David 0:00

How can employers turn pharmacy from a cost center to an investment center? We'll find out on this episode of Shift Shapers.

Announcer 0:09

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 ShiftShaper Strategies.com. And now, here's your host, Story Brand Certified Guide and Chief Transformation Strategist at Shift Shaper Strategies, David Staltzman.

David 1:00

We've asked Chris Anthepass to join us today. He is a PharmD and Director of Pharmacy Solutions at Henderson Brothers, Inc. Welcome, Chris. Thank you. Pleasure to be here with you, David. We appreciate your time. In a kind of short nutshell, what's your journey been like? Because I think that informs a lot of the work that you're doing today.

SPEAKER_01 1:18

Sure. So my journey in pharmacy began a while ago, graduate of the University of Pittsburgh School of Pharmacy, with a strong passion for community pharmacy and a desire to be a pharmacy owner. So spent my career going back to the early 2000s, all in independent pharmacy, leading up to the purchase of an independent pharmacy where I've practiced and managed a staff of more than 50 people. And soon thereafter, recognizing that the buyers of healthcare, namely employers, may be led down a pathway that is not really working in their best interest and maybe more importantly, the best interest of their employees, members, their families. So about four or five years ago, I got into employer benefits consulting around pharmacy. And I've been with Henderson Brothers for about three and a half years, which Henderson Brothers is a regional benefits brokerage and consulting firm, among the largest in our market here in southwestern Pennsylvania, the Greater Pittsburgh region. And we serve hundreds of clients from fully insured to self-funded. And through my knowledge and expertise, put a lot of my effort and energy on the self-funded client side. And it's important to note that along my pharmacy ownership journey, I also started, I founded a specialty pharmacy licensed in all 50 states, dual accredited by the highest accreditation standards. And so my perspective as an advisor and consultant is really informed by my direct patient care experience that's ongoing, which I sit today in my specialty pharmacy, and my understanding of the clinical and economic side of pharmacy. So really it's a, as I said, a pleasure to be here with you and share a little bit about my story.

David 3:10

Well, I appreciate that. And anybody who works from someplace where they put French fries on sandwiches can't be all bad. I, you know, it's it's a great place to be from. Absolutely. One of the things you said to me in the pre-interview that I think really struck me, because most people think that, you know, most employers, most plans think that pharmacy should just be a good deal, but you think there should be more to it than just a good deal. What does that mean?

SPEAKER_01 3:32

Yeah, it's uh really the focus of pharmacy consulting these days is on cost. And we are spending so many resources trying to nail down the price of medications and drive medication costs down. But if you pause from that initiative and you take a step back and take time to think about this, actually practically, you realize that we don't just buy medications just to buy them. We buy medications and patients expose themselves to adverse drug events, which, mind you, adverse drug events are the fourth leading cause of death in the country. So you're taking a medication with risks, generally speaking. We don't just do that to say we got a good deal, to your point. We're taking these medications because we're trying to manage an acute or chronic condition. And if we stop our efforts on pharmacy just to make sure we got a good deal, we're ignoring the most important part of the equation, which comes down to whether or not those medications are actually working. And in viewing this pharmacy benefit and pharmacy costs in this manner, you realize that, as you pointed out in the intro, medications are not a cost center. They're actually an investment center. You're spending money on them as an investment. We're exposing ourselves to risks in this investment with an expectation and a hope that a disease is going to improve as a result of it. And I really think there we are lacking in our entire healthcare ecosystem, we're lacking accountability to that outcome side of the equation. And that's really where we're spending a lot of effort, not only on getting the right price, but also making sure that the good deal includes efficacy.

David 5:32

Well, it's one of the things that, you know, I think employers and pharmacy managers and such are trying to track adherence. And they think that that's the way they measure whether they've gotten in the construct that we're talking about today a good deal. But they really aren't doing much of a good job of tracking it. I mean, aren't the only people who are really doing a good job is Medicare and Medicaid, right?

