The pandemic has brought — in addition to peril — promise for pharmacy operators who have become central to testing and vaccination efforts. The impact of the crisis on pharmacy’s present and future, among other topics, was explored during a Chain Drug Review roundtable held virtually in conjunction with the NACDS Total Store Expo.

Woldt: Let’s begin by asking Steve Anderson to give us his thoughts on the past year and what COVID and other developments we’ve witnessed mean for community pharmacy.

Steven Anderson
President and CEO, National Association of Chain Drug Stores

ANDERSON: Jeff traditionally asks me that question at these roundtables, and this year we have even more to talk about than usual. I just want to say from the outset as CEO of NACDS, I want to thank you, everybody on this meeting — members, chain members, associate members and allied organizations. — Doug Hoey of NCPA and I have worked very closely throughout the pandemic on these issues, and we’ve worked with other associations, and it’s really been a great honor to participate in this response to COVID with all of you in the last 19 months. I mean, nobody saw this coming. That’s stating the obvious. But I think what retail pharmacy has done has been nothing short of extraordinary, and that goes without saying. And we’ve always said over the years just give us a shot and we will show you what a great job we can do on behalf of the American people, and that is surely the case. I’m reminded of the article that appeared in Bloomberg in January of this year with the headline: “If They Nail It, Drugstores Will Be the Heroes of 2021.” And you surely did that. Let me describe the way I view NACDS’ role in this. Many companies at this roundtable have representatives on our board of directors and see this firsthand. For example, Brian is our vice chair, and Debbie’s on the board. From the beginning of the pandemic, the board of directors really was committed that NACDS was going to help our members in any way we possibly could. Some of you have heard Jim Collins, who comes to our meetings and conferences — the business guru — and he just loves retail pharmacy. He always talks about the flywheel, which symbolizes the fact that you have to keep at it and keep pushing and ultimately you build momentum and generate power. And NACDS reflects that flywheel in that we create a policy environment where you can do what you need to do, and you are doing it extraordinarily well. And then the next phase of our responsibility has been to communicate that to the media, to the American people, to decision makers, to policy makers at the federal and state level. And that allows us to be able to have more successes for you so you can do even more. In March 2020, CDC called on our members to do whatever was necessary to stay open and meet Americans’ needs. NACDS reflected that reliance on pharmacies in a series of ads. We ran an ad at the beginning of the pandemic in April that was so good that the major cable networks thought it should be a public service announcement. They gave us reduced rates. And it showed historic times when America was at crisis levels. We said that the pharmacies always have been there with our lights on and doors open every step of the way. And that is really what you have done. Over the last 19 months you’ve done — I was going to say a tremendous job, but that doesn’t even begin to explain it. It’s been amazing. Recognizing that we are recording this in August, the latest numbers I saw out of CDC and the White House were that through the federal retail pharmacy program alone pharmacies have administered more than 108 million COVID-19 vaccine doses. And that doesn’t even begin to count the number of shots that were given through pharmacies in the state programs as well. So it’s been an extraordinary effort. We have a lot more to do, and I know we’re going to get to that, but it’s just been a pleasure to work with you. And we just really want to thank you for your commitment to your associations. It just shows what we can do through what I would call the power of association.

Woldt: Doug, would you like to add anything to Steve’s remarks?

Doug Hoey
CEO, National Community Pharmacists Association

HOEY: Yes. I think Steve covered it well as far as pharmacy being a hero. There are a lot of heroes from the pandemic, but I think pharmacies are probably a dark horse in that hero race. I mean, most people would have predicted that nurses and doctors would have stood out in this pandemic, but pharmacists maybe were not at the top of everyone’s mind. And so I think it’s really helped reposition pharmacists and pharmacy going forward. And it’s been just over a year where pharmacists were granted the ability, the authorization to order and administer vaccinations. I think that’s a milestone. And if there’s a pharmacy historian looking at the annals of pharmacy, that date in August of last year should stand out. Because I think that was really a — I mean, game changer is an overused cliché — but it really was a game changer for the profession. And Steve mentioned one of the stats that I’m just very proud of as a pharmacist and just proud of for our industry, and that’s the 108 million COVID doses administered just through the federal program, as Steve said. And who knows how many more millions of doses have been administered through the state programs. So throughout the headwinds of the pandemic it’s given pharmacy a lot to build upon and to keep the momentum going. And I think that’ll be one of the biggest challenges we have going forward when this pandemic ends — if it ever ends. But I think that’ll be one of the biggest challenges that we have — everyone on this call, both the associations and our partners in the industry — is how do we keep it going? Gratitude is usually fleeting, so we want to make sure we frankly take advantage of the gratitude that we’ve earned in our profession. So there’s a lot to build on, a lot to move forward from. Challenging times, but it’s also a very exciting time in our profession.

Woldt: Now I’d like to turn to the retailers and ask a little bit about the past 18 months and then look ahead. I’d be interested in hearing your thoughts about the work involved in standing up COVID testing and immunization programs, how it was interacting with government agencies and other private-sector participants, as well as the response of patients and front-line pharmacists.

Tasha Polster
Vice President of Pharmacy Quality Compliance and Patient Safety, Walgreens

POLSTER: The last 18 months have probably been one of the most challenging periods for the pharmacies. And although it’s been challenging in the pharmacies, it has also been the most rewarding. One of the biggest wins that happened was HHS extending the technicians’ scope of practice to be able to allow administration of vaccines by a technician under the supervision of a pharmacist. I think it’s really helped take some of the burden off the pharmacy staff with the number of vaccines that are coming through the retail setting. And the extension of adding flu vaccine to be administered by a technician in addition to COVID vaccine in the states where it’s not already allowed was another very big win for the pharmacy. We need every available immunizer to help, particularly now that we’re seeing the potential for boosters, because we’re going to have all of those folks coming back into the retail setting. Keeping in mind that vaccine volume, with the work that the pharmacists are already doing today in filling prescriptions, the MTM, the counseling, this expansion of a technician’s scope of practice will help tremendously as we enter into flu season. I think we’re in for a very busy fall and gearing up for all that work has already started, as we’re seeing additional doses in the immunocompromised populations as well as an uptick in COVID-19 naïve patients in the vaccine-hesitant states. One thing that really stood out about the work evolving during this time in terms of both COVID testing and COVID vaccines is how the industry as a whole is helping us band together because it is going to take all of us to get through this pandemic. The biggest thing that really hit home for me was the amount of times that people said we’re building the plane while we’re flying it. I never really understood that expression until this whole project started, because all the tics and ties, the different changes, all the different directions and turns that happened based on the science that has come in have made it particularly challenging for all areas of the industry, which I think helped us all band together to get it figured out.

Woldt: This is an unprecedented situation, and no one has gone through anything quite like this. But is there anything comparable in anyone’s experience where the industry as a whole has had to gear up so quickly to deal with a crisis?

POLSTER: The only thing I can think of was H1N1. And H1N1 didn’t even hold a candle to what we’re going through with COVID.

But H1N1 helped put retail pharmacy vaccines on the map, and this just reiterates the importance of our profession and how near we are to the public — pretty much every person in the United States has access to a pharmacy within a reasonable drive and we can help get them healthy again and keep them healthy.

Siddharth Tenneti
Vice President of Pharmacy Growth and Insight, CVS Pharmacy

TENNETI: I think there are two things that people already knew about the pharmacy that were reinforced. One is our clinicians, our pharmacists and their clinical capabilities. And two is the importance of local — you know, how local we are. What I think this pandemic reinforced is our ability as pharmacies to react quickly to a changing environment. Very often when the regulations changed, eligibility changed, you would see that the pharmacy was the first one who’d make those changes. So people knew that if they wanted to get their dose, they would turn to their pharmacy first before the state, before elsewhere, because their pharmacy was ready before anyone else. So I think what has heightened during this pandemic is the public’s perception of a pharmacy as a place where they can actually go to meet a critical health need. I think that’s — Doug, to your point earlier — that’s what we have as an industry, and now how to make that stick.

Woldt: To what do you attribute pharmacy’s ability to respond?

