David 0:00

Are networks of locally owned pharmacies the answer to delivering lower cost, higher quality, and higher patient satisfaction? We'll find out on this episode of Shift Shapers.

Announcer 0:13

Change either paralyzes or energizes. The choice is yours. You're listening to the Shift Shapers podcast. You're about to learn firsthand from businesses and entrepreneurs who have successfully shaped the shifts in their industries. Get ready to become the change you want to see. This episode is brought to you by Shift Shaper Strategies. In sales, if you confuse, you lose. Clarify your message so you win more clients, crush your sales goals, and build your practice. Learn more at ShiftShaperStrategies.com. And now, here's your host, Storybrand Certified Guide and Chief Transformation Strategist at Shift Shaper Strategies, David Staltzman.

David 1:04

Our guest today is Troy Trikstatt. Troy is executive director of CPESN USA, which stands for Community Pharmacy Enhanced Services Network. Now, I don't know how many of you even know about Community Pharmacy. Some of you do, but by the time we get done, all of you will, and you'll understand why. It's a very interesting model, and that's why we invited Troy to spend some time with us today on this episode. Hi, Troy.

SPEAKER_00 1:27

Pleasure to join the podcast, and nice to meet you, David.

David 1:31

Thank you. Our pleasure to have you. So let's start with what is CPESN?

SPEAKER_00 1:35

CPSN by construct is a clinically integrated network. So some of your audience might be familiar with that term, some not. Clinically integrated networks actually a Federal Trade Commission concept. And the idea, particularly in healthcare, the Medicare sort of machination of this is the accountable care organization. But this idea of how do you get multiple, otherwise competing or needing to collaborate healthcare providers together to do value-based contracting, population management, network offerings, and together offerings. And so for small healthcare providers like the pharmacies that we serve, getting together to have collective value expression is pretty critical in an age where you sign contracts based on network adequacy and market presence, right? So at the end of the day, our job is to bring together the value propositions of a lot of mob pop pharmacies out there and really act like a chain without being a chain.

David 2:30

So what's the problem that's being solved and what's the scope of that problem?

SPEAKER_00 2:34

Well, yeah, if we go, I have a little bit of a health economist background by training as well, so I'm I'm inclined to go all the way back to the big picture. Oftentimes when I'm talking to groups or student groups, I'll say, you know, in healthcare, imagine going to the car dealership and picking out a brand new car, and after you've declined the undercoating and signed all the paperwork, it's there in the room, and they give you the keys, and you get into the car and you turn the keys to a brand new car, you push the button, I guess, now, and the car doesn't start. Well, what would you do as a typical consumer, right? I'm not driving that off the lot. Can I have another car? Can I have my money back? But in healthcare, we say, oh, we tried, right? And oh, by the way, if you need to fix it, we'll be happy to sell you. We can go down to the service unit and charge you for that too. And so we know this in healthcare, right? We've got this value problem, accountability problem, fee for service. How do we evolve from fee for service? Well, that evolution's been going on in medicine for, in clinical integration for decades, health systems, large medical groups, etc. Then we got into Medicare modernization of 2003. The group I used to work with was a primary care clinically integrated network in North Carolina, participated in the first ever shared savings program with a group in Indiana. Believe it or not, a lot of the antecedents in the part of the Affordable Care Act that people don't argue about, how we pay for healthcare differently, happened with Mark McClellan's uh Medicare Modernization Act of 2003. So there was that experimentation going on from 2003 to 2009, and then there was a lot of pages in the Centers for Medicaid and Medicare Innovation Center, and then commercials started to pick it up. So that now, depending on where you're at and what type of provider you are in the system, you've got either significant or almost sometimes complete, some sort of value-based arrangement, shared savings arrangement, captive arrangement. Well, all along the line when this was going along, we all left pharmacies out. What was pharmacies' access to value-based contracting? And so what we spend most of our time with is how do you gather mom and pop pharmacies that have an incredible level of value, but only when expressed in aggregate, if you're going to be doing value-based contracting across populations and offerings and services. And so for us, CPSN is all about how can you be a one-location pharmacy in rural Kansas, but contract with 3,500 other pharmacies to have a common product and a common set of performance metrics.