SPEAKER_01 5:53

Well, that's right. I mean, Medicare and Medicaid have built economic structures in their reimbursement and their incentives to health plans, providers, and pharmacies. They've built in their equations, you know, accountability to adherence. But even when we talk about adherence, adherence is discussed in the marketplace almost as if it's an outcome itself. But it's really not an outcome. Adherence is a means to an outcome. We measure adherence to know whether or not you're taking a drug. That doesn't mean that the drug's working. And to further complicate matters, is adherence today is measured by when a prescription is filled at the pharmacy. I own pharmacies, and our business model is we make money by dispensing drugs. Whether or not the patient takes the medication doesn't affect our reimbursement. We dispense drugs. So when you think about our typical, you know, recommendations that we're making to employers directing folks to mail order because it improves adherence. Well, you're not really improving adherence, you're improving claims transactions. And we really need to get down to number one, is the patient taking the medication? And are we measuring success? Whether it's diabetes, do we know what the A1C is? Just knowing the adherence metric based on a claim is one thing, but no one in my conversations can even tell me whether we know what the A1C is. And this is a fundamental issue. It's not a medical carrier issue. This is a pharmacy issue. We're taking drugs to reduce that A1C. We might have some lifestyle changes or adjustments we're making, but fundamentally, we're using oral and injectable medications to manage that number, that A1C. And it's really missing from the equation today, which is why it's the focal point of our pharmacy consulting in my practice.

David 8:09

Well, let's let's dive into that a little bit more because this is not a new question. I mean, if you go back to you, you chose diabetes as your example. So if you go back to the Asheville project, there that's 15 years ago, 20 years ago, as I recall. And we learned all of those kinds of things, and yet we're still sitting here not doing anything that gives us the answer to those questions. I mean, you know, they when they started studying, they found full-on diabetics who hadn't seen an ophthalmologist in 10 years. That's not a high bar to hurdle. Is this just one more example of the misaligned incentives between drugs, patients, employers, and plans?

SPEAKER_01 8:47

I you are 100% correct. Just last week, I was on a call with a pharmacist involved in the Asheville project, and we were discussing this very topic where we know these things. It's not that we need to work hard to discover that these pathways are relevant and material and important for us to address. And the obvious answer is that the numbers and the economics don't really support that. And it's not that it's not important to the employer because they are the payer. The employer is cutting the check. But vendors, such as pharmacy benefit managers and medical carriers or TPAs, and I don't want to throw my colleagues under the bus, but also brokers, we're not really financially incented to do anything different about it. To an extent, and we view this at Henderson Brothers as we're incentivized to make sure our clients are getting great value. So it's why we are motivated to flush this out at Henderson Brothers. But fundamentally, everybody else just wants utilization, utilization, utilization. But when you pause and look at CMS, they are very aggressively moving towards value-based care. They're aggressively holding medical providers accountable to A1C and blood pressure. And I think it's high time for employers to take a similar posture. And as a broker, we have the opportunity to help facilitate that with vendors. Essentially get creative in how we advise and most importantly, give opportunities to vendors in the marketplace that are actually doing this. Because to an extent, it's happening, it's just the exception rather than the norm.

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David 11:40

So if I'm a broker and I'm in a practice that maybe isn't fortunate enough to have a PharmD on the team and whatnot, you know, we've been focusing on the cost of the drugs because they've been going up so exponentially. And it's only recently that that in some cases the cost of the drugs may actually be more than the cost of not having a patient on the right drug. But the longer-term view, you know, we we talk to clients about partially self-funded plans or level-funded plans and how important claims cost is. And we tell them this is not your year-to-year take the least, worst renewal, jump to a new carrier model. It's a long-term model. It seems that what's that that trying to track the effect of the medications that people are taking is perfectly consistent with that. But but we're not doing it. So how do you change the model so that that actually happens?

