The pharmacy landscape is evolving faster than ever before. Join us as we sit down with Sandra Leal to discuss some of the current challenges facing pharmacies in the wake of the coronavirus. We’ll be discussing some of the new legislation for prescribing authority, testing opportunities for pharmacies, and deciphering the gaps in state and federal regulations for COVID-19.
Scott Vondeylen: 0:02
Helping pharmacists grow themselves, their business and driving outcomes. This is PharmacyNow.
Meet Sandra Leal
Scott Vondeylen: 0:23
All right, welcome to the PharmacyNow podcast. I am your host Scott VonDeylen. Excited for episode number five. We have a special guest here today. Before we jump into that, want to take a moment as we have been over the past several episodes, to thank the healthcare workers on the front lines out there fighting COVID-19. You know, there’s been a lot of national recognition for all those healthcare workers, but cannot say enough about the job that they are doing to keep us all healthy and happy during this really critical time in the history of our nation and around the world, for their service. We always have a great respect for first responders and healthcare workers, but really a round of applause for all of them out there doing their job and doing it so well during these challenging times. So we thank you very, very much. We are joined here today by a very special guest. Dr. Sandra Leal is here with us today. Just to give a little bit of background on Dr. Leal, she is currently the Executive Vice President of Innovation at SinfoníaRx that provides a medication therapy management services nationally. Dr. Leal is also working to establish integrated clinical pharmacy services in a variety of programs including a hospital discharge program, integrated behavioral health clinics, accountable care organizations, or ACOs, and patient centric medical homes. Dr. Leal received her PharmD from the University of Colorado and her MPH in Public Health Practice from the University of Massachusetts. Dr. Leal completed her residency at the Southern Arizona VA healthcare system. Her work has been published in diabetes care, advances in chronic kidney disease in the American Journal for Health System Pharmacy and a discussion paper published by the Institute of Medicine entitled Patients and Healthcare Teams Forging Effective Partnerships. And most recently in May of 2019, she was elected to a three year term as president of APhA. Dr. Sandra Leal, welcome to the show.
Sandra Leal: 2:45
Thank you so much for the invitation.
Scott Vondeylen: 2:47
Absolutely. We are excited to have you here. We have a number of things to discuss but to start off a little lighter, love to ask the question since this is PharmacyNow and you are of course a pharmacist. Sandra, how and why did you first get involved in pharmacy? I love to ask this question because I love to hear the personal backstory. But why did you choose pharmacy as a profession?
Sandra Leal: 3:15
Well, I chose pharmacy as a profession because I actually used to go to the pharmacist as a child to get my healthcare. And so for me, the pharmacist was the primary care provider. And I looked up to the pharmacist. I actually grew up in Nogales, Arizona, which is right on the border of… is Southern Arizona. And we used to go to Mexico, talk to the pharmacist, receive our care. And so it was a great access point for being able to communicate on any of the needs that we had for our healthcare. So that to me was the point of access for care and so I thought, yeah, that’s what I want to be. I want to be a pharmacist.
What is APhA Doing to Get Involved with COVID-19?
Scott Vondeylen: 3:50
I love it. And right there with you. I am not a pharmacist, as I’ve said very many a times, but had that same experience as a young man growing up in Ohio, going to the pharmacy to get all of our medical advice essentially with my mom, one of three children. And that really was the healthcare destination, was going to our local, independent pharmacy and remembering my mom asking all of the questions to make sure that we were all happy and healthy. So that’s amazing. Love to hear these stories. So let’s just dive into it. You’re the current president-elect APhA, you have this incredible resume. What is, during these times COVID-19, what is APhA doing right now to combat COVID-19? What’s their involvement? What does that look like today for the listeners?
Sandra Leal: 4:50
APhA has been incredibly involved in really trying to be a resource for pharmacists that are out there in the front lines providing care during this pandemic. And as we’ve all seen, pharmacists have really stepped up, they’re essential healthcare workers and they really address a need for patients that are out there with a lot of questions, anxiety and need for things like their medications, continuity of care and then testing. Now that we’re seeing that being a big thing. So APhA has been, has always been, but really has really been leading the efforts on advocacy to represent the profession and then looking for opportunities post-pandemic to make sure that a lot of the status that we’re receiving, the flexibility and being able to assess in order, testing and then the recognition that we’ve been seeking for a long time. APhA is very actively representing that. That’s one of the big elements, that advocacy piece. But aside from that, it’s also been a resource center for pharmacists providing, you know, immediate information around a CE related to COVID, a resource center for, you know, how to operationalize your pharmacy as it relates to things that you need to change or adopt the signed CDC guidelines. So they’ve been a really great resource center to be able to go out there and find information that’s impacting day to day needs.