TENNETI: Our expertise. We’ve done this for a while, we know how to do this, we have a fleet of people who have done this day in and day out. So when you think about mobilizing a mass vaccination campaign, who better than the pharmacy who’s been doing this for years.

Eyad Farah
President, Health Mart, and Senior Vice President of Pharmacy and Healthcare Services, McKesson

FARAH: I’ll just add commitment, too. Commitment to their patients and to their communities. I mean, we’ve seen that for so many years. And again here I would say maybe one of the differences from the H1N1 is you had extended periods of lockdowns and social distancing. They had to transition their business. You know, many of the pharmacies weren’t doing deliveries or curbside and they had to transition. I think the point about building the plane while you’re flying it — it’s a great example. But it really starts with the commitment to the communities, to their patients and the relationship that they’ve had for so many years.

Woldt: What kind of response are you getting from patients?

Becky Dedman
Vice President of Operations, Walmart Health

DEDMAN: You know, Jeff, it’s been absolutely overwhelming in the positive response we’ve received. For us this journey really started with our initial role of standing up COVID-19 testing sites in March of 2020. And whether individuals were in line to get a COVID test — which we continue to provide today, including through our drive-thrus — or whether we’re putting a shot in their arm, the response has been incredible. It’s been everything from tears of relief — especially early on when we were vaccinating seniors — to that sense of “OK, I can get life back to normal” to today, our pharmacists helping to deal with the hesitancy that’s out there by providing patients with education about the vaccine. We’ve trained our pharmacists to recognize and address vaccine hesitancy. And so we see the gamut of emotion, but overwhelmingly it has been extremely positive.

Woldt: Debbie, I saw you smiling when she said tears were coming to some patients’ eyes. Are you hearing the same sort of things from your pharmacies?

Debbie Weitzman President of Pharmaceutical Distribution, Cardinal Health

WEITZMAN: Yes, you did, Jeff. I’ve visited customers, including some of our franchisees, and witnessed patients go into the consultation room with the pharmacist. I’ve seen those patients enter with trepidation and then make the decision to get vaccinated. At a visit in Des Moines, I saw the pharmacy get flooded with patients inquiring about and signing up for the booster. While there are several diverse perspectives when it comes to COVID vaccines, it is evident that pharmacists are proud to provide this service to their patients.

Woldt: Brian, maybe you could talk a little bit about the retail experience, but also how COVID has affected the wholesale side of your business.

Brian Nightengale
Senior Vice President of Community and Specialty Pharmacy, AmerisourceBergen, and President of Good Neighbor Pharmacy

NIGHTENGALE: Actually I’ll add on a little bit to what both Debbie and Eyad said. If you go back to the early days of the discussions with the CDC around getting the vaccine out, many of those conversations went understandably to the members of NACDS and the large chains who had the infrastructure to be able to act quickly and get out to large populations in a rapid manner. But behind the scenes, in addition to that, I think there were some concerns from the CDC around how to engage with independent community pharmacies. And AmerisourceBergen along with our peers had a seat at the table, communicating the value of these pharmacies and the role they play in their communities. Following that, there was unprecedented collaboration and interaction with us and our peers at McKesson and Cardinal and also CPESN and NCPA, in terms of being able to create the infrastructure and network to make it possible to include independent pharmacies into the Federal Retail Pharmacy Program. We all collaborate at meetings and such, but this was daily collaboration, daily education with the CDC to enable the full force of community pharmacy — both the independents and certainly the chains — to come to the country’s rescue there. So I think that’s critical. And I hope that the important lesson out of that exercise is that — and I hate to sound negative on this, but the traditional public health response has typically been let’s get the people to the health care, let’s get the people to the vaccines — and I think what pharmacy showed here is that’s the wrong way to do it. Let’s get the vaccines to the people. Let’s get health care to the people in need. And the best way to do that is community-based care.

Woldt: Absolutely.

Lari Harding
Vice President of Sales Enablement and Operations, Inmar Intelligence

HARDING: Inmar works with our customers to understand their data and help them better assess what’s going on. We found that between 50% and 60% of the patients that were receiving vaccines in retail pharmacies were in that retail pharmacy for only the first time in the last 12 months. So there were a lot of new people coming into the pharmacy, interacting with the pharmacy, and I think the benefits of that to the overall business of pharmacy are yet to be seen. For a lot of folks it was a very positive, pleasant experience, and a relief that they could be protected. Hopefully that turns into longer-term business value.

Woldt: Brian, you are a seasoned industry observer. What are your thoughts on what we’ve seen over the last 18 months?

Brian Owens
Senior Vice President of Commerce Strategy, VMLY&R Commerce

OWENS: It’s just a pleasure to be part of this conversation. I think the role of pharmacy has just transformed, and I applaud the role of NACDS and all the trade associations’ ability to give more access to pharmacists so they can provide more care. So I think the role of self-care and the overall image of pharmacists have changed within the community. As I do retail pharmacy store tours, and as I talk to brands, my new role is to help brands convert more shoppers around the pharmacy shopping experience, and a lot of the research I’m doing is really around the new branding opportunities available since COVID, the new equity opportunities that a lot of the retailers on this call have right now. Because, frankly, consumers now have a different “trust” association with the pharmacy retail experience. There is now a new element of consideration where “a pharmacist is the new first source for health information.” They’re not trusting WebMD; they’re now trusting more consumer-driven online health information platforms, because a lot more information is credible there. The individual, especially in the community shopping environment, trusts the pharmacist who knows folks — where the pharmacist knows the individual and the pharmacist also knows their family. So there’s just a lot more of a family caregiver community priorities as an accelerating retail trend right now, and I wrote about that in my article, and I think human needs will help transform the pharmacy space. And frankly — not to be, you know, capitalistic here — but there’s a trade-up opportunity here too for retailers due to that trust factor. It’s not exploitative, I just think there’s an opportunity to drive more holistic well-being solutions to folks in need and, frankly, helping the lower-income shopper navigate the financial stress associated COVID is another brand opportunity. Because of the Delta variant, more lower-income folks are just on high alert. They don’t know what to trust, so the CVSs of the world, the Walgreens of the world, the Cardinal Healths of the world are positioned well to help these communities.

WEITZMAN: I would add to your point, Brian, that patients are turning to their community pharmacist and placing their trust with them due in part to the proximity to their home.

OWENS: Yes.

WEITZMAN: Traffic patterns have changed dramatically as more people continue working remotely and reduce travel, changing where they look for care. Many want availability within a short radius of their home.

Woldt: Before we end our retrospective look at COVID, I wanted to ask the two pharmaceutical executives here what they think of the industry’s success in developing  vaccines and the speed with which it was done.

Sean Spears
Senior Director of Trade and Pharmacy Relations, Eisai

SPEARS: It is great seeing Doug Hoey of NCPA, Steve Anderson of NACDS, Brian Nightengale of AB and Debbie Weitzman of Cardinal, and other leaders in the industry come together and work to defeat COVID. It is truly special what pharmacists have done. I am very proud of this effort and want to thank all your teams for their efforts.

ANDERSON: I’ll just follow up on what Sean said. You know, Ken Burns had indicated during the pandemic this is about as great of a crisis as we’ve ever had in our country. He put it on the same level as the Depression, World War II and the Civil War. In that context one can realize the impact the pandemic has had on every aspect of our society and our culture. And we’re still facing it. You know, pharmacy was front and center. It’s amazing to me — and Doug and I have been at this a long time — President Biden speakes consistently with our talking points in terms of the number of pharmacies. There are nearly 60,000 retail pharmacies serving Americans. He also uses all the time that number that I love: 90% of Americans live within five miles of a pharmacy. That’s extraordinary accessibility for the American people. We pick up the phone now, and we get the White House on the line all the time. We’re seeing this now with the discussions about these boosters and third doses and other emerging issues. It’s been extraordinary and, as I tell some of the people who work at NACDS who are earlier in their careers, “You are having a chance to work on something that you never thought you would ever do. And when you look back on your career you’re going to say this was probably the finest moment you’ve ever had.”

Woldt: I also wanted to touch on technology, because it seems to me that all this wouldn’t have been possible without the systems that pharmacy and the wholesalers have invested in for so many years. Mike, do you want to jump in on that?

