PharmacyNow Podcast: COVID-19 and the Pharmacy Landscape with Rear Admiral Pamela Schweitzer, PharmD

As Chief Pharmacist Officer for PHS, RADM Schweitzer was responsible for providing leadership and coordination of PHS’s pharmacy programs and professional affairs for the Office of the Surgeon General and the Department of Health & Human Services. Prior, she served with the Centers for Medicare and Medicaid Services and held varied assignments in the Indian Health Service (IHS) and U.S. Veterans Administration.

RADM Schweitzer has received numerous honors for her leadership and contributions to pharmacy, including the 2014 American Pharmacists Association Distinguished Federal Pharmacist Award, the 2012 USPHS Mary Louise Anderson Leadership Award, and the IHS Senior Pharmacist of the Year 2013 Award.

RADM Schweitzer received her Bachelor’s degree in Biological Sciences from California State University Fullerton (CSUF), earned her Doctor of Pharmacy from the University of California San Francisco (UCSF) School of Pharmacy, completed an Ambulatory Care/Administrative Residency at University of California Irvine Medical Center and is a Board Certified Ambulatory Care Pharmacist (BCACP). She currently is completing the Executive Master of Health Administration (EMHA) Program at the University of Southern California (USC) Sol Price School of Public Policy.

Introductions

Scott Vondeylen: (00:02)
Helping pharmacists grow themselves, their business, and driving outcomes. This is PharmacyNow.

Scott Vondeylen: (00:23)
Thanks for joining us here on episode four of the PharmacyNow podcast. Extremely excited about today’s podcast. We have a very special guest, Admiral Pamela Schweitzer. Want to give some background here on Admiral Pamela Schweitzer, very distinguished. She most recently served a four year term as the Assistant Surgeon General and 10th Chief Pharmacy Officer for the United States Public Health Service and was the first female in that role over the last 29 years of her career in federal service. She also has served for the Centers of Medicare and Medicaid services, CMS. Previously, she has also served in various other assignments including the Indian Health Service and the Veterans Health Administration. She’s earned her doctorate degree in pharmacy from the University of California, San Francisco and then also completed an ambulatory care administrative residency at the University of California Irvine Medical Center, making her board certified ambulatory care pharmacist or BC ACP, for those honors. And she has also earned several awards including the APHA Distinguished Federal Pharmacist’s award, the NCPDP Championship Award. And most recently in 2019, the ASHP Distinguished Leadership Award. And if that were not enough, in her spare time, she does enjoy climbing and his summited Mount Rainier, Mount Whitney and Mount Kilimanjaro. And if one time wasn’t enough, she did do it twice. So Admiral, it is an absolute pleasure to have you here with us today. What have you been doing lately?

Rear Admiral Pamela Schweitzer, PharmD: (02:05)
Well lately I’m probably like everybody I — And first of all, thank you so much for having me here today. This is actually just as exciting for me too and I appreciate the invitation and I look forward to our conversation today. So as far as what I’ve been up to today and just like everybody else, this is the middle of COVID-19. So we are probably all focused on that. So I’m just like everybody else.

Scott Vondeylen: (02:30)
Yes, I am right there with you. And again, appreciate having you and actually want to take a moment again as we’ve been doing to thank all of the healthcare professionals out there and first responders and the tremendous job that they’ve been doing. I know we’ve all seen in the media the round of applause that they have been getting in different cities across the country. But what a tremendous job. We always say thanks to first responders, but during this time of a global pandemic with COVID-19, you know, nurses, doctors, firefighters, police officers, and of course pharmacists who are on the front lines of healthcare and trying to do everything they can to keep our population healthy and happy and help those who have been affected by this to recover quickly. So wanna jump into this Admiral, we’ve got a lot to talk about as we’ve worked out, I think a great conversation in our outline. But wanted to just turn it over to you to give a little bit. I know I read some background there for you, but one of the questions I love to ask our pharmacists that are guests on the podcast, is why pharmacy for you?