Scott Vondeylen: 6:08
So in terms of the resources that you’re talking about, is it as simple as going to APhA’s website to find that? If I’m a pharmacist, for resource purposes, and I want to take part in one of these CE’s or gather additional information?
Sandra Leal: 6:23
Absolutely. So there is a, on the website, a pharmacist’s guide to coronavirus and within that page there’s a ton of resources that are outlined there. There’s public resources, there’s specific information about how APhA is working for the pharmacist. But there have been some town halls that they’ve been holding on a weekly to bi-weekly basis. A series on COVID-19, a 15 minute podcast kind of model where, you know, you go in and you listen to the latest FAQ, what, frequently asked questions are coming to you at the pharmacy, to respond to. So that’s been very helpful. I’ve been following that every week. And it’s been simple things like, you know, which medications are appropriate to be using based on the evidence. Does, you know, for example, does zinc work? Cause that’s been one of the questions that’s been asked multiple times, things like that so that you can actually be prepared with evidence to respond to whoever’s asking that question that’s coming into the pharmacy. So those are just a couple of examples, but they also link to other really good examples of resource centers like NASPA and NASPA has a lot of the state level information. So if there’s been, excuse me, specific, state level regulations or things of that nature, there’s a link through APhA to get to that and then to CDC, FDA for some of the recent changes with compounding and then also the information around testing.
Scott Vondeylen: 7:51
Great. So I did want to ask, you know, I talk to a lot of pharmacists on a regular basis. Again, not a pharmacist do not own a pharmacy. But what do you feel like, based on the information that you have at your disposal and your involvement at the level that you’re at, what is really the largest challenge when you talk about testing? And you know, rolling back regulations, pharmacies are able to get involved maybe perhaps for the first time in this type of initiative, outside of immunization services that I know 80 plus percent of pharmacies now offer, particularly in the independent space according to NCPA. What is the biggest challenge for pharmacies that are raising their hand and saying, we’d love to provide testing? What are you hearing right now?
Sandra Leal: 8:40
Right now, there is a lot of confusion about exactly what can be done and what can’t be done. And there has been some information that’s coming from a federal level, but that might differ from the state level and what kind of, you know, what kind of, regulations you do have on that local level. So I think that’s been one of the biggest source of confusion. So I have been participating locally in my own States town hall. So here in Arizona where I’m located, we have a town hall every Wednesday and I listened to specific state information, which is very critical, especially as I’m also hearing the federal information and trying to reconcile both and they’re talking, it’s not like they’re separate from each other because our state association is definitely in communication with the federal level and trying to get clarity. But that’s really where we try to work together to obtain that clarity. And APhA has been great at going back when there hasn’t been a specific guidance that people are looking for. You know, what kind of CLIA waivers do you need? Do you actually need them or not? Can you bill? And there is a separation between the authority of being able to assess an order versus the authority to bill. And so even, you know, within that, what is allowed and what isn’t allowed. So those are the confusing items that have caused a lot of questions for pharmacists because obviously they want to do it right. They want to make sure that they’re providing the most accurate information and obviously there’s a lot of implications when you’re starting a process like that that you want to make sure you have all the information so you’re not doing anything that would be of concern. So those are the greatest challenges right now.
Billing Options for Pharmacies
Scott Vondeylen: 10:22
I hear ya. Can we dive in for a second to the billing piece because I’ve got some information in front of me. Again, I’ve heard a few different scenarios but it may be you don’t have all the answers cause there’s a lot that’s evolving on a daily, weekly basis as we kind of work through this. But what do the billing options look like today for pharmacies that are getting paid and that are not getting paid? If you could speak to that a little bit.
Sandra Leal: 10:50
Yeah. And actually there was going to be, and I haven’t found out the status of this, but there was going to be a discussion on a national level yesterday to try to clarify some of that. So to your point, I don’t have the answers because it is literally evolving as we speak. And there have been conversations on a national level with CMS where the pharmacy associations are trying to be, to obtain that clarity to be able to pass that back to the profession. So, there have been some clarification. So in the process, CMS did release some information about a week ago where they’re talking about obtaining CLIA, you know, the CLIA certification and then that would allow pharmacies to be able to bill for the testing for COVID. But again, there’s still a lack of clarity because even though there was that potential billing option, the CLIA application, there were some questions around how to do that. What resources to do that with, even on the state level, like AZPA actually put together programming and a webinar for people like basically modules so that pharmacists could walk through that and really understand what the steps are, how to fill out that application appropriately so it doesn’t get kicked back and delay their ability to be able to participate. So those are the resources that I would highly recommend, you know, go to your local level because there’s those local specific resources that are available. But then definitely state, contact with your national associations because they’re also providing education and the most reliable, most recent information that’s available based on their meetings that they’re having on that federal level. So I’m still, I bet within the next 24 hours we’ll hopefully start hearing back some information about that meeting that’s happening to start clarifying some more of those questions that are still out there.