David 5:03

So let's discuss this in two contexts in terms of the problem and the solution. One is on the industry side or the plan side, if you will, and then the other side is on the patient side. And there's there's two very different avenues that you serve. Let's talk about the plan side first. What kind of a difference does this make for, I'm assuming it would be like a self-funded plan where you'd carve out pharmacy and then drop pharmacy back in? What kind of difference does this make for those folks?

SPEAKER_00 5:27

Depends on the self-funded plan. So if it's a school district somewhere where maybe there's three or four pharmacies, 10 pharmacies around their employees, they might be able to work together in some kind of an arrangement or relationship directly. Sometimes contracts and big networks, TPAs, PPOs, PBM network contracts might get in the way with that. But that's a different value proposition than say maybe an employer that's in 30 states, right, and has a thousand employees in each state needs some way of working across geographies and across otherwise disorganized healthcare providers called small pharmacies, independent pharmacy. So to be able to package that together so that it's sort of like an Airbnb concept. Hey, at least we can organize them together, common standards, common service offerings, common data flows, but you're still getting that local flavor, local feel, customized, meeting the needs of Western rural Kansas being different than the Bronx, for instance.

David 6:31

Is there generally speaking a financial delta? Is there savings involved in this for the plan, or is it pretty much apples for apples with going other routes?

SPEAKER_00 6:38

Interesting question. You know, there's really two parts to community pharmacy now. And the second part I'll talk about is the part we're most interested in. So the first part is look, I need medication, I need it filled. A commodity type of a situation, right? Very purposefully and by regulation, if you go get lysinipril 10 milligram tablets, which is a common medication that a lot of members will be on across the country, it's meant to be the same product in the same type of distribution method. Wherever you go, 60,000 pharmacies out there, or mail order, or defense department, very, very consistent. That's a good thing. So that whole sort of commoditize side, right pill, right bottle, right thing, right ingredient, right drug is one part of the business. That's the traditional part. The part we're trying to grow is the part where, you know, the American Pharmacist Association made a statement about 15 years ago that was validated during the pandemic, frankly, with vaccines and testing, etc. And that is the equivalent of the U.S. population walks into a pharmacy once a week. Right? So access readily available healthcare providers for a service, right? And so the idea here is that, you know, on that side of the business, it's a commoditized business, but on the service side, different people need different levels of service. Service providers are a little bit different, right? Some folks like a chain haircut, and that's what they need, that's what they want. Awesome, but it's a service. You know, the shampoo that they sell is the same pretty much anywhere, right? There's different brands of it. That's the product side. On the service side, though, some people want a hairstylist, some people need uh you know, wants, needs, and desires are different on the consumer side. So on the service side, for us, what we tell our pharmacies pretty frequently is you're not dispensaries anymore. You can't be dispensaries anymore. That's completely commoditized, and it's not a value proposition in 2022. What is a value proposition is to use that dispensing event and the trust and the access and the frequency of our interaction as a very qualified healthcare unit with very qualified, underutilized healthcare providers as a way of engaging a patient differently, right? And I'll often also say, so I'll ask you, David, what do you know what the leading cause of blindness is in the U.S.? Diabetes. What's the leading cause of lower leg amputation? Diabetes. What's the leading cause of chronic kidney disease, probably the most expensive disease state within Medicare? Diabetes. How do we treat diabetes in the U.S.? And before you answer, we're not keen on exercise and diet. It's meds.

David 9:15

Right. We pump people full of insulin. Yeah, absolutely.

SPEAKER_00 9:17

And it's titrating and working with them. And yeah, we want to do exercise and diet, but it's almost criminal that we don't let pharmacies work with other care team members to be that frequent touch point of contact. So on, you know, the product's the product, right? And it's meant to be very standardized and how we get it to you. But we have a whole lot of people that are not very well managed on chronic disease. We have a whole lot of people that want to access quick healthcare services like vaccines, flu tests, screening, strep tests, those types of things in a very affordable and convenient way with very qualified, standardized protocols around this stuff. And that's the area of the marketplace we're very, very interested in. We're not abandoning dispensing. It's actually that dispensing event that's giving us this unique frequent touch, trusted relationship with the public.

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David 11:04

So would it be fair to say that to the extent that there are savings, it's longer-term savings by creating a healthier population?

