The Evolving Role of Pharmacy with NCPA’s Doug Hoey

Melanie Marcus: Our subject today is independent pharmacy. It's a subject our guest, Doug Hoey, understands inside and out as the CEO of the National Community Pharmacists Association, where he's been for over a decade. Of course, it doesn't hurt that Doug grew up in the pharmacy world. In fact, Doug's father started a family pharmacy the same year that he was born. Who better to ask about independent pharmacy and its role in the future of patient care?

Welcome, Doug. I am so happy to have you on the show today.

Doug Hoey: It's great to be here, Melanie.

Marcus: Well, you've been CEO for the National Community Pharmacists Association, or NCPA, for about 13 years now. And the NCPA is quite amazing all by itself, having been around for almost 125 years. I want to dive into your background, but before I do that, can you just start out by telling us why independent pharmacy is so important, and what are some of the key challenges we need to address?

Hoey: Independent pharmacies represent about a third of all the pharmacies in the country, and that often surprises people. People are used to the big chains like CVS, Walgreens and Walmart. If you add them all together, that's about the number of independent pharmacies there are in the country. Independent pharmacies are in rural areas, urban areas and in suburban areas. But 57% of our locations are in areas that the CDC ranks as either socially vulnerable or highly socially vulnerable. So, we're in kind of the final mile of a lot of geographic locations. That's one thing that really came through during the pandemic, where pharmacists and pharmacy teams vaccinated over 300 million people and helped lead the world in overcoming the pandemic. So that's one important reason for independents.

Another is that independent pharmacies often have relationships. They've been part of their communities, and the communities trust them. And so people will come to their community pharmacies with issues and challenges that they just can't get served in other venues. I personally think that they are kind of a healthcare safety net, if you will, for millions of patients that don't sit on the “healthcare assembly line.” The healthcare assembly line is great if patients are the same and don't have a lot of individual needs. But there's millions of patients that have individual needs that take time to figure out. It takes a relationship to trust. It takes some background about that patient to know what the best medication solution is for them. And I really think that if independent pharmacies weren't around, there'd be millions of patients who would just kind of fall through the cracks, and that would increase healthcare costs. And I think, unfortunately, also fatalities, if there weren't these independent pharmacies there to be this kind of safety net for these millions of patients.

Marcus: Where did you grow up? How did you get started in pharmacy?

Hoey: Well, I grew up in the Midwest. I'm right on the Kansas—Oklahoma border. I grew up a pharmacist kid. My dad is a pharmacist and opened his pharmacy the same year I was born. So I was literally born into pharmacy. I started working in the pharmacy when I was 13. I kind of grew up inside the pharmacy. The pharmacy staff were, in some respects, kind of my surrogate family as far as teaching me things that I needed to know.

Marcus: What did you come to understand about the life of a pharmacist that drew you to that life for yourself?

Hoey: It wasn't an instantaneous realization. I have two older brothers and two younger sisters, and they went into other professions. I think it was really in college where I kind of caught the bug. I was already in pharmacy school, which is pretty hard to get into, especially in those days. And it was probably my second year of pharmacy school that it all came together for me as far as being able to make a difference in the lives of people. I'm not a kid at this point, and it just hit me that these people coming in the pharmacy, a lot of them either knew my dad or my mom or even my grandparents. I didn't know them, but they somehow knew me. And here I am as a youngster making a small difference in their lives. So that made an impact on me. Like, hey, I'm able to contribute something that is making a difference in these people’s lives. And even more importantly, the team around me, because they were able to really make a difference and contribute versus just the light things I was able to do as a 21 year old.

Marcus: So how did you end up at NCPA?

Hoey: I practiced in the independent pharmacy setting for—well actually, I worked at Walgreens for five hours in Denver. That didn't work.

Marcus: For five hours?

Hoey: Yeah, that didn't work out. But, you know, it was as much my fault as it probably just wasn’t a good match. But, for about five years, I practiced, and I was very fortunate to practice in settings that not only had traditional independent pharmacy, but we also did consulting for long-term care facilities. We had a contract with the hospice unit in our town of about 35,000 people. We also built a building to do home infusion. So I was very fortunate in the different places I worked, including for my dad for about a year and a half of that five years.

But as far as NCPA, I had been in the Midwest all of my life, and I was in my mid 20s at this point. And I saw that someday I'll probably settle down and have a family and kids and that will not be a good time to want to travel and have this kind of wanderlust. Just by happenstance, I applied for a job at NCPA that had opened up. I really didn't think I had any chance. I'd never thought I would be moving to the East Coast. But, to my surprise, they hired me. And actually, one of the first Surescripts employees was working at NCPA, and he was the person who recommended hiring me. That was 20+ years ago.

Marcus: But here you are working with independent pharmacies across the country. So not just one, but all.

Hoey: And it's been a rewarding experience to be able to represent 20,000 pharmacies and almost live vicariously through their successes.