Mike Coughlin President and CEO, ScriptPro

COUGHLIN: Sure. I’d love to. When you develop a technology solution, you never know for sure how much it’s going to mean to the users. ScriptPro developed its line of robots so they could fit in any pharmacy. We also added mobile apps for delivery and curbside pickup. We could not foresee how important these technologies would be when the pandemic hit. It has been mentioned here how critically important it is to enable staff — particularly pharmacy technicians. Technologies that ScriptPro has developed have become extremely important during the pandemic in enabling pharmacy technicians. It has been really exciting to see the part that technology has played in this navigating the pandemic.

Woldt: Marv, do you want to add anything at this point?

Marvin Richardson
CEO, iA

RICHARDSON: First and foremost, thanks to all of you and everything you have done during this time period. I have a daughter and a daughter-in-law who are pharmacists on the front line today and vaccinating patients in Indiana. But what we’re seeing really is a shift — and Debbie spoke to it as well in terms of traveling patterns — but really this “how does the patient want it” has changed so much. So, we’ve been focused obviously on automation to support not only independent retail pharmacies but also large chains in central fill. And we’re seeing many patients wanting different ways of delivery. So not only central fill back to the store, but mail order, same-day delivery, different packaging, whether it’s vial or pouch and O-T-Cs. What pharmacies are delivering has driven a whole new aspect to our business, and obviously we’re adapting to that through our introduction of Pharmacy Fulfillment by iA, our comprehensive solution that utilizes pharmacy automation technologies run by iA’s intelligent enterprise pharmacy fulfillment software platform, NEXiA, to manage prescription fulfillment centrally in order to help free up pharmacists to focus on patient-facing care. We created this to support retailers, because it’s really the retailers that are adapting to this and driving demand for it. So it’s been very rewarding, at the same time very demanding.

Bob Belknap
Director of Trade and Specialty Distribution, Boehringer-Ingelheim

BELKNAP: The major impact of COVID on manufacturers was managing the supply chain issues. We had some products that were impacted by patients, impacted by COVID. But the strain it caused to the supply chain was impactful. Downstream customers responded by hoarding or overstocking. We learned a lot from our drug wholesale partners’ management of their downstream customers. Drug wholesaler allocations ensured that all downstream customers had access to our products. As the COVID-19 Delta variant continues to spread, the drug wholesalers and retailers are prepared to manage the impact on the U.S. supply chain. The initial rollout of COVID-19 vaccines did not include retail pharmacy. Once retail pharmacies were included in the COVID-19 vaccine’s administration we finally have hope that we can control and manage this deadly virus.

Woldt: Let me shift now to a more forward-looking line of questioning. There still is a lot of vaccine hesitancy in the country. If I have the figures right, slightly more than  50% of Americans are fully vaccinated, which leaves a huge part of the population that is unvaccinated. What role should pharmacies play in trying to convince people to come and get
a COVID shot?

TENNETI: Sure. It’s similar to what the pharmacies are going to do even going forward, is build on the work we’ve already done over the last six months. When you think about vaccine hesitancy, it’s evolving, you know? People who are vaccine hesitant are different than the people that we were talking about earlier in the pandemic. We were talking about people who had less access to the information, less access to pharmacy, less access to the vaccine. So there were access issues. It seems like people who mistrusted the health care system as a whole now, it’s strong. But the work pharmacy did there was to partner with folks who these people trusted. And then to also make sure we were focused to where these folks were. We — CVS Health — purposefully rolled out its change in such a way that we were first where the highest vaccine hesitancy was. So we would open up, like we look at SVI index, and we would look at vaccine hesitancy, and we would open up our stores first there. So we were actually later to some of the other markets because we chose to put our professionals first in addressing the hesitancy issue. So I think it’s going to build on a similar approach — get our clinicians closest to these people, partner with folks that these people trust, and then the combination of those two — and then we have the access. Once people are convinced, we have the access. They can come to our pharmacies. We make it really easy to get the vaccine. So I think it’s a similar way, it’s just harder now. I think we’re going to move an inch every week to get to that 70% number, or 80% to 90% that we need to be at, but the playbook’s very similar to what we did at the beginning of the pandemic.

POLSTER: I agree. I would just build a little bit in, you know, with our pharmacists being imbedded within the community they do have the power to really influence and work with community leaders, work with church organizations, religious organizations, things like that, to help with off-site clinics. I know, for example, the First Ladies of Chicago are a very influential group, and we work with them to help do vaccination clinics at their places of worship. And I do think that we can’t underestimate the power that all of our retail pharmacists have in the community because they are a trusted resource. And we just have to — similar to what Sid was saying — really encourage them to continue to stay as involved as they can in the community, because they are making such a huge difference.

HOEY: Jeff, I’d just agree with what Tasha said. And I would add that those relationships are especially important. And I think just with the recent news of the booster that we’re going to see different layers of vaccine hesitancy. So we’re going to have vaccine hesitancy from the people who have not, you know, the 30% or whatever percentage of people who just for whatever reason are “No way” until they get COVID themselves or a loved one gets it, and we’ve seen some of those converts in the last month or so. But with the boosters rolling out and then the immunocompromised and it being a little bit fuzzy on who qualifies for immunocompromised and who doesn’t — I mean some of it is very clear, but some is not. I think that’s where the trusted pharmacist is really going to be called in by patients to hear, “OK, do I really need this booster? Hey, I was on board, I was sort of on the fence to get the vaccine in the first place, but now you want me to get a booster? Am I going to have to do that every eight months from now on? For the rest of my life?” I mean, it’s questions like that, where I think the trusted relationship of the pharmacist as the source of truth is going to be very important for, again, the second cohort of vaccine hesitancy as well as that initial cohort of vaccine hesitancy.

POLSTER: Yes.

HOEY: Tasha, you mentioned how busy the pharmacies have been and they are, and I don’t think that’s going to lighten up at all, because of all of these questions that are going to be coming through with the booster. But it’s a great opportunity for us at the same time.

OWENS: I want to build on Doug’s and Tasha’s point just around the influencer. So to take a step back and, Jeff, you asked a question around forward thinking, right? So a lot of the questions I’m getting from branded manufacturers as well as retailers are focused on trying to understand ways to help the shopper. The physical infrastructure of a pharmacy is now more needed than ever before to help the shopper with their health journey. Everyone on this call has a really good plan for care. But I think we need to figure out how we further align ourselves with what motivates the communities. Like, for instance, communities of color and folks who have just sort of a predisposition for not doing certain things. Our ability to understand those emotional barriers needs to be factored into our scientific process for shopper decision making. We also have to find more room to bring more of the J&Js into the bigger health conversations, as well as more retailers. Even smaller brands have new social capabilities to reach and influence more from an emotional standpoint versus the traditional top-down approach more brands take. I also think there is a new light, caring touch that the community pharmacist can bring to the new consumer health journey. But I think we all need to actively search for new infrastructure of technology to simplify things and so brands can reach new audiences with the right message at the right time.

WEITZMAN: Brian, I agree that there is a need for technology, especially as we operate as two parallel health systems.

OWENS: Yes.

WEITZMAN: The first health system is the management of a patient’s health information by their insurance company, whether that’s Medicare, Medicaid or a private health entity. Utilizing the connection to that insurer, we can push any number of health engagements to the patient through their doctor and pharmacist, using apps and tools that are part of that system. As we worked to respond to the pandemic and administer COVID vaccines, we established and are running a separate, disconnected system to get Americans vaccinated as quickly as possible, but the data is not available to link and connect people.