Rear Admiral Pamela Schweitzer, PharmD: (03:41)
Well, thank you for that question and I totally agree with you on the heroes, all the heroes, and the healthcare providers on the front lines. They’ve been doing a fantastic job. So how I started out, I actually grew up in orange County, California in a little town called Yorba Linda. And my dad was a pharmacist and he worked in one of the local community pharmacies there. And my grandfather was a pharmacist and he had his own pharmacist over in Los Angeles. So I grew up just knowing about pharmacy, but both of them really did not encourage me to go into that. They wanted me to like, pave my own way and do my own thing. And so I, you know, got my degree and I was working, doing research. I really liked the field of immunology. My cousin was marrying, you know, she was engaged to a pharmacist and he was a clinical pharmacist and that was actually my first exposure to what clinical pharmacists did and working with the providers and you know, being able to like manage, you know, chronic diseases. And at the time I remember clearly it was diabetes back then. So this is many years ago that pharmacists were kind of doing this a little bit already. So what happened was, I decided to just apply to pharmacy school and if I had a job, but if I got in, it was meant to be and I got in. So then I finished pharmacy school and went and did a residency and I loved the clinical part of it. I knew I had found my niche. I loved working on the healthcare team. I loved the hospital setting. That’s kind of really where I was when I did my residency. I kind of expanded and got more into ambulatory care and then I knew for sure that’s what I wanted to do. I was super excited to be part of the profession. I loved all the people I was working with. And I had gone to a pharmacy meeting at the time and I saw this, saw this display. So it caused me to stop and visit with the gentleman, you know, behind the booth there. And I visited with him a little bit and I had never heard of Indian Health Service and he was recruiting for Indian Health Service. It just so happens his name was Dick Church and he became my mentor at that time. He recruited me in and I went into the Indian Health Service and I didn’t know what public health was at the time. I was a clinical pharmacist seeing patients working in more of a hospital, you know, institution health system type environment. But they asked me, I had been there about three or four months and they asked me, we are looking for someone to be the health promotion disease prevention coordinator for the service unit, which is really like that whole reservation. It didn’t have to be a pharmacist, it could be anybody. And I just said yes. So you’ll find my whole career almost everything that happened, I’d say yes before I figured out what it was that I was doing. And that was the one incident that changed my life because it totally exposed me to a completely different world. And what that world was just learning how to work with communities and how to make changes within the community and how to work with the community and make those public health changes that need to be made. I was working on things like Tuberculosis TB, Hepatitis A, there’s a lot of alcoholism and a lot of it was education. But also getting into resources and the help they need to be able to make those changes. But even more important was to work with the leaders in the community so that they would kind of like embrace that and lead the community to making the changes. So it was a different style of leadership that I learned how to do really early on. Eventually, I kind of, fast forward, was involved in several national projects. Rollout of big national initiatives, you know, and I had a chance to be really working with C-suites and CEOs. So that all kind of evolved there. And then from there I went to, to still as an officer, I went to CMS. And then there I was working a lot on the Affordable Care Act early on with some of the pharmacy in the pharmacy division too over there in Medicaid so I really got familiar with how Medicaid works from being over there. And then I then I had gotten that role where I was the, the Chief Pharmacist Officer or Assistant Surgeon General. So that’s sort of was my career path.

Getting Pharmacists Involved in COVID-19

Scott Vondeylen: (08:16)
Sure. No, thank you for that. So let’s then fast forward a few decades and go to 2020. COVID-19 as all the listeners are all very familiar with the amount of information that is in the press every single day, everywhere you turn. But really for me, the first thing about COVID-19, I think in January, for those who were paying very close attention to sort of what was going on overseas, not quite in the United States yet. But at what point in time did you then begin to really get involved in, in terms of, opening up to the next part of our conversation, but when did you really get involved and think, okay, hold on a second, we’ve got to really look into how we’re going to solve this? And then obviously the thought of getting pharmacies involved for the testing. If we can kind of just roll to that timeline. I didn’t do a great job in outlining it there, but if we could start there and roll through the timeline from your perspective.

