Future Trends: Integration, chronic care lie ahead for pharmacy
What will retail pharmacy look like in 2027? Predicting the future is always iffy, but it’s certain that it will involve a lot of “C” words. Among them are connectivity; computing or, more accurately, the use of supercomputers in advanced diagnosis, medication therapy and drug development; collaboration; clinical care; and cost-saving imperatives.
All of those pursuits will involve the increasing use and sharing of electronic health records, or EHRs, and decision-making data to improve population health and lower the costs of care, and all will figure prominently in any pharmacy practice model that emerges over the next decade.
Looking ahead, Laura Cranston, executive director of the Pharmacy Quality Alliance, said, “I think pharmacy will be fully integrated, clinically, with the rest of the care provider team. And I think all the necessary steps are in motion.”
For pharmacy retailers, one big step toward a more viable and integrated future in partnership with the rest of the healthcare system, Cranston told Drug Store News, has been establishment of the eCare Plan for Pharmacists, written and developed by the Pharmacy Health Information Technology Collaborative. The plan, she said, is a template for linking pharmacists more closely with patients’ electronic health records in order to foster closer collaboration between pharmacists and other members of an integrated healthcare team.
“As medicine has moved to EHRs, how does pharmacy get its hands on the clinical data that resides in an EHR, and how do they access and use it? They will through this eCare Plan; it will be fully integrated in EHRs,” Cranston said. “It’s a critical step in the process … of an integrated delivery system.”
Cranston predicted “this high level of clinical integration” will be achieved by pharmacy’s “early adopters over the next 12 to 18 months. Then it will reach a critical mass, and others will begin to use it,” she said.
The eCare initiative will drive pharmacy-based health innovation and connectivity, according to the National Council for Prescription Drug Programs. “Pharmacists are increasingly participating on patient-centered care teams as essential members, providing clinically oriented patient care services,” NCPDP reported. “The Pharmacist eCare Plan will support the documented integration of these activities into the patient’s comprehensive care plan.”
‘Everyone held accountable’
Another ongoing trend that will continue to shape pharmacy’s future, Cranston said, “will be
for pharmacy and pharmacists to be held accountable in a value-based healthcare system. Whatever happens with the Affordable Care Act — repeal, replace or whether Obamacare stands — the notion that we are going to operate inside a value-based system will continue to grow,” Cranston predicted. For that reason, she added, “outcomes-based measures are the next wave of the future. And contractually, health plans, PBMs and other payer entities are driving this move to value-based care.”
Health economist Jane Sarasohn-Kahn agreed. “With the migration from volume-based payment to value, the healthcare provider … is taking on more risk in managing the outcome for their patients on an individual basis, or in terms of population health,” she told DSN.
Given this “migrating moment in healthcare payment,” Sarasohn-Kahn said the pharmacy “has a major opportunity to be the hub or platform in the health ecosystem. They’re in the community. They’re not on ‘pill hill,’ and they’re not in the doctor’s office, which is only open Monday through Friday so many hours a day.”
The challenge that pharmacy must deal with in its quest to remain a fully viable component of the emerging health system is the same one faced by all sectors of the healthcare spectrum, said Sarasohn-Kahn, author of the Health Populi blog. “How do different nodes in the healthcare system work together to create an ecosystem with the patient at the center? I talk about pharmacy playing a big role in that because they’re in the community, and they know the prescription list for the patient, which is a very powerful piece of information,” she noted. “If you know that, you know a lot about the patient.”
Increasingly, retail pharmacies are equipped and positioned in the healthcare marketplace to serve as a base not only for medication-related dispensing and counseling services, but also for a growing menu of other health products and services that support patient health and improved outcomes. In the coming years, they’ll serve as a key connection point and entry into the broader health network. “In this environment, digital health … is growing,” Sarasohn-Kahn said. “Digital therapeutics are a way for pharmacy to add value beyond the pill.”
Shifting from ‘sick care’ to wellness
Despite that hopeful outlook, pharmacy and the rest of the health system are a long way from creating a truly holistic, fully integrated and patient-centered model for cost-effective care. Even though “patient engagement is the lynchpin to any successful value-based care initiative,” said Judy Murphy, chief nursing officer for IBM Global Health, a 2016 study by the company found much of the health system still mired in what Murphy called “a no man’s land,” between the fee-for-service model and the value-based model.