ANDERSON: Jeff, just a couple data points on what Debbie just said. I mentioned the 108 million COVID-19 shots that have been administered to date  through the Federal Retail Pharmacy Program. Forty-four percent of those 108 million that went through the program have gone to a person from a minority group in terms of race or ethnicity. That is very important. That’s a really, really compelling statistic. And, you know, we’ve been promoting vaccine equity and confronting health care disparities. Also some of you know that we do a lot of polling in the field on a regular basis, and we use a polling firm called Morning Consult. We did a poll, and this was actually before the vaccines became available. In August of 2020, they found that 74% of adults trust pharmacists to provide their COVID-19 vaccinations. And this was really interesting. Further, at least 65% of each geographic, racial and political demographic indicated such trust. The fact that pharmacists’ trust held up across political demographics is particularly interesting and notable to me. A couple of months ago — Brian as our vice chair and Colleen Lindholz as our chair had an op-ed published. They said pharmacists are not only reaching arms, but they’re also reaching minds in terms of the vaccine hesitancy issue. And I am confident we have played a greater role than anybody else in the health care system through this process of providing COVID-19 vaccinations.

NIGHTENGALE: Steve, if I could just add to that. We didn’t practice this tee-up, but it’s a good one to what I was going to say earlier. In addressing vaccine hesitancy, it’s critical to acknowledge the long-standing socioeconomic and racial disparities that are embedded in communities, cultures and lives throughout this country. It’s going to take a long time and a lot more partnership and trust to overcome challenges associated with this. In addition to the hesitancy stemming from these issues, I’m seeing a hesitancy stemming from a certain type of mindset. And I think it’s a little bit more generational perhaps than anything else, and I’m just speaking from my own experience talking to my young adult kids about all of this. There’s a whole generation that isn’t used to getting vaccines. I don’t think it’s necessarily that they’re against the concept, they just never have needed them on a consistent basis in their young adult lives, and so why now? And I think there are many that have the mindset of “Well, if I can just get through this, then it’s going to go away and I’ll just go on about my business.” So I think there’s another role for pharmacists to play and, again, it takes time, right? So Debbie has a great point that there’s not a lot of time to have these conversations. But I see two things here. One is the potential. Dr. Scott Gott­lieb recently mentioned that the coronavirus is becoming an endemic and becoming like the flu, and it’s not — I think, Doug, you made this point — it’s not necessarily every eight months, but it’s certainly seasonal and you just get in the cycle, right? Because it’s going to come back in different ways. So that’s a mindset shift of “Hey, I’ve been doing OK, and this is going to go away soon — do I need to make this part of my regular thought process?” And then the second one is around the science of it. I think there’s hesitancy because these vaccines did come to market so fast that there’s a distrust in their safety. And I think this is an opportunity for pharmacists to educate that every single time a flu shot comes to market it’s a different one than was developed a year before. It’s the platforms that have been in play. The platforms that have been studied and tested for years, upon which these vaccines were built that allowed them to come to market so fast. This is not a rogue science experiment. So I think education around the development process would help a little bit.

Woldt: Maybe you could tell us to what degree people are coming to Health Mart and saying, ”What should I do?
What guidance can
you give me?”

FARAH: We’re seeing quite a bit of that. Obviously, a lot of questions for all the great reasons, right, that were mentioned. I will maybe add one element around the generational kind of differences. You have younger people that are not used to potentially even walking into a pharmacy at all and not only are you asking them to take the vaccine, you’re asking them to go to a pharmacy and do that. When thinking about our engagement with the different patient populations and meeting them online or meeting them at home — it’s a different engagement from maybe what we’ve been used to, and our pharmacies have been used to. So it’s a little bit back to, Brian, your point around changing the mindset in the way we engage with the patients to educate them. And so we’re seeing more and more of that. At least in the last year and a half I’ve seen a lot more of our pharmacies actually reach out on social platforms and start talking about what they’re doing and trying to educate their patients and all patients — not just their patients. We need to continue to think about how we reach those patients. Because they’re really engaged differently, and we need to help them understand all the benefits of the vaccines and have that conversation.

Woldt: Becky, it’s been mentioned that flu season is upon us, and today Walmart put out a press release about its plans for it. How concerned are you that the need for flu immunizations is going to coincide with continued demand for COVID vaccines? How much more difficult is that going to make things for the pharmacy industry?

DEDMAN: I think that there are definitely some opportunities as we head into the fall. I know we received an initial supply of the flu vaccine — we actually started receiving it last Friday. And so we’ve had plans in place based on a more normal flu season, with the normal peaks. And now with this uptick in COVID vaccinations again we’re seeing that it’s the intersection of both that’s going to really challenge our associates. I believe in our pharmacists and pharmacy technicians. I think we’re prepared for it, and we’re finding more and more ways to be innovative in the process. Having access to technicians being able to give vaccinations is incredibly important. We are definitely hopeful that more and more states will be adhering and adopting the PREP Act so that technicians can also give flu shots to children and adults. That would be a definite benefit for us in the process and keeping that smooth from a patient experience standpoint. But it’s definitely going to put some pressure on us. I think we’re preparing our teams right now for that. I know in certain areas of the country the need for access to immunizing pharmacists and pharmacy technicians will be more prevalent than others and it’s required us to put some strategic plans in place. It’s definitely going to be a challenge, and we’re up for it.

POLSTER: I think one of the good things that happened through all of this — just to add to what Becky was saying — is that CDC and ACIP [Advisory Committee on Immunization Practices] guidance allowing for co-administration of flu and COVID at the same time. I do think that we do have some challenges, particularly with patients that saw a more active response to the second dose — they might have a little hesitancy to get both flu and COVID at the same time when the booster comes along. But being able to get them both one and done and get the patient protected just in case from the convergence of a breakthrough of Delta and flu at the same time — which would be terrible. So I do think that that is one benefit, to be able to help decrease a little bit of the burden — you can do both at the same time and not have to have two separate appointments that would tie up more of the pharmacy’s time while they’re doing it.

Woldt: Lari, I know you’re involved in research and talk to consumers on a regular basis. How do you see things unfolding? Will people be hesitant to show up at the pharmacy for a flu shot because of COVID and the Delta variant?

HARDING: If you look back at last flu season a lot of people did not get the vaccine and a lot of people did not get the flu. Because we were in the middle of the pandemic, and everybody was wearing a mask and staying at home, and it certainly prevented a lot of that. And we saw a tremendous amount of flu vaccine coming back in the returns process. So it’s hard to say, because this thing is changing every single day with this Delta variant. And I know a lot of people are seeing the same kind of spikes that we’re seeing here in North Carolina. If people end up locking themselves in again and wearing masks all of the time, it may be, “Hey, we’re not really worried about the flu because we’re not going to go out and we’re not going to get it” — and it’s going to prevent them from wanting to get the vaccine. So I really think this is one of those day-by-day types of things. When information comes out and people are like, “Oh, the flu is bad this year, a lot of people are getting the flu,” then you’ll see people get more aggressive on that. So it’s difficult to say. I do think, though, the publicity around the Delta variant — I was just on the phone with the president of one of our local health systems here in North Carolina — 92% of the people that are being hospitalized, at least in the state of North Carolina, are unvaccinated. So the publicity is super helpful because that’s data and people have to draw a connection between the fact that if you’re vaccinated, you’re far more protected than if you’re not. And I think the simpler we can make that message across the entire industry, the more effective we’re going to be at encouraging consumers.

ANDERSON: You know, there’s an interesting article on the front page of The Wall Street Journal today. It used data from all the 50 state health departments and the District of Columbia in terms of breakthrough cases and the number of breakthrough cases — 0.1% of more than 136 million fully vaccinated people in those states came down with COVID. And Dr. Anthony Fauci said in July that 99% of the deaths in this country are happening to people who are unvaccinated.

HARDING: That’s right.

HOEY: Just to add on, I think those are really great stats, and I think they help empower the message. On the flu side, just trying to figure out what the crystal ball is for flu in the U.S. in 2021 we look to the Southern Hemisphere, and there’s an organization called The World Pharmacy Council that I’m the president of, and Australia is a member of this group. So last year we looked at Australia as predictive of what might happen in the U.S. And not surprisingly the number of flu vaccines done in Australia was up like 50%, but the U.S. was also way up. But the flu season in Australia, if it is predictive for U.S., was almost nonexistent. However, Australia’s been much more locked down. They haven’t done as good a job as in distributing the COVID vaccines early through pharmacies as we have in the U.S. So their flu season, again if that’s predictive in the Southern Hemisphere, was almost nonexistent this season. But then you have the factor that they were in a deeper lockdown than the U.S., so it’s really, you know, how big of a lockdown we are going to be in that will be predictive of the flu season. But it’s really hard to find a clear picture in the crystal ball. Others on the phone may have a better sight line into the flu season. But looking at the Southern Hemisphere, it doesn’t look like it would be much in Northern Hemisphere, if that’s predictive.