Rear Admiral Pamela Schweitzer, PharmD: (09:18)
Yeah, so I remember we were, I didn’t realize it was in the States yet. I don’t think any of us did. We knew it was up in Seattle. And I remember the first part of first week in March, I was in Hawaii. We came back and then I was back and then I was in DC and then we realized it had started spreading. And so I really started paying attention to when I knew they needed to start doing more testing. And I think at the time I sort of thought, Hey, pharmacists can be involved in this. I was thinking that already. I was chatting with some of the pharmacy organization leaders to see what kind of, what they thought a little bit about it. And then the date I clearly remember was when I saw on the news that that they were going to start increasing and doing more testing. And then I saw Admiral who is, I should probably go back and tell you a little bit more about the Public Health Service, but Admiral who is the assistant, he works in the office of the assistant secretary for health. When he announced that they announced that he was going to be overseeing the testing. So right away my ears perked up cause I know him and I used to, you know, work for him. And so I actually had reached out to the, some of the independent, the NCPA, the CPESN and then of course Tabula Rasa, Kevin Bosen. Reached out to them and just saw saw what they felt about doing some of the testing to see what there, to sort of get the temperature to see if they’d be interested and talk through what kind of needed to be done. And then we put together, I put together a real quick draft and I know NCPA was working on it too and I was going to send, my plan was to send it to Admiral, just, Hey don’t forget, think about pharmacy cause we can be engaged in this. So that same day, I actually, when we were thinking about it as soon as I did the touch and it looked like pharmacists were engaged and I of course, I’ve always reached out to my Indian Health Service colleagues to see what they were doing. Of course they’re all over it because they always are. Then I sent an email immediately to him and I said, Hey, let me get back to you, but I just want to let you know, heads up, that the pharmacy group can be all over this. And so then we put together sort of a, it was a two page and I sent that, it was about the 13th 14th or 15th of March. Sent that to him and in that outline we had already addressed some of the challenges that we were going to need to address getting PPE that was already becoming a problem, you know, some of the getting the equipment, which tests to use. And that started initially just conversations with the FDA at that time. We were starting to hear all this, these testing out there and how is the pharmacy supposed to figure out which is correct, which one is the right one to use. So we had some really good conversations with FDA communication back with them and they really helped sort of sort through this, some of this and help us figure out which testing to use. So we were all talking. All the pharmacy organizations did an amazing job. Every single one of them, they all stepped up and they all have their area of expertise working together. I knew they were meeting regularly. They sent messages to the Vice President’s task force that he was doing. They were bombarding there. Everybody was hitting where the areas that they knew. So I hit Admiral cause I knew him, but everybody, each individual was hitting the folks that they knew too, like in the administration wherever they were. And the task force, I have a copy of that memo that they sent that all the pharmacy organizations did really good. So I think it was like a, it was like an all hands on deck. Everybody just kinda like hit everywhere. And so people were aware that pharmacists could do it. I don’t think that that was the issue, but I did as we were starting to look into this, I knew this was going to be a problem and it is. It still is. Is there is a lot of infrastructure that needs to really be in place for pharmacists to actually move forward on any initiative. And I was involved back in 2009 when we had H1N1, at that point I was working at a regional and national level. So I saw what was involved in getting that vaccine now and I saw then at that time at least initially pharmacy didn’t have everything in place to be able to get reimbursed right away. So they had to go and work on that. Each state one at a time had to go work on that. And so what I’ve been working on right now is going back and a lot of this dates, they haven’t really touched pharmacy, the regulations on this, on these kinds of topics since back in 2009 back when H1N1 was there. So we really need to, and I can say this now, it’s kind of looking back, but this is a great opportunity because we have to open up that little window, that little door to go start getting ready for the vaccination that it’s a door that opens up that we can actually go in and fix some of these other regulations that are missed that need to be fixed. So example, being able to do a tele-health, you know pharmacists be able to do that if you go read the payment model. So there’s one thing that the pharmacist can do this. It’s a whole other thing about getting reimbursement and that’s kind of what I’m focusing on right now. So a lot of the States, sure pharmacy go ahead and do it. Just like that memo that came out on April 8th from the HHS. Sure pharmacists can do this, but we have to go, all of us as a profession have to go work in our little area, in each area to be able to like open that up so that we actually can get paid for which is a whole other story. So that’s the challenge right now is getting through and working with each state because this is, this can be done at the federal level if we can work with Medicare and I know the pharmacy organizations are working on that, but also the Medicaid and the private plans, that’s a whole other project there. So each of these are separate projects that, that the profession has to work on. And what we really need to do is stay working on this even when, even when this emergency period is over because if anything happened, if anything, we need to be able to fix it so we can jump in quicker during an emergency. So, for example, I was part of, in the Public Health Service part of a lot of, I guess I’m going to say disasters and afterwards they would, the state would come in and they would work on a plan like hurricanes and things like that. A plan that boom, as soon as we have an emergency, all these other things go into place and there’s not a question, you don’t have to worry about it. We need pharmacy needs to be in there too and do the same thing. A lot of these other emergency groups they put together so after the disaster so that they can make it go back into effect really quick. So even if they say pharmacy can go do this, if we’re not getting reimbursed, that’s a problem. We need to fix that. So we will always be able to get reimbursed right off the bat, if that makes sense.

Getting Reimbursed for Coronavirus Immunizations

Scott Vondeylen: (17:07)
It does. And so Admiral, my question for the average listener out there, so I understand it would just like to say that when it comes to immunizations, from a pharmacy’s perspective, I just have some numbers here in front of me. NCPA’s latest number is that there’s about 80% of 81% of pharmacies are now immunizing and that’s community pharmacies. So to the listeners there’s 60,000 pharmacies nationwide, on the latest number and then there’s 21 to 22,000, depending on what numbers you look at, independent pharmacies. So independently owned and operated pharmacy groups and about 80% of those independent pharmacies immunizing today. And they’re able to do that in most cases because they have a CPA, they have a collaborative practice agreement that’s signed off on a doc. They have a standing order, they can administer that immunization. But the reimbursement piece, if you could dive into that for just a minute, what is that looked like and how does that differ from state to state and then commercial versus Medicaid versus Medicare? If you could speak to that a little bit.