Future of COVID-19 Testing
Scott Vondeylen: 12:42
Makes sense. I wanted to ask, and I don’t want to put you on the spot to try and be the Nostradamus of COVID-19. But, when you talk amongst your colleagues, and again, you know, diving into these webinars and other podcasts and the information that you’re gathering there at Sinfonia and Tabula Rasa Health Care, et cetera. The timeline of COVID-19 is so interesting to me in the folks that I’ve talked to, different executives, pharmacy owners, et cetera, where it’s, are we too late? Can I really provide testing? Have I missed the wave of that from the business side of things? To say, is it something that I want to participate in? Do you feel like COVID-19 getting involved in the testing of that? Obviously the possibility of an immunization down the road once that’s approved and gone through the different rounds and phases of trials, et cetera. But do you feel like COVID-19 testing is going to kind of be a permanent staple in the model of pharmacy for the foreseeable future?
Sandra Leal: 13:47
I absolutely do because I mean, we have so many people we haven’t tested yet, so absolutely. So COVID for sure, antibody testing which is also receiving a lot of attention. Even if you’re looking, and I always look at other countries to see their experience because some countries have obviously experienced COVID sooner than us, in China for example. And in some of these areas that have essentially flattened the curve, they’ve cleared, they’re starting to see second rounds of infection again. So they’re starting testing again and trying to contain that. So I feel like until we have an actual vaccination in place or until we have a very good process in place on how to mitigate, we’re going to really rely on trying to get people tested. Make sure that we have that as an access point. And I feel pharmacies are well positioned to be able to do that. You know, like you mentioned earlier, pharmacists are already vaccinating. Obviously, we’re looking for a vaccine for COVID, much like strep testing, you know, pharmacies are able to do point of care, they can test. And then based on that and based on the scope of practice, you’re able to provide care at different levels. So I feel like we are still going to see that opportunity continue. And so I don’t think we’ve met, we’ve missed the opportunity there. I feel we’re in the beginning of that and we are still heavily, heavily, behind on where we should be to be able to really feel comfortable in reopening the economy and making sure people are going back to work with some, you know, with some comfort that we are getting there. So the contact tracing is the other piece to consider as part of that. And testing is a very key part of all of this.
What Are You Currently Focusing On?
Scott Vondeylen: 15:30
Couldn’t agree with you more. We’ve got 60,000 pharmacies nationwide. When you look at the big picture of it and as mentioned, you know, 60,000 access points for, you know, patients nationwide to be able to walk into a pharmacy, get that testing. And we’re,so, we’re all very happy to see some of those regulations being rolled back and allowing pharmacies to provide this type of care. So thank you so much for your thoughts on that. Well, let’s steer away from COVID-19 for a moment. I’m sure we’ll get back into that. And let’s just talk about what you’re really focused on today. You’re the Executive Vice President of Sinfonia RX that’s providing telephonic MTM services nationwide. You’re the President-elect for APhA. I read off there your resume and your intro just a few ago talking about some of the different things that you’ve been involved in. Well, what are you doing today? What are you focused on? I know this COVID-19 thing for a lot of us has kind of taken over and understandably so, but what are your initiatives and focuses right now outside of the COVID-19?