SPEAKER_00 11:11

It's both, really. So on the product side, on the independent side at least, going back to your question prior, if you look at consumer reports, independents over and over actually are the ones that provide their drugs at cash pay the lowest. Right? That's why a lot of school districts want to work very locally on sort of direct option. It's actually the cheapest. On the service side, we suffer, we, the pharmacy world, suffers from the same problem that primary care suffers from, that is still pronounced, but not as pronounced in other countries. And that is time horizon. In dentistry, they're very good at preventative medicine. But it's also mostly kind of a cash pay kind of a sector, right? But when you've got third party and those third parties or legislators operated on an annual budget or an annual decision making or an annual benefit cycle, you've got the problem in pharmacy and in primary care where you're trying to take care of a patient to put them on a trajectory that makes them healthier and provides savings and wellness over a long time horizon. And that's hard to do as a captive, an insurance concept. And you can all, you know, if we have a whole podcast about post-World War II labor rate controls and these type of how we got into this mess in the first place, right? But we're here. And a lot of it's the benefit cycle. It doesn't fit the value proposition of a pharmacy or primary care very well. Now, having said that, there's a good number of studies out there that do demonstrate that convenience care types of services, stuff that I would consider screening for brief intervention, referral, and treatment. Hey, what do you have going on? Can I screen you? Hey, you need a vaccine, you need flu testing. It's cheaper to go through a highly accessible, relatively straightforward, protocolized community pharmacy than to get stuck in a system that's both complex and leads to other types of potentially unnecessary services.

David 13:10

So explain a little bit about how the integration with the other elements of care works when you're working in this kind of a network scenario.

SPEAKER_00 13:18

Yeah, we ran into this with the oral antivirals and the pandemic. You know, the FDA came out and said, hey, the PrEP Act allowed pharmacists to order tests, allowed pharmacists to order vaccines. There were sort of broad protocols with public health. Pharmacists are really good at following instructions, right? Here's the protocol. It's our nature. What do you want me to put where and how? What service, how, under what circumstances otherwise, refer, you know, get to others. And one of the interesting things about what the FDA did is they, in an unprecedented way, is they specifically called out nobody should be able to order this except physicians, nurse practitioners, and physician assistants. And within a week of those products being launched that have a ton of interactions, right? So they're they're good, but there's potential pregnancy issues, potential concomitant condition, and contraindications with other medications. We were getting a lot of phone calls from our participants saying, look, we got docs that this is new. They don't necessarily know where the product is, they don't necessarily know which product as what kind of coverage. They don't know, and I can attest to this over 20 years. Most PCPs do not have on their medication list what you're actually taking. It's one of the worst places, actually. Now we want to help those PCPs, you know, sort that out, but when it comes to accuracy of what else is going on with your medications, and can we make sure that you don't have concomitant medication issues going on, concomitant meaning working with the other medications and conditions on board? I want to go to my pharmacist for that that's that I'm sending all my meds to. So there was a study done not too long ago, about 15 years ago, testimony to Congress. The average Medicare recipient with multiple chronic illnesses goes 13 different prescribers in a year. They're 50 times more likely to have a hospitalization, or 100 times more likely to have a hospitalization, they pick up 50 unique medications in a year. None of those 13 prescribers have the same meds in their profiles.

David 15:20

It's really amazing.