Rear Admiral Pamela Schweitzer, PharmD: (18:14)
We already know because it’s in statute when it was passed, you know by the Cares Act there at the end of March that it’s going to be a part for Medicare, it’s going to be a Part B drug. And so part of it is getting that infrastructure in place and making sure that all of our pharmacies that are going to be providing this vaccine have the capabilities of doing that. I know a lot of them do, but I do know there’s some that don’t. So knowing some of this now, it’s really a great opportunity to start getting all this infrastructure in place and get it ready for that time period. I am pretty sure in fact that the vaccine is going to be most likely just like N1H1 was, it’s going to be provided free and then what happens is though we need to be able to get reimbursed for the administration of that. So if we go through, we’ve got to, that’s all going to be worked out. And there needs to be, I’m going to say constant like nudging, nudging, nudging at the CMS level for Medicare so that they make sure that pharmacy’s included as being one of those folks that can actually be able to be reimbursed for that. So that’s partly the strategy that needs to happen there. And there’s, there’s Part D standalone, or excuse me, it’s going to be the on the Part B side. So pharmacy needs to be included in there. So part of this is the pharmacy profession has to keep pushing to make sure that the pharmacists are going to be included in there. Are they enrolled? They have to do all the nuts and bolts to be able to get in their positions so that they can submit a claim and it could get reimbursed. So if they haven’t done it before, they’re going to have to enroll to be able to do that into Medicare. So those instructions need to get out to everybody and they need to start kind of working on that once more information comes out. But I would, if I were all the pharmacy groups be actually reaching out now just to try to get ahead of it and start getting ready because it does take a little bit of time, even though they’re doing some things to kind of speed that up. You know, we have a little bit of time because the vaccine is not ready yet. Then on the Medicaid side, and that’s actually what I’m more focused on right now because I was involved in it. It’s gonna have to be every single state. You’re going to have to go in there and look in every single state Medicaid plan and see how the wording is for pharmacists to get reimbursed for doing the administration. And what I’ve noticed already is that some of the states, they’ve been real prescriptive and they say we only cover flu vaccine. So if that’s the case, we’re going to have a problem. So they’ve got to go in and make sure they update it now so that they will be ready for that COVID. And I would try to broaden it and they should really be, the wording should be for you know, vaccines that, that are covered by the state. You know what I mean? It should be a little bit broader, like a little bit broader language instead of so, so prescriptive. So, that’s something that needs to be done right now. Now I’ve already gone through some of that for a lot of the States cause I’ve been actually looking up every single state on their state plan to see where they’re at. So I have a lot of that information already and I’ve got to get that out here real soon. Then private pay. Private pay is going to be a whole other area too and that’s gotta be negotiated. So when you have a big network of pharmacies that can go in and start negotiating that kind of like PrescribeWellness has or, or just any of these networks, the CPESN, they have it to go and start negotiating this. That’s what really needs to be done up front. So they make sure pharmacy’s included in all these health plans that are going to be providing this vaccine. So if I were all of the pharmacies, I’d be part of something that you can go in and make sure somebody is negotiating with the health plans and that’s for the commercial side. I think for the most part in all the States, pharmacists are allowed to do immunizations and vaccines and do that. But there’s some States that are, again, prescriptive. And so to go in and work with their board of pharmacies and make sure that that scope of practice allows them, is not going to keep them from doing what needs to be done because almost every payment, the way the payment works, it’s paid. You can provide the service as long as it’s within your scope of practice. So what, depending on the state you’re practicing and if there’s restrictions or limitations, somebody needs to go in and start working on making those changes.

Provider Status for Pharmacists

Scott Vondeylen: (22:59)
Understood. And I don’t know if you’ve made it through reading the regs in all 50 States, but you know, in terms of the verbiage and how prescriptive it is, because of course always having the conversation around, you know, provider status and pharmacy. Which is also kind of, and correct me if I’m wrong here, Admiral, but kind of convoluted with what does provider’s status mean. I didn’t know if we could spend a minute talking about that cause it’s always a huge topic in pharmacy, even outside of course the immunization piece as far as the scope of practice and what pharmacies can get involved with. And as you mentioned, get paid for. So important, right? Because someone once told me a long time ago, if there is no money, there is no mission. And while, you know, we know how much pharmacies care about wanting to provide great health care for their patients and take care of their patients and how passionate they are about that. These are businesses and they do have to make a profit to keep, to keep running. So provider status, you know, I don’t know how long we want to dive into it, but outside of the immunization piece and what does that really mean for you and have you been working on that as well outside of the whole COVID-19 discussion?

Rear Admiral Pamela Schweitzer, PharmD: (24:19)
Well, I’m going to give credit to the pharmacy organizations who have done really good job of working on this. I’m going to say in the broad view of this. But it’s really tough because, so this is, you’re getting my opinion a little bit here. So we are providers, a lot of the States have gone through and we are providers. That’s the kicker of all this. So we’re providers, but the payment side is a whole other side. So everything is a little bit different. So for Medicare, the challenge for Medicare is that we’re going to actually have to stay change a statute. That’s where the problem is there. However, there’s work arounds and people have figured out workarounds to be able to still provide services. And it depends on the model and the practice. So if you’re in an institution or if you’re in a, you know, health system, this is not community pharmacists now the chances are the pharmacist are providing, they’re doing all of providing all those services just like you would think a clinical pharmacist would do. They’re managing drug therapy, they’re changing doses, starting stopping people on therapy, they’re practicing at the top of their license. It’s the billing side that is usually worked out in the facility. You will, a lot of times, they’ll bill as an institution. So from that perspective, they are practicing, they’re practicing at the top of their license and the billing behind the scenes isn’t the pharmacy billing and collecting the money themselves, it’s the institution billing on their behalf, if that makes sense. And it might be under the physician’s name. So they have different ways of doing the billing, I guess is what I’m saying. But they’re still practicing. So their providers and they’re still practicing. On the Medicaid side, for them to be a provider. So you can look at, there’s two, two divisions here. One is pharmacist providing these statewide protocols. Like, if you see the statewide protocols, if you look at all across our nation, every state has some kind of statewide protocol in place, whether it be for immunizations or hormonal therapy or nicotine replacement or you know, strep throat. You know, some of them have a lot of them. Like Idaho has several of them in place that they can do, their scope is really wide. And they can provide a lot of different services. The payment part is where the challenge is. So the scope allows them to do this. It’s just the reimbursement. So the reimbursement, you know, the immunizations for Medicaid, they had to go one at a time and be able to, each state one at a time to be able to get reimbursed for those services. And I’ll give you an example. Nicotine replacement therapy, the statewide protocol says that the pharmacist can prescribe it or you know, or give it or whatever the word that they had to use to get it approved, to be able to hand it out, dispense it, you know, without a prescription. So what happens is, is, okay, great, you can do that, but to get reimbursed there might be another set of rules. So the pharmacist is a provider, but if they’re not getting reimbursed, does that really count? And so that’s where the payment side, that’s where all our energy should be put right now is, is working with each of these different groups. And it’s going to be both the commercial side, the commercial, private sector plans, Medicaid is another project. And then Medicare is another project. We need to almost divide it up that way. So on the Medicaid side, and this is the part that I’m focused on basically for the rest of this year is focused on how do we get pharmacists listed as other licensed practitioners because that’s the service side. So in the example I gave about nicotine replacement therapy, that’s great. I’m going to get reimbursed for the product, but now I want to get reimbursed for the service, the time I’m spending with the patient going over the actual counseling that goes with it to be able to get paid for that, reimbursed for that service. That’s a whole other project right there. And that’s going through and getting the pharmacist listed as another licensed practitioner. Now several States have done that. Some of them have broader scope, some of them have real narrow, they only cover other licensed practitioner do one little thing. And some of them are real broad and they say within the scope of the practice, you know, collaborative practice, whatever, I can work with the physician, I can get reimbursed. But there’s only a handful of States that have gone through this. And so that’s why all of us need to work on this. This is our big project of the year that we need to go get pharmacists listed as other licensed practitioner. And not with a narrow scope, not with just doing immunizations, not just with doing the, you know, allowing to administer an injection that doesn’t count. We want it to be broad where we can actually practice a lot broader.