TENNETI: To your point, the only issue with the comparison to the south is the lockdowns in Australia — everything you just talked about, right? Like it was such a different situation that I don’t think they really allowed the virus to spread and take place. The one thing we are seeing right now is our cough and cold business, and all those other leading indicators are starting to show some strength there. So if you look at that, you start to believe that people are out in the community. The other thing that we’ve told our pharmacists is people probably have lost immunity over the last year and a half as a result of not being out and about in the community.

HOEY: Yes.

TENNETI: So the minute people start stepping out they are starting to fall sick and starting to have some of these upper respiratory issues. So that’s why I think it’s really important that even if there isn’t a severe flu season, any flu season you might not be ready for, given how locked down we’ve been over the last year now. So I think there are two things going for us — one is we’re starting to see that people are moving about. Even with Delta, people haven’t really dialed back significantly, in their communities at least. They might not be traveling broader, but they’ve haven’t dialed back in the communities. That’s a good indicator. The second clinical message that we’re getting our pharmacists is you’re not as immune as you were so take advantage of the flu vaccine.

OWENS: Wouldn’t you also say the pharmacy business results for the past two months across the board demonstrate that overall pharmacy foot traffic’s is up? So I think that’s a key indicator of success, right? People are coming back to the brick-and-mortar pharmacy and, frankly, the pharmacy footfall is increasing. So I don’t know if it’s flu or if it’s just COVID that are the contributing factors. But it just seems like shoppers are coming back and trust the pharmacist more than ever.

NIGHTENGALE: — You’re right. I think part of that is also due to more foot traffic in the physician’s office.

OWENS: Right.

NIGHTENGALE: There’s pent-up demand to go to the physician for checkups and those type of things, so I think we’re seeing some of that come back. Is it limited to a short time frame now? Who knows. But the physician traffic is part of that.

OWENS: Yes.

DEDMAN: I agree with the fact that communities are looking for ways to get their families immunized. Access to pharmacy is critical in areas where access to other immunizing health care providers may be limited. With kids returning to school this fall, too, I think that’s going to be that other contributing factor. We always counted on the fact that cold, cough, flu was going to start to increase in and around that September time frame, and so with kids back I think it’s going to be an entirely different story.

Woldt: That’s true. And I think the Delta variant is particularly worrisome in terms of children going back to school without
a vaccine.

FARAH: Yes. I was just going to add that I think the good news is we do have a strong infrastructure, right? A playbook in place now. We’ve done it many times and we have the reporting, the analytics, the connection, the scheduling tool. So as we think about the booster and the flu vaccine potentially coming together, I think we’re ready for it, so that’s good.

Woldt: I’d like to ask the non-pharmacy people here to give us their opinion about how the perception of the pharmacy profession has changed as a result of COVID.  Will the positive effects — and I assume there are some positive effects — be lasting? Because historically pharmacy would step up, do a great service, be thanked for a month or two and then be forgotten.

RICHARDSON: I’m a pharmacist, so I’m incredibly biased, Jeff. And there are two pharmacists in my family, so I do think this will have a lasting effect. I can’t help but think that what’s happening is the reaction the pharmacy community has had to COVID and to vaccinations in general is so critically important. This pandemic proved the health care infrastructure needs pharmacists front line going forward. Our job in the automation industry is how do we take this dispensing work and better automate it so that pharmacies and pharmacy staff have more patient-facing time. To me that’s what’s critical as we get into both a flu and a booster shot scenario. If we’re able to take a lot of this dispensing work — either get it out of the store or automate it in the store — that just gives pharmacy staff more time to focus on their patients. And that’s, I think, our job on the technology side, that is why we are ready to work with our customers to unleash the full potential of pharmacy.

COUGHLIN: I could add a few thoughts on that.  We used to talk about how much time pharmacy staff has to spend on the financial issues, on adjudicating claims. That continues to be a drain, against a backdrop where we’re trying to foster more patient-pharmacist interaction. It wasn’t too many years ago we were talking about how pharmacists stepped up to support the rollout of the Affordable Care Act. How they were right there on the front line helping people make health coverage enrollment decisions that were very complex. One of the effects of the Affordable Care Act has been to push more people into Medicaid. So, against that backdrop I would like to call your attention to an important development on the Medicaid front when it comes to simplification of the pharmacist’s job. Medicaid largely started as a fee-for-service program where the Medicaid authorities were supposed to be able to make all these decisions regarding what was appropriate and effective for health care. That has largely migrated into managed Medicaid, where the Medicaid authorities have farmed this out to insurance companies. But the managed Medicaid organizations then aligned with their captive or affiliated PBMs to have the effect of freezing out pharmacies from the program through narrow networks. Against that backdrop the state of Kentucky reorganized its Medicaid program by requiring all claims to go through a single PBM. Kentucky picked Medimpact after a selection process. Now, in Kentucky any pharmacy can provide medications through that program. This eliminated the narrow networks and variations in pricing. So this is one state where we have seen a simplification of the process and made it less frustrating for patients, and less time consuming for pharmacists, and afforded more opportunity for pharmacist-patient interaction.

SPEARS: I believe that the pharmacist has a critical role in the whole health care continuum. We had instructed our representatives to call on and educate pharmacists. COVID hit and we made the right decision not to interfere with the vaccination effort and discontinued our calls on pharmacy.With that, we had to figure out a new way to educate pharmacists. We worked with all corporate chain headquarters on an education program to assure pharmacies knew the basics of our new drug. We had to pivot and change the way we educate pharmacists. I think we will continue to pivot. I really hope we can get back in the pharmacy, but it’s going to take some time. Until then, I believe we will continue to work with our partners to assure pharmacists are educated with tools to counsel patients as well as basic drug information.

WEITZMAN: This very topic has been the subject of jokes by late-night hosts. If you know a college-aged student, you know how easy it is for them to get a “fake” as they call it to gain entrance into bars. And those “fakes” look good, like a state license, raising the question: How hard is it going to be to photocopy the vaccine index card? In hindsight, this is something that should have been considered before hundreds of millions of vaccination records were created. It will take a concerted effort to ensure this is a HIPAA-compliant, fraud-proof process. When we get into the endemic stage, we can pivot that into something else; it’s not impossible, but it will be a big undertaking.

HARDING: I just got back from HIMSS and, of course, a vaccination was required to attend. They used Clear, which has been providing these kind of services in the travel and entertainment industries for years and years and years, and I got to speak with the Clear people and they definitely are having a lot of conversations with folks in the industry, because I think that they see this as clearly an opportunity for them to help bring this together and provide a really solid solution for lots of companies beyond just travel and entertainment.

OWENS: I think the industry now has a strong brand-building opportunity. Using the pharmacy infrastructure as the focal point — for example, 9,000 CVS stores where you can get a vaccine — that vaccine incident or credential can be transfered via a retail pharmacy chain all over the country due to the retail pharmacy ability to track their members anywhere they go. Now, to get that legislatively passed, Steve, I’ll let you handle that, right, as you lobby in Washington. And I think it flows into what I wanted to share in terms of the last 18 months — what’s sticking? I think two things are sticking: As a primary care consideration it has accelerated, whether it’s telehealth or in-person. I think that’s one lasting impression. But the second one is communication, right? Advertising has changed, too, in this space. It used to be a lot of print; now some data I’ve seen shows 63% of pharmacy advertising is now digital. TV is still relevant. So for those older pharmacy shoppers, they still watch closed-caption TV, and now you can watch Comcast and you can do the ads when you stop and force people to watch. So I think there’s a lot of opportunity for us to engage and communicate to a lot of the bigger things. But I think what I want us to hold on to is that the view of care is still focused on the pharmacist as the focal point and his or her relationship with the community. I just think the communication around health experiences is where we folks should be investing next. Whether it’s TikTok or Snapchat. Things that Gen Z want to see. I think we all need to try to figure out new ways to adapt health and O-T-C messages on these new emerging social commerce platforms.