Indeed, Murphy said most healthcare organizations still are operating “in a ‘sick care’ episodic and transactional mindset, whereby the main drivers of patient engagement were brand loyalty, positive patient experience and regulatory compliance, as opposed to a health-and-wellness, continuum-of-care mindset, where the focus is on value.
“This finding represents a challenge because involving patients in their own healthcare decision-making is a critical element in shifting to a value-based model of care,” Murphy noted. “It is the only way to truly deliver a system designed to address the needs of a healthcare population.”
Today, “the health ecosystem is faced with ever-increasing demands and is riddled with obstacles, complexity and siloes,” agreed IBM chairman, president and CEO Ginni Rometty.
Anil Jain, VP and chief medical officer for IBM Watson Health, said all health stakeholders will have to continue knocking down the decision-making silos that stand between the fee-for-service model and the collaborative, outcomes-focused care model.
“Despite progress and a movement toward value-based care, the U.S. healthcare system still tends to struggle with acquiring and analyzing the varied data sets needed to meaningfully improve health care,” Jain said. “In many instances, health data remains siloed and fragmented by hospital boundaries, incompatible vendor systems, interoperability issues and complex regulatory challenges. These hurdles often mean that a complete picture of care across the continuum for a patient or a population is challenging, if not impossible.
“Today, the need for complete patient and population health profiles is growing under the demand of many stakeholders,” Jain added. “One motivating factor is the shift to value-based care, supported by the Centers for Medicare and Medicaid Services’ goal to have half of its payments in alternative payment models by the end of 2018. Another factor is the growing number of accountable care organizations and clinically integrated networks that often need access to interoperable systems across multiple business entities and providers with different EHRs.”
However, Jain said, “there is good news: We are making steps toward sustainable and scalable interoperability. It is possible to aggregate and analyze data from many different sources in near real-time, using a platform that uses a flexible data model to standardize, store and report patient data.”
CVS Health’s collaboration with IBM Watson Health, launched in mid-2015, exemplifies the shift to data-driven care and the effort by pharmacy to contribute to a healthier population. The alliance blends the data generated by CVS’ massive database of more than 70 million prescription users with IBM’s supercomputing firepower to develop improved algorithms to track and care for patients and boost the ability to predict disease before it occurs.
One goal of the partnership, said Shahram Ebadollahi, chief science officer and VP of innovation at Watson Health, is to create an integrated, seamless system that would give every healthcare professional that a patient encounters access to the most up-to-date information — and the tools to be able to make sense of it. The information could be generated by a variety of sources, including “apps and wearables” and “touchpoints by pharmacists … to help you get back on track and help you help yourself,” Ebadollahi said.
The role of artificial intelligence
Given the advances in computing power and increasing integration of health providers and patient data, “it’s a new world where artificial intelligence is moving beyond a back-end tool for the healthcare enterprise to the forefront of the consumer and clinician experience,” Accenture Consulting noted in a recent report on digital health technology. “Robots are working alongside people. Smart machines are performing triage to augment clinician decision-making. Contextual intelligence and deep-learning algorithms are raising the bar for transactions and interactions in health care.”
“The relationships between healthcare organizations and people will never go away,” Accenture reported. “But AI will play a primary role in making those relationships stronger.” Coupled with that growth in data-enabled decision-making will be an explosion in the amount of patient data that will be available.
“By 2020, experts predict that more than 20 billion everyday objects will be able to capture, receive and share data via a global network linked together by inexpensive sensors, GPS and ‘the cloud,’” noted Dr. Joseph Kvedar, VP at Connected Health Partners and author of “The Internet of Healthy Things,” or IoHT. “Just around the corner, real-time biometric data will automatically be captured by these objects and used to learn more about the impact of lifestyle on chronic diseases and wellness, and ultimately change behavior to improve our health.”
“Connecting to the IoHT presents a huge opportunity for all sectors of business and society, including payers, providers, pharma and biotech companies, and technology vendors,” Kvedar added.
Fewer in-person visits
Another factor that will have an increasing impact on the evolution of retail pharmacy over the coming decades will be the growing influence of the aging Generation X, Generation Y and millennial generations. According to Sarasohn-Kahn, younger consumers may not frequent the local pharmacy the way their parents do.