Marcus: So let's move to your role then as CEO of NCPA. NCPA's mission is to promote the interests of independent pharmacists to serve their patients and communities. You have said that your approach is bifurcated, which really means you're working on today's challenges and you're also working to address the future. So let's dig into this. What advantages do community pharmacists have? In other words, what's their ace in the hole in this business environment, today in healthcare?

Hoey: I think one of their aces in the hole is that they're connected to the community. Patients want to see them. When patients have a choice, they want to go to their independent pharmacy. There is a connection. There's a relationship there.

The second one is that they're highly motivated to care for that patient, not only because they're the owner and their livelihood depends on it, but also, they're going to see that same patient at the grocery store, at their church, at their synagogue, at the Little League field. They're going to run into that patient again. And relationships do matter. So, I think that the motivation is very, very high for that owner and his or her team to make sure that the patient is taken care of. It almost sounds cliche, but they take healthcare personally. If that patient gets cared for or doesn't get cared for, that's something they're thinking about at 3 in the morning. “I personally was able to help or couldn't help that patient.” So it's a very personal experience, which is 99% of the time a big positive. And again, the trust in the relationship that patient has.

Those are two. I guess also the accessibility. There are a growing number of pharmacy deserts out there, and those deserts are largely created when an independent pharmacy is forced out of business.

Marcus: So we can see that about two thirds of counties in the country have less than one primary care provider per 1,500 population. And we can also see that more than two thirds of those counties have enough pharmacies to make a difference. And that's really where you're headed with that, right? It’s that pharmacy has an opportunity to help in these care deserts.

Hoey: Yes, that's exactly right. There's a growing shortage of primary care physicians in the country. And pharmacists are not interested in replacing primary care physicians. That's not our desire. We are able to supplement primary care. And again, we saw this during the pandemic, where vaccinations are one example that had traditionally been done in a traditional primary care environment. The pharmacy has become the preferred place for patients to get their vaccinations. And there are other primary care services that pharmacists can provide that supplement the work of other primary care providers.

Marcus: You know, the other piece of data that we saw on the network this year is some growth in pharmacists as prescribers. Now, it's not a lot of pharmacists that are prescribing. But we've seen a 28, almost 29%, growth in pharmacists year over year as prescribers. Where does that fit?

Hoey: Yeah, I think that's a growing trend. I don't know if that data was run during the pandemic. Because I know from my own mother’s experience. My parents are a little bit older and dad got COVID. So I said to my mom, who's a fairly recent breast cancer survivor and she has a vulnerable immune system. I said, “Hey, Mom, that's great that you're helping Dad while he has COVID. Get on Paxlovid, please.” And she called a primary care provider, and they did not return her calls. I called her primary care provider as a concerned son from a thousand miles away, and they didn't return my calls. So I prescribed it.

I only give that story because I know pharmacists on the front line, they were able to prescribe things like Paxlovid. They were able to prescribe the immunizations themselves. And so, some of these essential primary care services and prescriptions, pharmacists are well positioned to prescribe. And I think that's going to only grow, not only in competition, but in partnership with other primary care providers. Because pharmacists are so accessible, I think it will ultimately be good for patients from an access standpoint, and they’ll be able to get medications they need that keep them out of the emergency room and the hospital.

Marcus: What is the advantage? I mean, there's probably clear advantages to the community that does have one. What can we do to help prevent some of these closures?

Hoey: I'm glad you asked this because it's a real crisis that the pharmacy community is seeing right now. In the independent sector, we're seeing a pharmacy close a day on average. Last year we saw two chain pharmacies close per day. The economic model is just not sustainable for our pharmacies. And there’s the consequences. I know one member, he sent me an example where a family came to him. A family member was using multiple medications, many of them for mental illness. And what this pharmacy did was they were able to package these medications for mental illness, for this family member, so that it was easy for him to be adherent with his medication. And they saw great improvements with this family member who was battling a mental illness. Unfortunately, that pharmacy had to close, and the next pharmacy was 15 miles away and they had limited access to transportation. So they were not able to get this family member’s medications packaged the same way—got them probably through their mailbox. And unfortunately, that patient is no longer doing well. They are struggling with their mental illness and their medication is not helping this patient because they're not taking the medication in an optimal way. Gosh, that seems like a simple problem. Can’t we just package the medications correctly? Can’t this patient somehow get that? What these independent pharmacists are doing, they’re that last safety net. Again, that's helping that patient who can't get services or doesn't fit in the mold of other patients. They’re a lot harder, a lot more challenging, a lot more complex. And it takes more time. And those are the patients that I think really hurt when a pharmacy closes.

Marcus: You talked about the assembly line, and that's all very convenient if you're not a complex patient. But if you're a complex patient, these meds and the care stacks up on itself and it's not all automated. In a value-based care arrangement, they're incented to make it work. How does all that fit together?