Scott Vondeylen: (29:37)
So what I hear you saying, and again, just for the average listener out there, you’ve got three different fronts that we really have to kind of come together and put together a game plan, mobilize and go after. And that is the commercial side, so the big payers that everyone knows; the United Healthcares the Humanas, the Blue Cross and Blue Shields, those sorts of plans. Again, commercial plans. And we have Medicaid, which a lot of that falls at the state level. And so you’ve got 50 different Medicaid conversations perhaps with the 50 States and then then the Medicaid, excuse me, Medicare side is federal. And you had mentioned earlier that’s gonna have to have some new statutes passed. And does that tie back into, just for the knowledge of anyone listening, does that tie back into key sections of the Social Security Act?

Rear Admiral Pamela Schweitzer, PharmD: (30:31)
Correct, that’s key sections. And let me go back and talk about Medicaid one more time, too. So the way the mix is, at least how I have it in my head, is for Medicaid that also includes the managed care groups too. They tend to be more at risk and might be willing to utilize a pharmacist, but the pharmacist still needs to go through those hoops of getting listed as another licensed practitioner, if that makes sense. So the mix is like 75/25 as far as like the managed care plans that manage Medicaid beneficiaries at the state level. And then Medicare is about the opposite. You know, most folks that have Medicare are not in managed care plans. You know, it might be like 70, I don’t know what the exact number is, but it’s, it’s almost like the reverse. So most of them are just in a regular Medicare plan and they have Part D in addition. They’re not in the Medicare Managed Care Plans, MAPDs.

Scott Vondeylen: (31:39)
And so, would I be correct in saying that the Medicare battle will be the toughest?

Rear Admiral Pamela Schweitzer, PharmD: (31:49)
The Medicare battle will be the toughest. And part of that, and this is my opinion, is that we need to do a better job, we meaning the pharmacy profession, need to do a better job of helping, not only helping Medicare just understand the difference between a pharmacist clinician, a pharmacist practitioner and their value and the value compared to a pharmacist that might be providing different kinds of services, which might be to me all the services that the pharmacist provide are important, but they have a real hard time differentiating. How do we differentiate that? And they’re looking at the number of places that they probably have to change all the regulations. And so, I think we just have to be strategic in how we move forward and how we go through and do this. I will tell you that for the pharmacist practitioners that are practicing in Medicaid that have this broad, broad practice that they can, you know, that they’re practicing their prescribing, they’re doing all of that like in New Mexico or maybe even in Minnesota has some North Carolina, you know, that they’re practicing. Even in Montana, they have this broad payment there. In other words, they can be reimbursed for providing clinical services like front line prescribing. Not very many pharmacists actually go through and do this. So I was really surprised as I was putting together information, I reached out to check with just New Mexico who’s been there the longest. They have this pharmacist clinician that has been around forever and, you know, it takes a lot of hours to get it and I think they only had, they say they have 200 listed or 200, I guess enrolled are getting with this extra licensure. But I think there is not that many that are practicing. I don’t think all of those are practicing. And so it’s not like they’re going to be bombarded when we get these other clinicians in there. I think it’s a little bit of work to anyway. I just don’t think it’s going to be a big impact cause everybody thinks it’s going to be. And they’ve been around for years and there’s not that many of them out there. The other piece that we need to sort of, I’m gonna say empathize with the payer side is that we, the profession, don’t have a really good way, and we haven’t done a really good way of being able to track how do they know, how does the payer know that this pharmacist that is, I’m receiving this claim from, how do I know that they’re legit? That this person has a credentials that they supposedly have. We don’t have a separate database. And I know that APhA has profiles. I know some of the States have a way to be able to carve out. How do I know there’s a collaborative practice in place? So the payer doesn’t always know that. So the States that have put that infrastructure in place, it sure makes it a lot easier for them. So I know they did that in California. I know New Mexico has it, North Carolina has it. So some of the States that have that infrastructure in place, it makes it a little bit easier for the payers to know, you know, when they enroll into their health plan or when they enroll that they know that that person is legit, if that makes sense. So that infrastructure on the back end needs to be put in place at the state level.