“With Amazon, we have a generational issue,” she noted. “Boomers and the ‘greatest generation’ are still craving personal interaction with the pharmacist, but then we’ve got people younger than that — Generations X and Y and millennial generations — who could care less about the face-to-face interaction. We may see a decline in demand for face-to-face, real-time interaction.”
“Millennials really don’t care even about a medical home, or even about a primary care physician relationship. So over the next decade, we’re going to see a lot of drop-off in the demand for face-to-face [interaction] with a pharmacist,” Sarasohn-Kahn said.
“Millennials shop differently than you and I do,” said Jeff Newell, CEO of Pharmacy Quality Solutions, so “there will be less face-to-face” interaction with pharmacists in stores. Instead, he said, “I can see drones dropping off prescriptions and the [young patient] not going into the pharmacy ever, which is going to change the pharmacy model dramatically.”
That doesn’t mean an end to the critical role played by pharmacists, he said, only a change in the way they interact with patients. For instance, Newell said, “pharmacists will be notified that the drone dropped the script, somebody accepted it, a videoconference will start and they’ll do some type of interaction with that person. Pharmacy is developing those platforms now with telepharmacy and telehealth, and with different mobile applications.”
Since millennials also “tend to seek more information” via mobile devices and are adept at researching that information online, “the provision of information will be important,” Newell said. “It’s going to be more of, ‘Can I provide information and allow that patient to be able to retrieve it anytime, anywhere?’” Pharmacies, he said, are “going to have to be very savvy about providing information in multiple formats, … [and] it’s also going to have to be retrievable when that patient needs it.”
Shifting to chronic care
How will pharmacy retailers respond to that possible falloff in demand for personalized, in-person care and counseling? Telehealth relationships offered by such chains as CVS could be one answer, Sarasohn-Kahn said. “I think moving toward telepharmacy over the next decade — getting your ducks in a row for that, getting your infrastructure and your network of pharmacists [ready] — is really job one for pharmacies,” she said. “Amazon is figuring this out right now.”
Advances in drug therapy and dispensing automation also will alter the retail pharmacy landscape, according to Bryan Gildenberg, chief knowledge officer at consulting firm Kantar Retail. “With the technological changes encompassed by automatic replenishment, cost pressures and the changing nature of scripts, … pharmacists will probably be filling fewer prescriptions in the future,” he predicted. “But the prescriptions they will be filling will require more care per patient and be more expensive per patient than the scripts they’re filling now.”
What’s more, he told DSN, “Probably 30% to 50% of the conditions most people go to a primary care physician for, by 2025, will be diagnosed remotely through a mobile phone or some sort of in-home device. So they won’t need a primary care doctor if they have an earache.”
That means that “the nature of primary care starts to shift a little, where the pharmacist has less busy work to do and more care to do,” Gildenberg said.
“I think the area where the pharmacist will probably have the most change in their role isn’t in primary care, but it’s in the ongoing management of chronic care — for patients with chronic, ongoing conditions who need to check in with a medical professional, but who probably don’t need to go to a doctor on a regular basis,” Gildenberg said. “I think that’s an area where pharmacy can provide a pretty significant role. So the pharmacist of the future will probably be much more … about ensuring people are compliant with the course of treatment they’ve been issued, and measuring whether that course of treatment is effective.”
“That means less busy work [for pharmacists] from a pharmaceutical distribution point of view, and fewer patients with more complex treatment regimens,” he said. “It also means more possible involvement in primary care, but certainly more involvement in ongoing chronic care.”
Innovations aid expansion of services
As Lewis Drug marks its 75th year in business, its long-term success “still comes down to relationships,” according to Bill Ladwig, SVP of professional services.
“If people mention pharmacy in the Sioux Falls area, they think of Lewis,” he said. Indeed, Lewis’s strong identity as a prime pharmacy and health resource extends to dozens of communities in South Dakota, northwestern Iowa and Minnesota, mirroring its expansion into those markets over the past decade, largely via the acquisition of independent pharmacies in smaller towns and rural communities. That buyout program dramatically expanded Lewis’s reach and gave it a smaller, more traditional pharmacy- and health-focused drug store format called Lewis Family Drug.