Woldt: Will pharmacy be able to hold on to these gains? The PREP Act, for example, has expanded the scope of practice. 
Is that going to be the case three years from now if COVID does, in fact, fade away?

HOEY: I mentioned before, Jeff, that gratitude is fleeting. But I’m very optimistic, very glass-half-full. That said, I think it’s something we have to continue to bang away, you know, not only NCPA and NACDS from an advocacy standpoint but again our partners on this call of the importance of pharmacy because, again, gratitude is fleeting. You know, we’re already in a little dip. It’s quieted in the last couple of weeks, but some of those who would prefer not to see pharmacists in a broader role — they were already popping their heads up just as the pandemic seemed to subside. So, the opponents, they’re not going away. They’re quieted for the moment because they realize that if they go against pharmacy as we’re helping to save the world, that’s not good optics for them. But it’s not going to go away, it’s going to be a continual struggle. That said, I think because of the track record that we’ve shown, especially over the last 18 or 19 months, that the evidence is undeniable that pharmacists play a broader role in public health care. So I do think we’ll get there. I do think we’ll not only hold on to the authority, but we’ll be able to grow it. But I think it’s going to be a dogfight. I just think that we have more of an arsenal now because of the proven track record that we have. But it’s not going to come easy.

ANDERSON: As was said earlier, these PREP Act declarations have been huge, and we worked really hard on all of these to get them enacted from the get-go. And they have had a profound impact. Secretary Xavier Bacerra — our new HHS secretary — has been leading the effort on this saying that the state laws are still preempted by the federal government. It was alluded to earlier in this conversation — on August 4 he gave the PREP Act declaration to include pharmacy technicians among those who can provide flu vaccinations to those 19 and over, as they can for younger Americans. And we just have to keep fighting for these important flexibilities, as Doug has indicated. The NACDS strategic plan that we adopted in 2021 is premised on how we leverage this progress to make even more of a difference for the American people and for the viability and future of pharmacies. I’m sure we’re going to get into this — what would a meeting like this be without discussing the need for DIR fee reform and other crucial policy issues? But we’re seeing strong progress. Frankly, you thought Washington was dysfunctional before, but if we can’t reach common ground on masks and the vaccines, I mean it kind of makes us wonder. Scott Galloway at the NYU Business School was talking about what Americans would have done during Dunkirk in terms of sacrificing for their fellow man. He basically said all you had to do was walk into a pharmacy and you can solve this issue. But we’ve worked really hard at the state level — as Doug has — and just this year we’ve had 60 different improvements in state laws as it relates to pharmacy scope of practice issues. And we’re seeing more of those issues surface at the state level. As a result of the U.S. Supreme Court’s Rutledge Decision we’re seeing a flood of legislation by leaders who want to step up to the plate in the state capitals, regulators and legislators who want to help pharmacies. So we are leveraging that. And Doug is correct, the window is narrowing, and it’s incumbent on all of us to work together. Many of you will recall an individual by the name of Tony Civello who was passionately involved in the industry. I see Brian smiling, and Lari. And his mantra was basically “one voice.” He emphasized that pharmacy had to quit fighting among themselves and work to achieve common ground, and we’ve done that with NCPA and other partners. And I know that by doing that we can really leverage the success that we’ve had — that you’ve had — on behalf of the American people in the COVID response and earn other public policy victories so you can do even more for patients.

HARDING: Yes. Just to add a couple of data points to that, Steve. What we’ve seen with our clients is that the revenues generated from the vaccination process were ranging between 5% and 10% of the pharmacy receivables. That’s a pretty significant number. We also saw these patients more interested in their health now than ever before, and a lot of categories — vitamins, etc. — began to really grow. At the same time, all this COVID-related activity brought in new patients. So you’re seeing a lot of really positive things happening, but the reality is some of our clients have said to us, “If it weren’t for the vaccinations we wouldn’t be making any money at all.” The overwhelming economic condition in pharmacies right now is very, very complex. In 2019 generic effective rates were AWP minus 87.2% and brand effective rates were AWP minus 18.8%. DIR was averaging 2%. That was in 2019 before the pandemic. In 2021 year-to-date generic effective rates are lower at AWP minus 88.2%. Brand effective rates are lower at AWP minus 19.74%. And DIR fees are currently averaging 2.5%. It’s really hard to make money in the pharmacy business. And that is something that we’ve got to overcome.

HOEY: Or we’re not going to be here for the next pandemic.

HARDING: That’s exactly right.

Woldt: A comment was made that consumer attitudes toward health care are changing. Does this open up opportunities for retail pharmacy?

POLSTER: Well, I do think that the pharmacy is still going to be seen as a trusted health care resource. The challenge that we continue to have is it’s a free resource for lack of a better word. I mean, a patient can come in — they get free advice and counseling on perhaps what they could get O-T-C or something like that before they have to pay a physician to actually have a doctor’s office visit. So I completely agree with what’s been said. I mean, we have got to figure out how we can get reimbursed for some of these cognitive services better than we are today. Of course, we have MTM and other services, but I don’t know if anybody’s figured out how to really bring in enough financial benefit of those services to make a difference to the bottom line in a retail pharmacy.

HOEY: We haven’t talked much about the point-of-care testing, but I think that would be one of those opportunities. You know, Arkansas passed a law where pharmacists can do point-of-care testing and actually do some of the prescribing following that point-of-care testing. But just that service — we talked a little bit about flu season and being able to distinguish between flu, strep, COVID — I think we’ve all experienced growth in point-of-care testing, and we see that as a big opportunity for pharmacy going forward.

POLSTER: I agree, Doug. And I think one of the hurdles that we need to get across as an industry to that exact point is the certification and credentialing of our pharmacists to be able to bill for those services on a medical claim, because that is one of the challenges today — there is just not an easy way for a pharmacy to be able to bill, because not every insurance or PBM sees a pharmacist as the provider. They have to be credentialed, they have to be registered to be able to bill for that medical service for the testing. But, yes, completely agree, and I think it’s in its infancy right now, and I think it has a lot of potential, but I think we still have a ways to go in terms of making it easy on the billing side at least.

FARAH: I’d maybe add one last thing. I think remote patient monitoring is another area of opportunity, right? There isn’t an easy way today — obviously pharmacists can’t bill for that. But as we think about patients — hopefully we don’t go into another lockdown — but as we think about potentially engaging with a patient differently, I think that’s another opportunity that if we do enable them to bill and create the platforms and the services to do that, I think pharmacists could definitely play a great role there.

COUGHLIN: The tactics of insurers and payers are pushing business out of the pharmacy by requiring medical billing. We have built medical billing into our operating system to deal with that. Pharmacy needs to be able to do medical billing across a broad range of services and medications, particularly infused medications, because some of the leading-edge meds are coming out in this form. Those are being pushed to the centralized fulfillment resources of the payers and taking that business away from pharmacy.

Woldt: I want to touch on a couple of specific things. One of which is the pharmaceutical supply chain, which I think most people would agree held up pretty well, even when other parts of the supply chain were challenged by the pandemic. Debbie, what lessons have been learned?

WEITZMAN: Your introductory comment leading into this question highlighted that the pharmaceutical supply chain held up incredibly well — a positive of the pandemic we should have shared more broadly. There was so much confusion, anger and focus on the supply chain breakdown for PPE that it became the blanket statement about the entire health care supply chain. As Brian mentioned earlier, the level of cooperation, guided by industry groups, including federal involvement, provided transparency into the supply chain that we did not capitalize on. I’m proud of the way the pharmaceutical supply chain has and continues to perform during this pandemic. Red flags were raised early about potential disruptors, resulting in well-planned and well-forecasted strategies to ensure minimal to no supply chain disruption. This same proactive approach will be critical as the industry faces challenges on drug pricing. The concept of reimportation has the potential to set us back 10 years, before we had traceability and supply chain integrity. Everything we’ve worked on over the past decade could be damaged with the stroke of a pen, add confusion to the supply chain and create risk for patients nationally and globally. We need to look ahead to ensure changing policies on drug pricing do not negatively impact the pharmaceutical supply chain.