Sandra Leal: 16:41
So for my, pretty much my entire career and also, you know, as part of the reason that I ended up really working and getting involved in a political way, I guess within the profession, is to actually have pharmacists recognized as part of the care team. And so I have been working as a care provider in a federally qualified health center previous to joining Sinfonia. I was in an FQHC for 14 years. Really developing collaborative practice agreements and models where pharmacists were part of the team before the prescription was written. So actively managing people with chronic conditions, making sure they have the best outcomes and really trying to make sure that the pharmacists were being utilized the way that we are trained. And so that’s always been a really significant focus of mine and truly the platform for why I ran for APhA, to represent the profession and to make sure that our profession is really respected in that way and included as part of the primary care solution because we have so many patients out there that don’t have a very good access to care. And now what we’re seeing in rural communities and in many areas is that there are pharmacies closing, there’s hospitals closing, there’s provider, physician offices closing. There’s a lot of consolidation. And so we’re seeing areas of the country that actually have less access to care. So I’ve always had a passion for working with underserved communities and so this, all of these things have really come to a significant crosspoint where I feel like a lot of what I’m doing is trying to address those areas of helping people with access and then also positioning pharmacists to be able to help as part of that solution. So I joined Sinfonia because of the opportunity to provide a very scalable model and being able to utilize pharmacists and being able to utilize technology to reach people that had challenges and being reached. And so I love technology. I love to use what’s out there and to leverage that in a way to access and better help to reduce that fragmented care for the patients. So it’s just been such a great opportunity to be able to do that. And that’s what the Sinfonia has been able to provide. So really taking the models I learned at the FQHC level, taking those and really trying to make them apply on a national scale and then looking at our relationship with the community pharmacist to be able to leverage both. Because one of the things that I, you know, personally been challenged with and what I get questions about all the time is like, well, you know, tele-health isn’t the same as face to face. You can’t have that same type of relationship with the patient. And my, you know, my discussion point around that is that it’s not one or the other. It’s actually both. And you need multiple touch points with that individual patient to be able to make sure that they have continuity of care all the time because people don’t just need you once a year. They need you multiple times because questions come up. And so how best can we do that? And the best way to do that is by having those different ways to reach people and basically using the ways that they want to be reached versus how we feel we want to reach them. So it is really thinking about that combination to have better outcomes for the patient.
Scott Vondeylen: 19:59
So if we walk through that patient journey for a second, for those listeners that are not pharmacists and aren’t involved at the level that you are with the extensive experience. If I’m a patient in an underserved community, in a rural community, that perhaps the pharmacy in my community closed, three, four, or five months ago or my physician’s office has been taken over, where do I start in gaining access to care? And I know that might sound like kind of a, I don’t want to say dumb question, but you know, where does that journey start for me as a patient to find that care if my normal provider has closed down? And then kind of, where does your model then come in, if that makes sense?
Where Can Patients Get Care?
Sandra Leal: 20:49
Yes. Our model comes in in multiple ways. So we have different programs that we’ve developed to be able to reach patients. For example, one program that we just launched this past year, we’ve been working with the American Pharmacist Foundation and the CDC to launch a diabetes prevention program that’s available through telephonic and tele-health. It’s actually, modules that we created for DPP for diabetes prevention that are available to individuals through a telephone, through a computer if they have access to data, even if they don’t, they can call in for the classes. And then we actually use our staff and in our call centers to be able to reach, on a weekly basis, out as health coaches for individuals that can’t come in to one of the classes or for many reasons, maybe there isn’t an accredited DPP program within any proximity to them. Or there are numerous classes that have to be attended to be part of that program. And a lot of people have challenges. Even if you have a site locally, sometimes you can’t get there once a week because you have competing priorities like, you know, your family, your job, childcare issues, things like that. So what we were, what we created is something that actually creates that flexibility for individuals and they don’t, there’s not a geography that they’re bound by or even a specific time that they have to attend because they can access it at whatever convenience is good for them. So those are the kinds of things when we look at current programs, what we’re trying to do is look at those models that we know are successful and then trying to create an access of those programs in a way that actually worked for the patient versus expecting them to show up to class, you know, for 26 weeks for a year to be able to do that effectively. So it’s those kinds of things that we’ve been able to do that. And so we actually, we have worked with local providers, local pharmacies for referrals for those programs with grocery stores. We thought of different organizations that we can partner with, you know, schools, things like that where it kind of your non traditional collaborators to be able to do outreach for programs like this. So that we’re making sure that we’re reaching those that might not even know about our programs.
Prescribing Authority for Pharmacists
Scott Vondeylen: 23:07
Amazing stuff. And so really a nice transition because one of the other subjects we want to get into is, what does the future of pharmacy look like with prescribing authority? Really a hot topic from anyone involved in this and you know, all the articles and movement out there. You mentioned before your involvement in legislation and government of course, and how that relates to APhA et cetera. And again, a topic that we cover regularly with guests on the show. When we talk about prescribing authority, let’s just dive in. You know, when you talk about that changing the landscape of pharmacy and how it’s really shaping the future for the lay listener, what does that really mean in terms of how that can change pharmacy when we talk about prescribing authority?
