Genoa came to Figueroa’s attention in early 2014, when Nautic Partners, a private equity firm, approached him about becoming chief executive officer of the company, which Nautic was forming through the merger of Genoa Healthcare and QoL meds. The goal of the deal was to develop enough critical mass to begin to fill a conspicuous gap in community pharmacy by addressing the needs of patients confronting serious behavioral health issues. Figueroa was quick to grasp the possibilities.
“The concept is relatively simple,” he explains. “We believe that if one of our closed-door pharmacies is on site at a community mental health center, integrated with the clinical team and engaged in a high-touch level of pharmacy practice, we can positively affect the well-being of the patients in this setting who are severely challenged.
“Our experience has shown that when we work directly with the physician as part of the clinical team and interact with the patient right after therapy, we have a chance to make a major impact, which translates into greater than 90% medication adherence rates.
“That’s much different from letting the patient walk out of the clinic without pharmacy care and having a 20% to 40% adherence rate. That’s really the crux of our model.”
Attaining 90% adherence would be an enviable achievement in any practice setting, but it is particularly notable when serving mental health patients. The success of Genoa pharmacists in that regard results in up to 40% fewer hospital admissions and emergency room visits than when similar patients are treated in a traditional community pharmacy, according to Figueroa.
Genoa, with annual sales of $1.1 billion, now has more than 300 pharmacy locations in 40 states and the District of Columbia.
The foundation of Genoa’s pure pharmacy approach, which includes dispensing prescriptions for any ailment a member of its patient population might have, is service. The work flow of the company’s professionals is dictated by the needs of individual patients.
“We expect our folks to have a real dialogue with every patient,” says Figueroa. “We refuse to have an interaction where the patient hands us a prescription and we simply dispense the medication.
“We sit down and engage with every patient to talk about what they just heard from the doctor. On some occasions the physician will bring the patient down when they’re a first-time visitor and introduce us. Our pharmacists counsel immediately with every patient and make them familiar with what we’re going to do for them, including MTM [medication therapy management].”
The support that Genoa routinely provides extends well beyond MTM. Patients, 90% of whom are either Medicare or Medicaid beneficiaries, frequently receive help obtaining health insurance, securing prior authorizations for medications and learning how to take their complex medication regimens. One of the most important extras that customers benefit from is individualized product packaging, which is designed to make it as easy as possible to comply with a prescription drug regimen.
“A lot of times with mental health patients, doctors don’t want to give a full 30-day prescription, so they’ll give them a seven-day or a fourteen-day script, and we’ll package specifically for that consumer,” Figueroa notes. “The services that we offer are done individually in all of our pharmacies. Each pharmacist and their staff are responsible for taking special care of every patient that walks in the door.”
To make its service-oriented strategy work, Genoa recruits highly motivated pharmacists who want to practice at the top of their profession. Many of them are younger professionals whose education envisioned an expansive role for community pharmacy.
“At Genoa, you are a clinical pharmacist,” Figueroa says. “If you go to pharmacy school with the idea that you want intensive engagement with patients, you can either be an in-patient pharmacist in a hospital or work at Genoa. None of the other retail models are as close to the patient as ours, and pharmacists flourish in that environment.”
In light of the company’s clinical orientation, it’s no surprise that medication adherence is always top of mind. The problem of noncompliance, which is estimated to cost the nation’s health care system a total of $290 billion a year, is particularly daunting with mental health patients.
“We not only speak to our patients face to face for that first meeting, but normally call them after they’ve started to take a med and ask them how the first dose went, if everything was OK, and the majority of the time we get good information,” explains Figueroa. “We’ll follow up a couple of days later. We’ll walk them through the early stages of treatment to make sure that everything is OK.
“Behavioral health is like oncology was years ago, when there was a lot of hit or miss in prescribing. There are so many medications, the doctor will hone in on what he or she thinks is effective, but might change prescriptions a number of times until the doctor gets the right dose for a particular patient with a particular disease state. So we communicate with both the patient and the doctor on an ongoing basis. If needed, our pharmacists will meet with them when the patient makes a follow-up visit to the physician.”
The level of attention given to each patient — coupled with such services as personalized refill reminder calls, medication synchronization and MTM — has given Genoa patients a medication possession ratio of 92%.
Impressive as the company’s adherence rate is, Figueroa and his colleagues on the management team, who include chief operating officer David Vucurevich and chief commercial officer Mark Peterson, recognize that the new gold standard in health care, the one on which future remuneration for pharmacy operators and other providers will be based, is patient outcomes. As a result, the company is involved in an independent research project that aims to quantify the effect of pharmacist interventions with mental health patients.
“We’re hoping to tap into payer data to make a stronger case for what we do,” Figueroa notes. “All the figures on adherence and staying out of the hospital — it’s really the payer that has the data that will allow us to make the comparison with other providers.
“So if one behavioral health patient comes in and goes to a traditional retail pharmacy setting and another stays at a community mental health center with one of our pharmacies, we can see whose scripts are continuing to be filled, and whether either one of them winds up in the hospital or the emergency room.
“We want the people at CMS [the Centers for Medicare and Medicaid Services] to examine the evidence and understand the great work that we’re doing, so that when we come in and say, ‘The next reimbursement cut is going to be devastating to this patient population,’ they will take a second look at it. We’ve had some success at the state level, where health care officials would conclude, ‘The last thing we want to do is affect behavioral health.’ That way we can protect some of the reimbursement.”
In addition, Genoa will use insights gleaned from research findings to fine-tune its business model. The company’s ability to adapt has already proved to be a source of strength, as demonstrated by its acquisition of IDocWay in November 2015. The largest outpatient telepsychiatry service in the United States, IDocWay was purchased to help address the psychiatrist shortage mental health centers are facing, and has also resulted in a positive impact for Genoa.
“Helping our partner clinics overcome challenges they face helps us succeed as a business,” says Figueroa. “They told us that it can be difficult to retain psychiatrists in that setting, so we bought the telehealth business to help our partner clinics with staffing to continuously serve our patients. When our partners and patients benefit from a solution Genoa provides, we all succeed.”
Unlike at least some of their counterparts in psychiatry, Genoa pharmacists like what they do and are in it for the long term. Figueroa attributes the company’s turnover rate of just 5% to the satisfaction pharmacists derive from the job.
“They know they make a difference in patients’ lives, and that’s very rewarding,” he says. “We’re a small component of the care for behavioral health, but we believe we’re an important piece.
“There are a number of statistics that will show that if patients stay on their meds, they become real contributors to society. It’s when they fall off their meds that they don’t. Our pharmacists are proud of their success in helping them stay on the right track.”