Woldt: You made a great point when you said that the health care industry as a whole — and pharmacy in particular — gets a bad rap and really doesn’t do a good enough job defending its position. Have manufacturers experienced supply chain challenges?

SPEARS: We have not experienced supply chain issues, thanks to all our wholesale and supply chain partners. I want to highlight what AmerisourceBergen did throughout the pandemic. They conducted monthly meetings with all suppliers to keep them informed of supply chain challenges and future plans to keep the supply chain secure and efficient. I know these are very popular webcasts, and I would encourage all wholesalers to do the same. They are very informative.

Woldt: Brian, do you want to comment on that program and what it’s done for your customers?

NIGHTENGALE: One of the learnings through all of this was just how important communications is, right? Otherwise if you’re not effectively communicating either upstream to your supplier partners or downstream to your customers — to Debbie’s point — the assumption’s going to be you messed up and it’s your fault or it’s a breakdown in the supply chain. When in fact, again, all parties involved did a great job of making sure the supply chain was there. I mean, we started early on with both sides initiating weekly teleconferences with customers and then also with our suppliers. And sometimes there were thousands of people on the call — sometimes there were a couple hundred or so. So it just varies based on the flavor of the day or the issue of the day. But, again, I think educating each other throughout these types of crises is important so that everybody understands, “Hey, if there is a glitch here or there that we can all work together to get through it,” versus pointing fingers — and I think that’s been the key learning.

FARAH: I think Brian said it best: Communication and collaboration are critical. There are a lot of moving parts, especially in the early phases as we were also trying to kind of build the infrastructure to support the administration of the vaccine. I think a lot of learnings in terms of our ability to change and move quickly also while probably many of the organizations, if not all, were trying to move to remote and working from home. It was a lot of moving parts, but I think it comes back to communication and reaching out and really putting the patient at the center of it. In all of our distribution centers we have a sign on every entrance that says, “It’s not just a package, it’s a patient,” and I think everyone would agree with that. So just continuing the collaboration and the communications across the different parties I think is the right strategy here.

BELKNAP: I think a safe and secure supply chain is certainly something everyone can get behind, whether it be Doug, Steve or HDA. And I think we could do more to communicate publicly about how safe our supply chain is. But we also spend a lot of money on product integrity and security, our investment in DSCSA — we would be very disappointed obviously if drug importation became something that we’ve got to deal with.

Woldt: Let’s turn to DIR fees. Steve, perhaps you could give us an overview about where efforts to address the problem stand.

ANDERSON: This is so serious, and it’s getting more serious. A few years ago the government said that these fees had gone up 45,000% from 2010 to 2017. Well, as everybody knows, it’s gotten worse. In May the government said that these DIR fees increased 91,500% from 2010 to 2019. You know, I guess this loophole originated in the Obama administration and had certain unintended consequences that we’re all seeing today. And they did say before they left office — the Obama administration — that these things needed to be fixed. We had a golden moment, and we spent years on this in the Trump administration. And we had a rule that came out and, to his credit, Secretary Alex Azar did an amazing job of putting this together. I think Doug would agree with that. We spent an inordinate amount of time with his team, and we thought we had this thing fixed. And then it went to the White House and because of the dysfunction over there and the infighting within the Trump administration it was killed. And our board went in to meet with the White House saying pharmacies are going out of business, and they charged us with then going back and saying, OK, let’s try a legislative solution once again. Which we’d been trying for many, many years. In 2020, an excellent legislative solution was included in a drug-pricing bill but that larger bill did not make it through Congress. So we’re back at it. We’ve earned strong support in Congress. Probably five, six or seven years ago, when talking about DIR fees nobody would understand what we were talking about. But now there is understanding and together pharmacy will make the most of opportunities in drug-pricing legislation that is being developed by Congress. The bill that would contain drug-pricing measures – the budget reconciliation – could have political difficulties of its own, though. We are making the case that something needs to happen to get some type of relief because, as Doug pointed out, a lot of pharmacies may not be around when the next crisis hits. And this is a top priority for us, and I know it is for Doug, and we really need a united industry on this. Industry members really have to call their members of Congress out on this issue. Many legislators pay a certain amount of lip service to this issue, but we need action on this as quickly as possible before we lose more pharmacies.

Woldt: Doug, you also feel very passionately about this issue.

HOEY: Everyone at NCPA does. As Steve said, for us it’s the No. 1 issue — it’s the No. 1 thing when pharmacies say why they went out of business it’s because of pharmacy DIR fees. We filed a lawsuit against HHS January 15, and that’s moving through the process. It was sort of a last resort filing a lawsuit against the federal government, which is your single biggest payer, but we had no choice. As Steve said, we collectively have tried legislation, we’ve tried regulation, and it just hasn’t worked, so in addition to the lawsuit we continue to advocate. As Steve said there could be legislation — we’re hopeful because we’d much rather have a legislative solution than to continue to push it through the courts, but it’s got to stop. And it’s not just the independents, it’s the chains that are getting hammered by pharmacy DIRs as well. One big holdup that we see on the congressional side is that pharmacy DIRs artificially suppress patient premiums by causing drug costs to go up for seniors who use the prescription drug benefit. And probably everyone on the call knows that, but no politician wants to have that campaigned against them that they were responsible for increasing premiums on a senior. Even if it’s only, you know, a couple dollars a month versus higher prescription costs. But we’ve got to get members of Congress to understand that it’s an artificial suppression and it’s causing everyone else in the system, including the people who use it, to pay more for their drugs. And to Steve’s point, as far as reaching out to members of Congress, especially the leadership — the Pelosis, the McCarthys, the McConnells, the Schumers of the world — those are the ones that are really some of the choke points in our estimation for this legislation. So if anyone knows Chuck’s or Mitch’s number, help us give them a ring and tell them to get on the stick with pharmacy DIR.

FARAH: Here’s a stat that reflects what we’re seeing. More than 70% of the time whatever the pharmacist sees at the point of sale is irrelevant, right? I mean, how can you manage a business when you don’t know what you’re actually making on that individual transaction? It takes sometimes 15 to 18 months after that they can actually truly understand the profitability. I mean, this really doesn’t make sense. It continues to be challenging for pharmacists to manage their cash flow — predictability, you know, these percentages continue to grow. There’s really no stop, and we continue to see pharmacists just bear the burden of that. And, Doug, you talked about the patient — they’re going through the Medicare donut hole much, much faster, because the DIRs obviously are, in fact, basically increasing the price at the point of sale only to come back later. So there’s impact to the pharmacy, there’s impact to transparency, there’s clear impact to patients, and that’s why we’re very supportive of DIR reform.

Woldt: We’ve talked about community health care being the wave of the future. Retail clinics seems to be riding the crest of that wave. Siddharth, maybe you could tell us a little bit about CVS’ experience with the HealthHUBs and the Minute Clinics.

TENNETI: We see them as an important part of our ecosystem. When you think about some of the conversation we’ve had about where pharmacy should go and what the pandemic has amplified, when you think about supply wheel, and you think about a patient walking in, and you think about how we can help perhaps from a holistic care perspective — I think that’s where we see the clinics come in. You know, the pharmacist and nurse practitioner in our HealthHUBs offering more holistic care. That’s certainly something that we are all probably looking at, and I think HealthHUB is our first foray into that. And it’s really trying to take the conversation away from some of what we talked about — the dispensing — trying to reframe the conversation at the pharmacy as a health care setting and less as a place where you go to pick up your prescriptions. And the clinic and pharmacy work together to create that kind of environment. So I’d say that’s where we’re trying to go is rebrand ourselves from an image perspective, from a consumer perspective. And I think the pandemic will help here as well. We are not just dispensing prescriptions; we can help with your health care needs. And there are many things we can do within those four walls to help with your health care needs.

Woldt: Becky, you are working on a very ambitious model — Walmart Health. How is the format evolving?