SPEAKER_00 15:21

It's really amazing. And so I think what I often tell folks when I'm in care team member kinds of conferences, look, pharmacies don't want to take over your jobs. That's the last thing in the world they want. They want to figure out how to work with you efficiently and effectively to optimize care delivery. And one of the really cool things about a lot of these local pharmacies is that they've got different relationships, oftentimes integrated, maybe not in the big systems, right, where everybody gets lost anyways. But if you go out to Salina, Kansas, or Winfield, Kansas, great example with Graves drug out there, town 11,000 out on the plains, right? And you go to the drugstore, those pharmacists tend to have a pretty good, close working relationship with the primary care providers in town. And it's a meaningful professional relationship. It's not just are we dealing with pro authorizations, et cetera. And when we first started these networks, it was interesting because I was on the primary care side with about 4,500 primary care providers in a network. And we said, hey, crazy idea. Would you want to work with pharmacies out there? We've got 1,200 care managers, 40,000 home visits every quarter, all these prescribers. Now we've got all these high-touch management. How do we change health trajectory of patient-patients? And you're in front of them all the time. You tell us which pharmacies you want to work with. And of the 147 pharmacies they sent in in a week, 139 of them were small community-owned pharmacies. So this is frontline healthcare providers, right? So then I go back to them, some of their leads, and I say, Hey, what do you think about working with community pharmacy? It'd be great, but boy, that feels like it's on the hard pile. What do you think about working with Ashley Abode out there in the East? Oh, she's great. We work with all of our hard patients with her. You know, hey, Dr. Robinson and Conqueror, what do you think about working with community pharmacy? I love to Norman Rockwell painting, Motherhood and Apple Pie, but it's just kind of hard mechanically. It's messy out there. What about working with Moose downstairs? Oh, yeah, we work with them on all of our hard patients. And so what had happened was when we started putting this thing together was all of these kind of one-to-one relationships already exist. Frontline providers, not management level, frontline providers to front prime providers, fixing problems out there, no payment model around it, right? No formality to it. And we said, well, wait a second, what if we string all these together and leverage all of these local relationships, but create a common way of value expression so that you know if I've got a membership, I can go to any one of these and be in a system, but still get that local relationship. And so most of our folks have really, really, really strong relationships, trusted, respected working relationships with particularly primary care, particularly family medicine across the country.

David 18:04

Well, with all due respect to you youngsters, I'm just old enough to remember when that was the normal relationship with a local pharmacy. So we're kind of taking all the gobbledygook that's been strung together that's made it impossible, and we're now weaving the old fashioned y stuff back into it so that it actually is possible. And I can tell you personally, it was a much better model. We've got about two minutes left. Where do you see this? How do you see this moving in the future? And is it mostly going to be geared towards people with multiple chronic conditions or long-term serious disease?

SPEAKER_00 18:36

I would have said that prior pandemic, we are at two million household doorsteps every single month with medications. Think about that. We're in the process of figuring out how to train those folks to do meaningful healthcare-like or quasi-healthcare interviews, these kinds of things at the door. They're already delivering the meds to their houses, right? Most of our pharmacies, they're synchronizing. Like when you think of Amazon PillPack, they've been doing that for years, right? They just haven't been organized in a marketing campaign, right? It's really very hyper-local. So most of their clientele tends to already be the types of clients that need extra services. If you're getting $4 amoxicillin or augmenting for an ear infection, you're kind of going anywhere for that. And that's fine. So they're already kind of concentrated with patients that need these extra services for chronic disease. Most of the patients in these pharmacies are scheduled with an appointment already ahead of time. That's called the appointment-based model with med synchronization. But then the pandemic came along. And it turns out that these screening for brief intervention, referral, and treatment types of activities. Hey, do you need a vaccine? What type of vaccine do you need? Do you need testing? These kind of micro episodes of care, they're also really good frontline. Hey, here's what's going on, looks like it's taken care of, or here's what's going on. I need to get you to somebody. I think both of those dualities now are going to be the case going forward in time. How you package those as a chain pharmacy or a CI, a clinically integrated network of independent pharmacies, and figure out how pharmacy does that like medical does it. Because right now, the contracting and the networks are built off of product reimbursement. They're not built off of services, right? So that's what needs to sift out is how do these pharmacy networks that provide these services, chronic and sort of convenience care, acute, screening types of services, how do they actually contract and adjudicate, and then how do they get into this value-based contracting? So a lot of, we've got over 100 contracts that are very pilot-ish, but the marketplace hasn't matured because pharmacy got marooned off in the early 80s, where it's its own IT, it's its own way of reimbursement, it's its own everything, and the rest of the world's moved forward with services and value-based contracting. We're just trying to bring pharmacy along with it, right?

David 21:00

Well, we hope you'll come back as this grows and as this becomes more entrenched and more mainstream, and those little pilot projects end up being more of the norm. Troy Trigstadt, Executive Director of CPESN USA. Troy, thanks so much for sharing your expertise with our audience.

SPEAKER_00 21:15

I'd love to be here. It's a podcast I listen to on my bike. Thanks for having me, David.

Announcer 21:20

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