Sandra Leal: 24:02
Absolutely. So I mean, I think that the COVID example, again, just because it’s so topical and relevant is an example. Right now, we’ve been given the authority to assess and to be able to order COVID testing. So what I think of when I think of pharmacy is I think of access points and I think of them providing a service, especially in areas that don’t have maybe that ability to have so many access points. Even in the example like I discussed earlier, diabetes prevention, diabetes health, self management, those are services that pharmacies are already providing. So this isn’t even the future, it’s happening now. But I see those being able to be expanded because there’s so much need. When I think about just the condition of pre-diabetes, we have almost 90 million people, so one in three basically people who have pre-diabetes in the United States. So there is no way with our current providers that we could ever manage the volume on just that one without, you know, without really getting everybody on board. So when we think about what the pharmacist can do is that they can be another access point that provides these types of services, access points for diagnostics, a lot of assessment on social determinants of health, which is now becoming a really hot topic for my own practice. And for my previous 14 years as a federally qualified health center, that’s all I did is address social determinants and barriers to take care of such as, you know, how to access medications that were expensive, how to make sure people aren’t having duplicate therapy because they’re trying to access care from multiple providers. You know, understanding the socioeconomic challenges that people have. If people right now, a lot of people have lost their job, what do they do in the interim with their medication if they can’t now afford it because they don’t have insurance? Like how do we sit with them and really talk about alternatives and options for them to actually receive care and not miss a beat as they’re still trying to maintain their condition. So those are all roles that pharmacists are actively playing, but that we continue to focus on, on being able to do. But I think one of the biggest challenges for pharmacists is that, you know, we haven’t had that same level of recognition as other providers. So what we want is parody. We want to be recognized like other providers and be able to provide that same level of care so that people have better outcomes because truly we need to have a better handle on the increasing costs of care. And I think that pharmacists are a very, very significant contributor and being able to help with better outcomes and true value based care.
State vs. Federal Regulations for COVID-19
Scott Vondeylen: 26:42
Yeah. And you mentioned a little earlier, there’s a big difference as we all know on several subjects between the federal level and the state level. So, you know, there’s a big difference as a comparison to listening to the white house versus listening to the governor, As it would apply to, you know, the COVID-19 crisis that we’ve been in and state lockdowns things of that nature, but with pharmacy at the federal level versus the state level. And we had a guest on a few weeks ago, we dove into this because the state level adds this other layer of complexity. What is the involvement right now, at the state level, that you’ve been involved with or focused on and helping pharmacies and how does that challenge in your mind differ from the federal level?
Sandra Leal: 27:36
So this is a great question because we always go back like back and forth, even at APhA and here locally, you know, at what level should we be involved? And I always talk to pharmacists about being involved in students cause we have a lot of students that we work with and we’re affiliated with universities, but advocacy has to start at every single level. And I even think about within your own local organization where you work. So when I think about advocacy at your local level, it’s the policies and procedures within your own pharmacy or you know, or health system because you can actually advocate and do things within a system like that that have a lot of impact on your day to day practice. But then obviously on a state level, there’s a lot of implications about Medicaid payment within your state. And then also the commercial payers within your state. And then on a federal level, which we consider a lot of times it’s referred to as a Holy Grail. If we make some federal sweeping legislation, then that could potentially impact a state, you know, state authorities and things like that. But as we saw in this example with COVID, even though we did have more of that federal language that came out, there was still a kickback to the state. So there are very, you can’t decouple them. Essentially you have to work with both of them. And then you have to be advocating on both levels and learning from each other so that you can actually massage the language to actually get to the point where you need to with your practice. And that’s where I think collaboration, not just within your state, but with other States taking best language, best practices, what’s worked with one state that you can actually model to bring back to your state. And then, you know, pulling that together on a federal level for example to federal legislators that they can also see as viable options. That all comes together when you’re really having an effective advocacy agenda. And so on both levels and again, on your local system level, I think that it’s very critical to be involved. It’s very critical to constantly be looking for examples and to share. You know, I always, I think the key things that I’ve always leveraged is, is good PR, talking about how we make a difference. You know, having patients speak on our behalf, sharing examples of things that we do to contribute those go a long way to make a big difference. And showing the value that we bring to, you know, to care. So I can’t stress that enough because it really comes down at the very basic level to the stories. But obviously you do have to follow that up with data and the outcomes that you’re having to show that what they’re investing in, which is, you know, you and the interventions you’re making, they do have a good return on investment for the system. And I think we consistently show that time after time. We just have to keep reminding them as they’re trying to make those policies or those laws.
Scott Vondeylen: 30:27
Yeah. So would you say the best way for an individual pharmacy to be involved in this ongoing effort to shape and mold and change a policy is to get involved at the state level first? So if I’m a pharmacy owner in Kentucky or Ohio, would be to really just get involved with my state pharmacy association first and foremost?