SPEAKER_01 12:29

Yeah, it's a great question. And I think that's what we're working to at Henderson Brothers. We are in a mode of determining can we partner for this? Or maybe it's just a market that needs built. Maybe it's a solution that needs to be built, and we leverage our knowledge. I have biases because I'm a pharmacist that also happens to own pharmacies. I own a community pharmacy. We fill more than a thousand prescriptions a day, very high volume when it comes to community pharmacies, a single location. We deliver patients to patients that are 50 miles away. But one thing that's clear about what kind of care can be delivered in the community pharmacy is that relationships with patients can drive behavior change. And pharmacists are the most accessible healthcare provider. We believe that we can achieve outcomes accountability through the community pharmacy to a large extent. The paradigm in pharmacy distribution is that all pharmacies are the same and really convenience is king. So we evaluate pharmacy networks by proximity of the pharmacy to your population. Our pharmacy network says, you know, you name it PBM, our pharmacy network has pharmacies within two miles of all of your members. Not in any of those conversations do they ever talk about quality metrics that say one pharmacy is better than another. Because I can tell you that in my pharmacy, for example, Asty South Hills Pharmacy in Pittsburgh, we have a program where we proactively manage patients' refills. I know that David got his diabetic medications filled on January 15th. I know that I dispensed a 30-day supply of those medications to David, so he's going to be due in the first or second week of February to get those meds. So I call David and say, David, you're due for your meds. And if David says anything but, yeah, sure, send them over to my house tomorrow. Maybe David says, I don't need all of them, I just need these. I have plenty of my statin, my cholesterol medicine. Well, why? What's going on? I at the pharmacy have the ability to jump in and do something about that, identify what's driving that problem, and resolve it. So there are several different ways that we're evaluating, addressing this for our clients in our markets. But one of those key areas is recognizing the difference in quality where the prescriptions actually get filled, and taking advantage of personal relationships and accountability that can be managed by the local provider that just so happens to be their community pharmacist.

David 15:19

Well, I mean, I think that's that's a great start. But I wonder, you know, the question that comes up in my mind is okay, that's great, and that makes sense. How do you then show value to an employer or to a plan, if you want to talk ERISA talk? And how do you demonstrate a demonstrable, repeatable ROI in terms of patient cost that overcomes the additional cost if there is one or the cost of linking these systems? How do you get from where you're thinking is today into the employer's balance sheet?

SPEAKER_01 15:51

Yeah, it comes down to data. You need to have robust analytics. Again, another area at Henderson Brothers, where we have a dedicated team leveraging tools in the marketplace that you're very familiar with, these analytics platforms that are taking in pharmacy claims data, medical claims, vision, dental, all the other sources, any source of data, it's coming into a repository that can provide member level detail. And so what we do is we identify, hey, 15% of or 20% of your population is diabetic. We're going to push them in these channels. We're going to evaluate and track them as a cohort over time. Projects like the Asheville Project and countless other studies, clinical studies out there, they can give us pretty good evidence on what an ROI looks like. For example, a reduction of 1% in the A1C translates to X thousands of dollars in medical cost savings per year. What we need to get is that number. What is the A1C? Can we get that data back into our system? And again, through, I believe, the community pharmacy as an example, we can measure that in the pharmacy. We relied on community pharmacies to take to help us get through a pandemic where we needed COVID testing, we needed COVID vaccines, and my pharmacy, for example, has a CLIA waiver. We can do that in the pharmacy. We can check A1C, and guess what? We can report that back to these analytics platforms, and we can actually measure the impact. And our pharmacy is part of a network. The network for listeners that might be interested, it's called the Community Pharmacy Enhanced Service Network, CPESN. And that's 3,500 community pharmacies across the country. So when you talk about scale and ability, these accountable pharmacy organizations like CPESN can do it. We can measure the actual biometric, we can report it back, and we can leverage analytics to validate that story over a period of time. It's absolutely doable, and we feel that it's a necessity for employers to be moving in this direction. Otherwise, we're on a pathway to unaffordable health care. It's just not going to work.

