed tremendously. I remember when I was a new pharmacist asking for lab values, and I got my butt chewed by the physician down the street. But the younger generation of practitioners would call me and say, ‘hey, I need help with this.’ [00:27:54]And so I think now that the the medical professionals are training with each other when they’re in school, I think they understand the value that each discipline brings. And so that also is a mindset change in the profession. [10.7s] So a lot of that communication I think is getting tighter. I think, there’s a lot of opportunity for the profession. And I think the touch points you have with patients can make a huge difference in their care. And so hopefully more patients will expect that too, because I’m sure there are a lot of people in the room that may have stories about showing up to a pharmacy and you can’t talk to anybody, and it’s really difficult. And so, you know, I tell even my in-laws get will tell me how it took them four weeks to get a prescription at an unnamed big box store. And I’m like, did you go to the independent down the street? And I probably could have helped you in just a few minutes and learned your name and all those things. So hopefully patients will learn more that they need to expect a certain level of care at a pharmacy. And find those places that will take take good care of them and be their advocates. I mean, we we like to be advocates. We like to, to help them navigate the system. We like to, work with other health care providers and that process as well.

Beth Zemkoski [00:29:01] I think [00:29:01]if we can do what we’ve done in the HCP systems and the practice systems with point of care messaging and critical points and times and nudges on the pharmacy side, it will help us realize from a from a manufacturer perspective, the entire patient journey. And there can’t be anything wrong with that. [23.1s]

Larry Dobrow [00:29:25] Nothing wrong with it at all. This was terrific. Brett Beth, thank you guys so much for this. Thanks. Great.