Sandra Leal: 30:54
I think it definitely, I mean, I would say absolutely. The state, absolutely. That is very much your local practice. So that would be something that I would highly recommend, but I would say don’t stop there. That’s definitely one that you have to be involved with. I also think on that national level because both have implications to the practice. Truly, both of them do. So you really have to think about, you know, how to leverage both together. But if you have to choose, you know, it’s hard for me because I’ve always been involved on both levels and I see the impact with both that are very critical. In fact, you know, I use the experiences like I mentioned earlier, AZPA and I take that to APhA and vice versa APhA back to AZPA and then the communication that needs to happen for those to be successful. We’ve seen it here with COVID. I know that a lot of States have taken action, but they obviously still have to understand the federal policies that are coming down. You know, things like PPE and the implications around that. You can try to work on it on a state level, but at the end of the day, you need to have both working together in order to actually have a better strategy.
Scott Vondeylen: 32:01
Yeah. So thank you for that insight. Wanted to also get into the conversation around immunizations and just to show, I think to the listeners, sort of a little bit of the complexity of what we’re dealing with at the state level as it applies to the subject of immunizations with COVID-19 out there on the horizon, again, when that immunization may be available. If you could just give me a little bit of insight. So my understanding is that today at the state level, pharmacies can provide immunizations based on the regulations at most state levels and it’s kind of fragmented that they can provide the N1H1 vaccination because of the way that it’s written. But many States have that written in there specifically. So it may be a challenge to provide the COVID-19 immunization as an example in the future if they don’t get that rewritten at the state level. Is that correct?
Sandra Leal: 33:04
That’s correct. And we are seeing that that’s the case and that’s where NASPA has come in really handy. NASPA is the state group that’s really collecting all of the different State specific information. But yet on a local level, you do have to look at what your own practice act States and then look to see if it’s flexible enough to allow for the current language around COVID. And so in some States do have to do that. They have to rewrite it. So that’s already starting to happen on a state level. Also, a lot of the practice hacks have specific vaccination requirements around agency. So pediatrics at what level can you actually vaccinate or to what level to what age level. And so that’s another discussion to have because if you’re only able to vaccinate adults, for example, obviously you’re going to miss the opportunity to vaccinate kids or vice versa. So those are all the intricacies you have to look at to be able to be prepared for when this vaccine becomes available. So obviously it’s the type to start that is today. Because when the vaccine does come out, you want to be prepared to be able to have a maximum impact and the max amount of opportunity to really help on that public health effort.
Scott Vondeylen: 34:16
So if we get the legislation changed at the state level, does that then ensure adequate reimbursement for pharmacies that would be dispensing a COVID-19 vaccination?
Sandra Leal: 34:29
Well, so the scope of practice is slightly decoupled from the billing right, for the reimbursement. So we still have to marry those two and make sure that the language for both are supported. So it is not just advocating on the scope, it’s advocating on that plus the level of reimbursement. And then we’re talking about federal from a Medicare level, from a federal level, but then we have to look at things like Medicaid that’s a state specific reimbursement and then the commercial payers. And that again, could be a local type of decision or an employer based decision based on if it’s self insured employers. So it doesn’t stop just at that federal level. You still have to work within all of those different types of payers to make sure that the billing follows the ability for you to be compensated based on the scope of practice that you’re able to practice at. So it is multilayered. So there’s not one blanket answer to that because you do have to take all of those things into consideration. But you know, I think that’s where I mentioned earlier the importance of being involved on different levels. It’s really important to be involved in different levels because you want to make sure you have the most ability to impact your population in a positive way by being able to be able to impact at those different levels, I guess.
The Future of Pharmacy
Scott Vondeylen: 35:45
Wonderful. So there’s a bit of a paradigm shift happening right now in the way that pharmacies operate before COVID-19 hits, there was already a shift taking place because we know that the dispensing side of the business is not as profitable as it once was. Pharmacies are not getting those reimbursements. In terms of the dollars by just simply again, dispensing and filling medications for patients. So when we think about the future of pharmacy with it being less profitable today and profit margins being squeezed, where do you really feel like that is heading? And I just want to hear your feedback. I know that you’re not an owner/operator of a pharmacy currently, but, you know, having this conversation all the time with pharmacy owners. Where do you really see them making up for those lost profits from an owner/operator perspective to set the overall patient care aside for a minute. Where do you see the future of pharmacy evolving and then being able to make up some of those losses on the dispensing side?