Prescribing Authority for Pharmacists

Scott Vondeylen: (35:36)
That’s great stuff and really fantastic insight. And speaking from your experience of course, I did want to ask, I know this is big picture stuff, we’re talking about provider status. We’ve gone through, you know, immunization to some COVID-19 and dabbling in some different places. But talk, if we can just start off the conversation around then, how does prescribing authority for pharmacies work into this conversation?

Rear Admiral Pamela Schweitzer, PharmD: (36:06)
Well, so don’t forget, I’ve been in the Indian Health Service and also the VA forever. I mean I was in them both in the VA and there a lot of them are really good friends and colleagues and the same thing with the Indian Health Service and they do this all the time already. And if you go into, there’s a lot of practices all over the country, I travel everywhere, they’re practicing at the full scope. They’re changing doses, they come in, they manage, somebody comes in and here’s how the model works usually is a physician may see the patient for whatever reason, let’s say their blood pressure is up or their diabetes or their a COPD, whatever the diagnosis is they give them. They refer them to the pharmacy to manage all the drug therapy and the referrals made and then the pharmacist will take and manage it and depending on what the instructions are, the pharmacist may manage that patient for a long time. There’s communication that goes back and forth between the the physician and the pharmacist. It’s not just like a one and done. Here’s the patient you’re on your own. There’s communication that actually goes back and forth between them. And when I say between them, they may see them, Hey, by the way, here is going on and they’ll see the pharmacist notes. So this practice has been around since way back in the nineties when I first was talking about this. The way this practice is, it’s just how do we convert all this practice type stuff to get reimbursed on the private sector. And part of the problem is, is that the infrastructure is not all in place there to be able to practice that way completely. So, you know, with all the it piece and everything like that so the pharmacist can do that. And then the other problem is pharmacists have tied too much to dispensing. And what I hear a lot is that they don’t have the opportunity really to break away to be able to do all these clinical activities. Well, I will tell you that’s actually when I, one of my jobs that I had when I first came to the, like regional office after I left the pharmacy was my job was to take and convert all these Indian Health Service facilities and get them to be more clinical. What had happened was the workload had taken over over the years and we had a few, maybe about eight places that were really clinical though, the ones that were getting out and about doing all the presentations. But the rest of the pharmacies were just overwhelmed with workload. And I’d go visit them and say, all right, let’s go. We’re going to get going with clinical activities. And they would look at me and just go, yeah, right. And I saw them and I could see their workload and there is no way they could do anything clinical. So again, you already know what the answer is. I see some of the problems. We’ve got to get some automation in here. So before we even, we’ve got to get rid of this prescription filling and how do we get out of, how do we get out of this filling all this prescriptions and get the workload moves so that we can free up. Nobody’s going to give you FTEs, full time equivalents. Nobody’s going to give you new positions. So how do we do this? So it was actually a project that happened over a period of, it took about a good several years to do that. And then what we did is we actually made a deal with the medical directors and with the CEOs as we started getting more automation in there and freeing up the pharmacist, I did not want them to cut the position. That’s the last thing we want to do. So the deal was they had to, how do we get them so that they can go into the clinic, start working with the medical staff, you know, start working with the nurses in the clinics and then that happened really slow. But once they got in there, they loved them. So then it grew from there, but if we didn’t, if we didn’t push, if we didn’t like push that a little bit, we always could find a physician, one physician that might want a pharmacist but not everybody. You had to kind of like work your way in there so it doesn’t need to be start all or nothing. It could start, you know, a little bit at a time. So if I were in the community pharmacist, what I would do would be, and even if you brought somebody part time in, I would start going over and visiting those physician offices and just visit with them, chat with them, start educating them to see where they are and see if they’re even open to having a pharmacist come to them. It could be a morning, a week or two mornings a week or every morning depending on what they do. Once they get started, they’re going to want a more, but there are, of course you have to work out the reimbursement piece for that. But if that’s what we’re working on right now, if we’re able to bill, if the physician is able to bill for that pharmacist services, if the physician wants to do the billing for that pharmacist service and get credit for it, that’s how we’re going to get our foot in the door. Because then it’s like they, it’s like a no brainer for them. But we’ve got to work out the reimbursement piece first.

Collaborating with Physicians

Scott Vondeylen: (41:20)
So I hear you loud and clear there. And my next question to that Admiral would be, if I’m a pharmacy owner and I have that conversation with a local physician, do those services in most cases start with chronic care management? Or what is it that the majority of pharmacies would be able to provide in terms of a service to a physician that would have immediate impact and value to that doc?