Hoey: I think that's where the biggest opportunities are for community pharmacy. It's also been one of the biggest challenges because payers and other healthcare providers aren’t used to working with pharmacies outside of the dispensing mode. But those are some big opportunities. So for example, some of these more complex patients or high cost patients are walking into the pharmacy. There are many opportunities for the pharmacist or someone on their team to be able to sort of check in with that patient. “How are you doing today, Mrs. Smith? Are you taking your medicine OK? Are you able to swallow those tablets? Are you keeping them in the refrigerator? Maybe we could take your blood pressure today and record that.” If you're an insurance plan and you want to reduce costs as much as possible and you want to keep that patient out of the hospital and out of the emergency room, are there some simple things that you can do working with the local pharmacist and their teams that can reduce the risk of emergency room admittance or hospitalization? We're working on that through an entity called CPESN, which stands for Community Pharmacy Enhanced Services Network. It's a network of about 3,500 local pharmacies through most of the country where they're providing some of these value-based care services. And they've seen some nice successes by being able to help a state plan, a Medicaid plan, a local insurer or a national insurer provide services that help these socially vulnerable patients so that they can stay healthy and their costs are reduced.

Marcus: I’m so glad you brought up CPESN. Can you give me an example of where value-based care has worked and where the pharmacist is really part of that evolving care team?

Hoey: Our last president was dealing with remote patient monitoring, where he and his team have partnered with a local physician. And the physician gives the pharmacy access. The patient goes into the pharmacy. The pharmacists and their team equip this patient with technology to be able to remotely monitor the patient. And some of that's self-explanatory, that the technology is able to send information to the pharmacist and their team. And that's good. And they're able to check on that. The other part of that is that the physician has given the pharmacist authority to adjust medication therapy. Maybe they're monitoring blood glucose and they're seeing their blood glucose go up. Or for longer term A1Cs, they're able to adjust the patient's medication up or down based on this remote patient monitoring information. And what that does is, No. 1, it's healthier for the patient. Better quality of life and a better outcome. It also results in the physician getting paid for some of their quality measures that they're being judged by.

So, for example, the A1C. By doing the remote patient monitoring, if they're able to lower the patient’s A1C, that triggers bonus payments for the physician. And the physician and the pharmacist have worked out an arrangement where the physician then shares some of those extra payments with the pharmacist. So, their services are paid for. And that's something that we see growing, where pharmacists are embedded in physician practices. And again, receiving this information from patients who are outpatients at home. And the pharmacist is able to use their expertise as the medication expert on the team to adjust the patient's therapy. And of course, they report that back to the physician so the physician knows what's going on. That's an example of some of the different ways beyond dispensing that pharmacists are able to partner with other healthcare team members.

Marcus: That's a great example of value-based care. What are some of the things that need to change around policy and payment to help make the pharmacist part of this expanded care team?

Hoey: The biggest thing, from a policy standpoint, would be for pharmacists to be recognized as providers in Medicare. But because Medicare is such a large payer—so many patients are affected by it—not having provider status has been a huge barrier. Quite a number of states have passed laws that recognize the pharmacist and are able to pay the pharmacist.

Marcus: For our listeners, having provider status would allow Medicare to pay those pharmacists for the more clinical services that they provide. Is that what that is?

Hoey: Yeah, that's exactly right. And right now pharmacists are paid through Medicare Part D. And unfortunately Medicare Part D is very siloed. It forces people to look at the drugs as a cost center instead of thinking about the prescription drugs as really a way to lower overall healthcare costs. And Medicare provider status would allow pharmacists to be able to provide services and be paid for those services which would lower overall healthcare costs for the entire system, for patients and for other providers.

Marcus: So then, whenever I've heard this talked about, somebody will eventually come up and say pharmacists want to get paid to provide more clinical services. (Again, not taking on the role of a primary care physician but supplementing it.) Aren’t pharmacists burned out too? And where does that fit in the equation? How do they have time to provide these services?

Hoey: There have been a number of high-profile stories showing many pharmacists are overwhelmed and are burned out. It's more prominent in the big chains. And that's where the national stories have been focused on. However, across the board a lot of pharmacy teams are under stress to do more with less. Part of the problem is the economic model where prescription drug reimbursement is so low that it's causing economic strife and pressures from a staffing standpoint. That's one of the problems that needs to be solved for. And when those three ingredient ingredients were put together: that pharmacists had the authority, pharmacists were paid fairly, and there was scale, great things happened. And as there are other opportunities, if pharmacists again have those three ingredients, they are able to make huge impacts on healthcare systems.

Marcus: This year we're thinking about how healthcare can heal itself. Healthcare's hurting. You've just talked about some of it. What's your diagnosis for what's wrong?

Hoey: One problem is the waste. We have inefficiencies that not only cost more, but also do not result in optimal healthcare outcomes for our patients. Healthcare is local for the most part, and the bigger and bigger healthcare gets, it seems like the harder and harder it is to get healthcare and to get those optimal outcomes.

Marcus: And so how would you heal healthcare? What prescription would you write?

Hoey: The communication between health systems and healthcare providers. Some of the lack of coordination is startling to me. The duplication of efforts. And for one provider not to know what another provider has done. And again, this is something where Surescripts is playing a big role and continuing to play an even bigger role in supporting that coordination of care. But if I were to wave a magic wand or have a magic prescription writing pen, it would be, I guess, not a pen anymore. It’d be Surescripts. It would be that coordination of care.