Sandra Leal: 37:03
I absolutely think that the service component is going to be a very key revenue stream for pharmacies moving forward. You know, and I think it’s happening now if you’re looking at their transformation with all the discussions with CPESN, all of the act, you know, discussions with the colleges of pharmacy and they’re now they’re focused on community pharmacies with this pandemic and the focus on the service that pharmacists are bringing as essential providers. I really feel like pharmacists can step up into that primary care role for access points and service points to be able to make some of that revenue up from the loss of the dispensing revenue. And so that is the transition that we have to get to. It’s a pendulum, you know, I think we always want to, you know, have an immediate, you know, I guess resolution, how are we going to do this today? Because people are truly struggling right now, right? We’re having community pharmacies close today. And it’s not happening fast enough to get there. And I think we’ve talked about this a long time when we’ve talked about the shift from fee for service to value based care. It’s the same challenges that primary care providers are facing and systems are facing. So I always try to look at both and not just think about this as a situation that’s happening to pharmacy. This situation is happening in healthcare. A lot of the way that physicians and that other providers have been paid is changing dramatically to the point where a lot of physician offices are closing. There’s been a lot of consolidation in healthcare and it’s challenging. So it is not an easy answer, but I truly feel like those that have been very innovative in trying to be some of the first adopters and in that transition are the ones that are probably going to have the most success in getting through this successfully because they have been willing to, you know, be creative and create partnerships and think about ways to be able to leverage these opportunities and get to that point before they have to think about worse outcomes. So I do think that that is something that people really need to embrace and change is hard. But there is, you know, this is what’s happening. Unfortunately. So, I do see though a lot of opportunities and upticks of the communication happening with independents, outreach, a creativity that they’ve been able to provide, you know and people like I said earlier, they see their pharmacist now as essential. That’s where they’re going to, to access care. And so we do have to make sure that we create those opportunities with what we’re doing to provide those, those clinical interventions that do add to value. And eventually we will get to that value model that I think we’re, we’ve all been trying to get there sooner, but it hasn’t happened quick enough. But that to me is a shift that that pharmacies have to make. And it’s at all levels. It’s independent, it’s the larger pharmacy, retailers, pharmacy in general is really having to shift how they think about delivery of care and be an access point. Clinical service point for patients that are really looking for that because they definitely need that flexibility. The other thing that, and we haven’t really talked about it, but it is the whole tele-medicine, tele-health model. Again, a big shift, lot of providers who did not necessarily embrace it initially and now that they’ve actually had to buy almost by force, embraced tele-medicine. They’re like, wow, this isn’t as bad as I thought. This is actually something that I can continue to do post COVID. So there’s going to be a huge shift in the view of tele-medicine and what continues post pandemic. And I think that it can be positive because now people need flexibility. There’s just so many things that are competing priorities that if we create new ways for people to have access, that will have hopefully a positive outcome in the health of the population.
Scott Vondeylen: 40:57
Absolutely. One of the things I wanted to touch on with you as well as we hear all the time from guests, from pharmacy owners, from executives in the industry, that one of the challenges for so many of these independent pharmacies as it is for so many business owners around the country, regardless if they’re in healthcare or not, is they just don’t have enough time. And you know, none of us have enough time. When you think about pharmacy in the current model, wanted to get your opinion on how important is a med synchronization program to pharmacies at this stage? When you talk about, you know, reorganizing the face of pharmacy and the model of pharmacy that it has to be. And I’m not saying that it has to be, but want to get your opinion that it should be or needs to be a migration to an appointment based model of medication. For the average listener. You know, you wouldn’t go to your doctor’s office without an appointment. You might go to an outpatient center or an urgent care, for example, without an appointment. But to see a primary care physician, you don’t just walk through the door, whereas pharmacy is a retail setting. You can walk through the door with a new prescription or to get an OTC product. But for managing that patient population and making that transition to have the time within the workflow of a pharmacy, to have those consultations with patients or to perhaps set up my tele-health operation to be able to have the bandwidth within my staff and my workflow to have those conversations with patients. Do you feel like med synchronization is essential to making that transition for pharmacies?