Rear Admiral Pamela Schweitzer, PharmD: (41:51)
I love that you asked the question that way. So remember, my very first experience working at the tribe. So what I’ve learned to do, and I would highly recommend that this is the way to do it. You’ve go see where they’re hurting. You have to know the mix of the population that they’re seeing. Every physician has a certain mix, and to sort of almost figure out what would help them the most to break, get your foot in the door so we can come in and we used to have this all time. People would start clinics, it’s tobacco cessation clinic and I go, why did you start that when there’s nobody smoking in your community? So we don’t need to go sell something and we have to find out what they want and then us tailor to what they need. The chances are the pharmacist can do any of it, but that’s where you almost need to go visit with them a little bit and see where their needs are first and see like do you have, and you might have to help them brainstorm like they might have an older population. You have to see what their mix is to do. They have a lot of Medicaid patients, do they have a lot of Medicare? Do they have private, their mix is going to be real important. They’re not going to make a lot of money off the Medicaid patients. So that would be like what their mix is. So maybe they would rather have you come in and take care of those so they could take care of the ones that they’re going to get reimbursed more. So part of it is going in and seeing where you can get your foot in the door and at least lay it out. All these ideas for the provider, sort of really planting seeds, you know, we can help you with this, this, this and this, you know, and find out what, what it’s going to be important to them, if that makes sense.

United Healthcare Remaking Care Model in Ohio Amid Coronavirus

Scott Vondeylen: (43:35)
It does. Absolutely. And I liked the way that you’ve said that. So, I wanted to touch on a story that was recently in the news. And so United Healthcare is working to remake the care model in Ohio’s community pharmacies amid the Coronavirus. And so the paragraph here is stating that United Healthcare is working with some community pharmacies in Ohio to deliver primary care to its Medicaid patients. The healthcare giant last week told the dispatch of plans to pay pharmacists to spend time. You mentioned that earlier, key to spend time with patients in an effort to better manage chronic conditions such as diabetes, high blood pressure, and other problems. Keeping those populations healthy would actually then free up precious hospital beds during the Coronavirus outbreak. The partnership between United Healthcare and Ohio’s community pharmacies opens up a new chapter in recent years. They’ve typically been at odds over, of course, prescription reimbursement. So the future possibly with some of these regulations being rolled back. Now all of a sudden this is almost bipartisanship if you would, between payers, and community pharmacies as stated, they’d been at odds because of reimbursements over prescriptions. Now the willingness to pay them because of the pressure during a global pandemic to keep beds open at hospitals. What does this mean, possibly in your eyes for the future of independent pharmacy?

Rear Admiral Pamela Schweitzer, PharmD: (45:15)
Well, first of all, I want to commend United Health for like paving the way for this group. I think it’s great that their leadership, you know, the folks saw this and Ohio, the people in Ohio who have just really been on the cutting edge. I saw a video a while back on just the passion that the health plans had for pharmacists and it was in Ohio. And I think, you know, that’s like a perfect example. Here they figured out that we’re crazy not to use pharmacists. And I love how they came across so passionate. So kudos to everybody for doing that. And I’ll just kind of go back, one of the challenges has been, it’s the way the reimbursement is working is that, so there’s a pot of money that goes towards the pharmacy benefit. So the, you know, reimbursing for the drug. They do all the, the PBM, they do all the negotiating and all of that. They’re not going to pay for the services. The tough part is getting over to the health plan side. So the United, you know, United taking this on, I think that’s great. And for Medicaid managed care, they’ve negotiated probably with Medicaid, you know, for a certain rate of reimbursement that they’re getting for these to manage this population, these group of patients. And so I think what they’ve realized is that since they’re at risk that they’re crazy, again, not to have a pharmacist because the pharmacist can do so much. They can actually help the patients find their medicines, they can track them down, they do all those little extra things to make the world easier so patients can take their medicines so they’re adherent so that they help them sort through the side effects and fix everything so that the patient’s happy with their medications. And I just think it’s a win-win and it’s a great example and I’m glad that, you know, they’re leading the way on that. Now, the problem is, I’m going to go back on the problem, is still we’ve got to get Ohio that’s going to help. That’s going to be okay for the Medicaid manage care, but for any fee for service and even the pharmacist being able to, they’re going to have to be tricky about the billing. It’s because it’s United Health is being able to manage all this and be able to cover all this. But on the Medicaid side of the house, a pharmacist still need to be enrolled as a licensed practitioner too. So that’s going to take a little bit of work to still work on that and eventually they’ll come around. We have to, we’ve got to keep helping Ohio so that we can eventually get that through.

Scott Vondeylen: (48:07)
Well said. And a little bit in my mind, a little bit of irony there with that particular story because you know, I’ve experienced over my time and working with pharmacies and obviously your career has extensive and in depth as it’s been, that pharmacies can truly have an impact in keeping hospital beds empty all of the time. And not just during a global pandemic because of the additional pressure on the healthcare system suddenly. Just wanted to read off a couple of quick figures and I know that you know these really well, but for the listeners, and this is directly from the Milken Institute, which is a big think tank out in California. So total cost of US dollars for direct healthcare and treatment of chronic health conditions totaled $1.1 trillion in 2016 which is equivalent to almost 6% of the U S gross domestic product, the GDP. And leading at the top of that list in terms of conditions, the most expensive condition is diabetes, followed then by all Alzheimer’s. And then of course, cardiovascular related or high blood pressure, kind of bucketed into one there. And the impact that pharmacy can have, being on the front lines, having 12 to whatever the national numbers are. What I’m trying to say is much more encounters with a patient than their primary care physician or their specialist and how medication adherence factors into the overall health and outcomes of that patient in their therapy to keep them out of the hospital. That, in my mind, has been the big push for a few years. You mentioned CPESN earlier and NCPA, but that pharmacies can play this huge role in the lives of patients and managing that therapy of their medications, offering these additional services and education and information to keep them healthier, to keep them out of the hospital. But it took a global pandemic for a United Healthcare, which again, congrats to them as you mentioned, awesome. That we’re all working together, but it took that adversely to try and keep beds empty by paying pharmacies for their times to manage those patients. That’s just, it’s like kind of full circle. But I don’t know what your thoughts are on that.