David 18:13

Well, how do you keep from feeling like with some of the initiatives that Amazon has recently announced about drugs? How do you not end up getting cast in a David and Goliath kind of a battle there where you've got the 800-pound gorilla who's got all kinds of reach, and essentially all they're doing is sending out a 90-day supply just like Mail Order Pharmacy has done for years, but they don't have that personal interaction like a community pharmacy does. How do you counter that?

SPEAKER_01 18:40

I don't think you need to counter it because to your point, you just made the point. There's not, they're different channels. A good friend of mine, a colleague out of Missouri, Trip Logan, he said something very poignant several years ago as we were at some of our industry conferences. He said, some people, some patients need a pharmacy, and other patients need a pharmacist. If you're on the happy path, you're managing yourself appropriately, you just need a pharmacy, you need a vending machine to get you product. And absolutely we want to do that as quickly, conveniently, cheap as possible. But the cohort of patients that fall in the category that they need a pharmacist, we need to ensure that our pharmacy network has the resources to support that. And we know that 5% of employer populations are driving 50% or more of their costs. We're not putting pharmacy on an island. This is all together. You buy a drug, you spend money on the drug, you reduce the cost on the medical side if the drug's doing its job. So this is total cost of care. There's a small percentage driving that. And those arguably are the members that need a pharmacist. So if you have a solution that can address their needs, and then you leverage the Amazons of the world that aren't going to interact with you personally, they just don't have enough butts and chairs to talk to patients. Make sure they're servicing conveniently, cost-effectively, efficiently medications for your patients or members that don't really need that love. So I think they're complementary and you can win using both channels.

David 20:19

So we've got a couple of minutes left. I'm curious how you move that cohort that needs a pharmacist to a pharmacist. Do you write this into your plan document? Do you segregate people? I mean, how do you actually get the people to the appropriate modality of care, whether it's a pharmacist or a pharmacy?

SPEAKER_01 20:38

Again, the Asheville project, it's called incentives. If you reduce barriers or reduce cost, you can move patients. We've done a very good job. And it's no surprise the largest three PBMs have the three largest mail order pharmacies. How did they accomplish that? Well, if you take three months' worth of meds and charge the member two copays, you get them to make a move. And arguably, there's been no greater source of pharmacy waste than mail order pharmacy. Yet we continue to incentivize it. I could present a 140-slide presentation that shows community pharmacies being the recipient of bags and bags and bags of unused medications that were automatically shipped by mail order. We know that patients can be moved through financial incentives. So assuming your pharmacy benefit manager is willing to give you flexibility in controlling the network. That's one of my responsibilities. I'm intimately familiar with pharmacy network management and plan design and all things pharmacy, we essentially build in incentives that reduce or eliminate out-of-pocket costs for the medications used to treat chronic conditions that are driving medical cost in order to direct members into the channel. Then once they're in the grasps of their community pharmacist that has taken responsibility for achieving a clinical outcome, then that community pharmacist does their job alongside the product. That's what's so critical. And the final point that I'll make is that there are a lot of vendors that are trying to say you can manage this from a call center, which we know call centers have, I mean, a 20% engagement rate is great, right? But when you tie the product that the patient and the member want to the clinical care, you can do some incredible things that you just can't cannot do from a call center. So there are ways to do it. You obviously benefit from having advisement where the pharmacist knows what they're doing, but there is excitement here, and you don't really have to look much further than what CMS is doing. And these initiatives are taking hold in government-funded plans because they also can't afford these skyrocketing costs. So really excited about where the future lies with accountability, really. It's really accountability in the space because it's much needed. And there is a, you know, there is an offering out there that can meet the need for sure.

David 23:17

Well, we hope you'll come back and chat with us as this grows out and as this takes takes root. Chris Antipass, Farm D and Director of Pharmacy Solutions at Henderson Brothers, Inc. Chris, thanks so much for spending some time with our audience today. We appreciate it.

SPEAKER_01 23:31

My pleasure. Thank you so much, David.

Announcer 23:33

The Shift Shapers Podcast is a production of Shift Shaper Strategies and may not be reproduced or quoted in whole or in part without our express written permission. Copyright 2020, all rights reserved.