Sandra Leal: 42:42
I think so. When done appropriately, right. Like, you know, I don’t think that just med sync by itself is a value unless you’ve actually med sync’d the right meds. So those are, I always think about that because I think people, again, when they think med sync, they’re like, Oh, they’re just gonna tie them all at the same date, anchor date. And there you go. But there’s a whole process to get to an appropriate Med Sync and then obviously it changes because prescriptions are just prescribed at that same level. Obviously you’re still getting care and things can enter your regimen within middle of the month. So you still have to make an active effort to really reevaluate is this still appropriate? So, but I do think from a workflow management and what makes sense med sync as a concept is really trying to align that. And to your point, you do need to start thinking about different models. This is where I think this is really critical for pharmacists as they’re thinking about what’s the future of pharmacy. And a lot of times we want to super impose what we want and from what we know versus what we need to do. And sometimes it’s to like completely reevaluate what we’re doing and potentially blow it up and start over again. You know, I mean, it’s very easy to say, but very hard to do. But really it’s not trying to retrofit a process into something that it may be not the way it needs to be anymore. But really thinking about, you know, how do I take an aspect of this and really reframe it and try to create new opportunities. And you know, one of the ways, because I’ve always had the same challenges, right? I never had enough resources. There’s always all these barriers, but think creatively about potential partnerships. We here at the I worked at and with Sinphonia, we leveraged university relationships with the colleges of pharmacies. We use workforce from the students that actually need to training opportunities to obtain some of those resources and residency training opportunities to bring in residents to help us with some of our quality improvement projects. And some of the new things that we want to try out when we don’t necessarily have the money to hire, you know, two or three new FTEs. And from that we learned, okay, this is something that is viable, that can become sustainable. And then from that, build it to scale. So it, it does take effort. Obviously if it were easy, everybody would be doing it. But it is thinking of those ways to leverage resources that are out there that creates a win-win opportunity. You know, training for them, a new site for them, and then potentially an opportunity for these individuals to create their own new job once, you know, once they finish that experience. So those are the kinds of things that I think are really effective ways to be able to do that, to reevaluate and then think about ways to improve. And so med sync, back to the question, Med Sync is one tool that was, you know, thought of as a way to create that opportunity to reevaluate workflow. I think it’s great and it’s obviously not just that it’s an evolution, so med sync and how do you improve upon that and how do you continue to make that a better process? So at the end of the day, what you’ve created is something that actually gets a person to the best outcome. And ultimately what my thing was, the one thing I think about in everything that I do, everything personally, professionally, is what is the mission of what I want to accomplish. And, and for me, it’s always been to make sure that what we do and what we design leads to better patient care, better outcomes for the patient. And if you really work with that as your guide that really drives a lot of that, that collaboration to get there in an effective way and think about it. And ultimately, you know, one of the things that’s always been said to me, and I’ve always known this, is if you’re doing it for the right reasons, if you’re having the best outcome outcomes possible, you will be paid for that because at the end of the day, value, you know, value is what really pays for that. And that’s how I’ve always been able to justify my FTE, the FDA’s I brought on board. How do we grow programs by having that best outcome for the patient. So that people see why it’s so critically important.
Scott Vondeylen: 46:46
I love that. Absolutely. You’ve got to have that mission statement and that purpose in place as the foundation to build on top of and I could not agree with you more. So I wanted to, if you could, you’ve mentioned a lot of different organizations, a lot of places where pharmacies, patients can even go for additional resources, information not just on COVID-19, but even above and beyond that, can you just mention again some of those different resources in places that listeners can go to?
Sandra Leal: 47:23
Absolutely. So I would definitely start with the American Pharmacists Association, no bias there, but I mean that’s, you know, that is the umbrella organization for pharmacy. And they definitely have links to a lot of the resources that I mentioned. They have the links to NASPA, it’s the National Alliance of State Pharmacy Associations, CDC Centers for Disease Control, the FDA Food and Drug Administration. All of those are linked through the APhA pharmacist’s guide to coronavirus. So they have a lot of resources there. And like I mentioned earlier, some of the most print literature evidence on what is effective based on the evidence as it’s coming because, Oh my gosh, there is so much evidence and misinformation, unfortunately, also. So we have to make sure that we, as pharmacists, are providing the best information based on the evidence that’s truly out there right now.
Scott Vondeylen: 48:18
Fantastic. Well, thank you so much for your time today, Sandra. It has been an absolute pleasure. I know you’ve got a full plate, so I don’t want to hold you up any more today. Let you get back to it. So thank you again for being here with us. It has been an absolute pleasure.
Sandra Leal: 48:36
Thank you so much. I appreciate the opportunity and thank you for all these informative podcasts that you’ve been putting together.
Scott Vondeylen: 48:43
Oh, thank you. Yes. And so again, thank you, Sandra. That concludes episode five of the PharmacyNow podcast. Special thanks to the best producer in the biz, Gary Feiner for always being here and put this thing together. We will see you next time on episode six.