Rear Admiral Pamela Schweitzer, PharmD: (50:42)
Yeah. Before the pandemic hit, to me, there’s just the biggest opportunity ever and it made me think of it when you were talking is in the area of rural health. I just got off a meeting earlier today on this and there is just so much opportunity right now because if you go look in rural communities, you know, those independent community pharmacies are the primary healthcare in that community. And a lot of times they’re front lines and they can be doing so much more. They could be in public health. Just the whole topic of public health. You know, it’s crazy that pharmacists don’t embrace it because they’re in the community. People trust them, you know, they know them, they’ve been there forever. And it’s just a great opportunity. So I always encourage pharmacists that we should embrace everything, public health because they can make such a big difference in their communities and in improving the health and their community because people realize that we need public health. And right now is like the perfect time to just try to beef up some of our public health in our communities right now. Because over the years it keeps on getting cut and cut and cut.

What Can Pharmacists Do Right Now?

Scott Vondeylen: (52:00)
Yeah. Well I wanted to ask, I know we’ve been on here and we only have a few minutes remaining, but I wanted to ask, you know, based on your opinion and of course your vast experience, what is it in particular, and you’ve mentioned a few things here along the way, but what is it in particular, global pandemic aside for just a second, that independent pharmacies could be doing and should be doing right now? And again, I know you mentioned a few of them, but just to kind of go back over that list of things that they could be doing right now to benefit their businesses and to start to change the paradigm a little bit there with the old model of, you know, stick it in liquid type of thing and just filling prescriptions the dispensing of medications. What else could they do?

Rear Admiral Pamela Schweitzer, PharmD: (52:51)
Well, that’s a great question and almost what they really need to do is sort of do like an assessment of where they’re at and what they need. Kind of make that decision you want to move forward and then kind of go from there. You know, if they want to expand on those other clinical services, if they want to even go down that path, you know, what’s the strategy to get there? And I actually think, it’s going to be really important to be part of if they can, something is going out to do to negotiating with these health plans because you’re going to need to be part of that. It’s the same thing. Like when they negotiate with the PBMs, you know, you go in and they have the agreements with that. They don’t go one at a time. You’re with another group. So they almost have to be talking to get into some kind of network so that they can be able to do some of this. Either that or start looking at the agreements themselves and go through and read them. It’s a little bit of work to go through and enroll in these and do these other to enroll. It’s actually a lot of work. You listen to physician offices that go through when they enroll in a provider to enroll in these health plans so they might want to just look and just see what’s workable. There’s ways to not do it too but you have to be tied to a physician then and looking at different copies of agreements, looking at their IT systems to see if their IT system can communicate back and forth electronically with the physician. So either through direct messaging, I know all the systems have something, it’s just a matter of whether it’s another module you have to pay for, whether it’s part of the main one. So you have to kind of see what system you have to make sure you can communicate with the physician too. You always want to be able to at least have easy access to talking to them. And this is for managing when there’s a physician referring to you for the public health that’s a little bit different. I know that a lot of people, if they just come in, they may not all have a primary care provider, but for the ones that are referring to you that you’re managing their diabetes or you’re managing their hypertension, you’re going to probably want a relationship with that physician and a way to communicate back and forth and getting that infrastructure, make sure you’re working on getting that infrastructure in place and, you know, finding the areas in your community where there might be a need. So, you know, and a lot of it depends on the mix of the patients too. It’s going to be depending on the mix and finding out where you can make the biggest dent. And then of course, working with the, you know, the pharmacy groups that are moving forward to try to change some of the regulations in the state. You know, it doesn’t take everybody involved in doing this, but it takes, everybody wants somebody to support. You have to support somebody to go do this. When I say support them, I mean just send notes or saying comments or whatever. So you have to figure out if somebody’s doing this in my state, how can I, you know, chip in and give my 2 cents on this and endorse it or give him feedback that you need to find out who’s working on it in your state and kind of get engaged with them.

Outro

Scott Vondeylen: (56:17)
Yeah, absolutely. Thank you for that and thank you again for your time today. I know you’re very busy all the time, but with everything that’s going on with COVID-19 and your ties to so many other individuals that are having a direct impact and the policies and procedures as to how we move forward on this front. Thank you so much for spending this time with us. It has been extremely insightful and can’t wait to premiere this episode. So, Admiral again, thank you so much for your time, and being with us today.

Rear Admiral Pamela Schweitzer, PharmD: (57:00)
Well, thank you. You’re a wonderful host, by the way. You followed all that. That was like impressive.

Scott Vondeylen: (57:07)
Thank you. Yes. No, it’s fun. I can’t believe they pay me to do this. So, it’s been fantastic. And, that concludes this episode of PharmacyNow.