DEDMAN: It continues to develop and grow. All of our pharmacy sites across the country are working to be centers of well-being for our customers and for the communities that we serve. And that’s 5,300 locations. We’ve also opened 20 Walmart Health Centers in Arkansas, Georgia and Illinois. And we’ve got more to come in Florida. And so as we continue to grow that unit, that mechanism of taking care of the whole patient, we’re going to continue to add offerings. Currently we offer primary care, hearing, dental, counseling, optometry, lab services, X-rays, and nutrition and fitness classes; we also provide education on health insurance enrollment. The list goes on. But it’s really looking at that collaborative approach within that health care system — the ecosystem within those units — that’s really providing a different level of care that’s really special. And so we’re going to continue to lean into that space. More to come next year. And I think they’re pretty special in what they can offer patients.

Woldt: Tasha, at Walgreens you are working with VillageMD. Can you tell us a little bit about your experience with those outlets?

POLSTER: Definitely. The VillageMD partnership as we start expanding into more of a collaborative agreement between the physician office and having a pharmacist imbedded within that practice to help with outcomes. We’re starting to see some really good results — very positive results with the patients and showing what a difference a pharmacist can make in the health care team to help with the patient’s outcome and their health condition.

Woldt: I’d like to ask about building digital-based ecosystems for health care. All of the people here have at least given some thought to that. Mike, are we going to get to the point where we have a digital-based health care system?

COUGHLIN: It’s an interesting question. We have so many different applications from robotics to pharmacy management to financial management, etc. And we are in the process of porting this into sort of an overall data structure that is made available to our customer and doing it in such a way that it’s on a large-scale platform — Microsoft Azure in this case. And also it has connectors so that our customers can use their common, their preferred BI tools — business intelligence tools — to tap into that system. And then that can become part of the overall data warehouse, which is a term that’s commonly used for the health system. So, yeah, there’s definitely progress being made in this area, and it’s extremely important.

Woldt: And Marv, will that trend extend from the business partners to the pharmacy down to the consumer?

RICHARDSON: Yes — and we’re in the early stages of understanding how health care can shift from an acute care setting to the retail setting. I like what Steve Anderson noted about 90% of Americans living within five miles of a pharmacy. That’s a real opportunity for iA to work with our customers on the back end to help create the time pharmacists need to step into that role and change the way consumers think about the health care setting. I think you probably saw the announcement last week about NEXiA. It’s a big initiative that helps iA’s customers learn from the data to help pharmacies improve the management and efficiency of prescription fulfillment, enabling pharmacists to spend more time with patients. That’s when the back end reaches the front end and the consumer — because when common tasks like dispensing are removed from a retail environment, we create the time and provide pharmacists with the information they need to practice at the level they are trained for.

Woldt: Brian Owens, you watch the market and the consumer closely. Is this something the consumer is ready for as a means of interacting with pharmacy?

OWENS: Yes. I think a lot of this conversation circles around consumer-based technology, so we think about Google, we think about a lot of the interoperability of data. The ability for our consumer to be able to transport their data. I mean, I’ve worked with you guys a lot about talking about some of this stuff in the past. You know, as your phone becomes more of your portal to yourself, that leads us to an opportunity to be able to reach and engage and change. So, in my article, I talked about Thrive Global. I think about those behavioral services. The ability for somebody to be able to diagnose themselves. I think the retailer is more of a custodian of these services — an enabler and almost a connector of all the departments to that individual. So I think the bigger opportunity is really that 360 care — how you bring product services but more in a digestible way for that individual to understand. I don’t think we’re there right now. But I do think Generation Z will be there when they have more purchasing power in the next five to 10 years. So our ability to build an infrastructure now around that and almost test more, almost push ourselves to do more of those almost engagement platforms — I think that will allow us to have more permission to be able to push a lot of the science that we all possess right now. I just think the consumer is behind the industry a little bit when it comes to the value that we provide. But I think the infrastructure of technology is giving us a new pathway, because digital health is going to be growing at 25% over the next five years. I think it’s like $657 billion. There’s a lot of money out there. And all the VCs and private equity are spending their money in that space. So the transformation might not even be coming from here, it might be coming from some kid in Idaho who is really good at coding and connecting dots. So I just highlight that because direct-to-consumer is a phenomenon that’s transforming a lot of the spaces that we all participate in.

Woldt: So are we headed to personalized care on a mass scale?

OWENS: If we go to value-based care and outcome-based care, yes, if the legislation allows that, I think we get here faster. So I think Washington, Affordable Care Act, all that stuff will allow us a clear gateway for what we’re talking about in this conversation.

Woldt: One final question. Brian mentioned value-based care. Is the industry making progress in trying to persuade payers — both the government and the private sector — to move toward value-based care as opposed to the current fee-for-service model?

NIGHTENGALE: I think we’ve got to stop commoditizing the prescription. You know, pharmaceutical care is the most valuable, the most impactful type of care there is in terms of prevention and wellness. But it’s been commoditized. And so it’s really difficult for pharmacy and pharmacists to participate in value-based care when their entire profitability is based on a percentage on a prescription and a product. And so as that margin as we’ve talked about quite a bit here, whether it’s DIR fees or other recoupments or just base reimbursement going down, that margin goes down and down and down — there’s no money left for the pharmacist to put at risk, right? And so value-based care is predicated on being able to put some skin in the game to get some value back for the positive outcomes that you contribute. The pharmaceutical model doesn’t allow for that right now. So the faster we can get to decoupling care from the product and changing the basic reimbursement structure model for pharmacy, then pharmacy can participate in that. So we need a fundamental change in the reimbursement model for pharmacy in order to be able to participate. Because right now some DIR fees are tied to “quality” and you’re not getting any upside. Even if a pharmacy does everything possible, they might get a quarter of what was taken back. So it’s fundamentally broken, and we’ve got to fix the pharmacy reimbursement model. And then and only then can we capitalize on all of the clinical care the pharmacists can and do provide and incorporate that into these broader value-based care models. That’s my soapbox.

HARDING: I would just add that so much of our industry operates on this annual cycle. And the problem with that is if a patient doesn’t take their blood pressure medicine every day it’s not a problem that they’ll necessarily have this year, it’s a problem that they’re going to have that will be much more expensive several years from now. And they may or may not be covered by a particular payer several years from now. So the payers are not worried about several years from now. It’s the trickle-down of incentives across the health care supply chain that we haven’t lined up in such a way to really be successful. It’s a tough problem to solve. There was quite a bit of discussion on this very topic at HIMSS last week. Even in the health system world where they’re seeing a lot more of their reimbursements and value-based care, it has definitely not taken off the way people originally thought it would.

HOEY: I think that’s exactly right. And it’s a hard problem to slog but I think we’re making slow progress — it’s just very slow. Lari would know the exact stats, but it’s something like $16 billion taken back in DIR, but only about 8% of that is paid back in actual rewards to the pharmacists, to Brian’s point. But I think in addition to pharmacy DIR one of the fundamental problems we have are the quality measures that are being used. They’re not attached to outcomes. So the quality measures like proportion of days covered, PDC, for example, is a very imperfect measure of adherence.

HARDING: Yes.

HOEY: A patient could have a cabinet full of medication and not take any of it, but the PDC score for that patient could be 100%. So the patient could have a terrible outcome but have a high PDC score. So I know that’s something, and we work with NACDS on this and others to try to fine-tune those quality measures to something that really is an outcome. So we’ve got the CMS hurdle to try to understand that. Especially with new administrations you have different mindsets coming in. But then also on the commercial side CPESN has had some success with some payers on paying for outcomes. But it is a very inch-by-inch, step-by-step kind of process to get to where we need to be. But it is forward progress; it’s just super slow.

COUGHLIN: If you look at the inpatient world, it’s almost all value-based care, OK? It’s capitated, DRGs [diagnosis-related groups], etc. — you get paid a certain amount, period. They don’t even report to the payer the drugs they’re using. I mean, they just use what they need to use, and they get a flat amount. That is so different from pharmacy, because in an inpatient world you know the patient’s there, they’re in the hospital bed for a period of days. In the outpatient world you have no control over them. They could go to another pharmacy, etc. I think this is almost a pipe dream for pharmacy if you look at where we’re at now versus where we need to go to really replicate something like that.