The company’s newest expansion vehicle is telepharmacy. Lewis set up its first telepharmacy kiosk within a Lewis Family Drug store in a rural market some 20 miles from Sioux Falls in early July, overseen on a live basis by remote pharmacists working in other Lewis drug stores.
A pharmacist will continue to staff the store one day a week, and technicians will continue to provide dispensing services. “It’s the evolution of small-town health care,” Ladwig said.
Innovations and outreach
Ladwig joined Lewis in 1978 as a staff pharmacist, when the chain consisted of five stores in and around the Sioux Falls, S.D., market, and has been a key architect of many of Lewis’s pharmacy and patient-health innovations ever since.
One area in which Lewis has been a pioneer has been flu vaccinations, going back to the early 1990s. Fast forward 25 years, and South Dakota is ranked first in the nation for per-capita flu immunizations, according to Ladwig. “I think it’s because we got engaged early in promoting it,” he said.
Under Ladwig’s tutelage, Lewis also has developed other sustained community care programs, including an annual screening event called Melanoma Monday, created two decades ago and held in early May.
“We bring all the dermatologists of Sioux Falls together and create a waiting room environment with temporary curtains, and the dermatologists volunteer to conduct this 10- or 12-hour service for free,” said president and CEO Mark Griffin. “They donate their time for the good of the community.”
Lewis created another program that has become embedded in a growing number of communities, “The Big Squeeze,” which is an education and screening effort to expand public awareness of the dangers of high blood pressure. “We started with a small group and got the churches involved,” Ladwig said. “Then the city started taking notice of this … and embedded it into their wellness program. Now the city is running our Big Squeeze program.”
“We got the local health plans engaged in this, too,” he added. “We have pharmacy and nursing students who volunteer. Hy-Vee and Walgreens now also participate. It’s ecumenical.”
To further that integrated model, Sanford and Lewis now can communicate via an online portal. Lewis has read-only access to patients’ EHRs through the portal, and is working to develop applications that will further collaborative care efforts.
Personal touch pays off for Lewis Drug
Over the past 75 years, Lewis Drug has come to epitomize the best of regional drug store retailing. Based in Sioux Falls, S.D., the company has become deeply embedded in the life of many Upper Midwest communities, and the go-to resource for pharmacy and front-line healthcare services in dozens of towns scattered throughout eastern South Dakota, Minnesota and northwest Iowa. Its largest stores wield a remarkably wide assortment of products and generate in excess of $10 million annually.
The company now owns and operates 54 stores, including 10 Lewis Drug units in and around its central Sioux Falls, S.D., market area, and more than 40 smaller drug stores under the Lewis Family Drug logo within a 200-mile radius of Sioux Falls. “We have two concepts — a smaller, traditional-sized drug store serving rural communities, and Lewis Drug, which has been around for 75 years,” said Mark Griffin, president and CEO.
Large-scale Lewis Drug stores in Sioux Falls and larger towns in South Dakota feature the kind of broad-based selection that could rival that of some supercenters, and range up to 50,000 sq. ft., although that format is being replaced by a more condensed and more efficient prototype of 25,000 to 30,000 sq. ft. in newer stores. On the other hand, Lewis Family Drug units feature a much tighter mix of pharmacy services, prescription and OTC medicines, HBAs and basic drug store offerings in a much tighter format of 3,500 to 4,000 sq. ft.
“We’re a two-pronged entity,” said Nikki Griffin, corporate VP. “We want people to think of us as a top pharmacy provider they trust with their prescription, and as a great retailer where you … can find basically anything you could need.”
In some towns and rural areas, Lewis is the sole resource for many health products and services. “If it’s not us, it’s probably not going to be anybody,” said Scott Cross, EVP and CFO. “We probably have 15 or so communities where we’re the only pharmacy in town.”
Through an innovative alliance with Sanford Health, a major regional health system, Lewis has further extended its reach as a health services destination in two of its large-format stores, which are co-located, side-by-side, with a Sanford health clinic. “The side-by-side retail/clinic has been a really strong model for us,” Cross told DSN.
The home team
Lewis’s combination of high-touch health services, personalized customer care, broad-based merchandising and community involvement have pushed total revenues well past the $200 million mark — and kept Lewis front and center with Midwestern consumers despite repeated assaults on its home marketing turf from some of the nation’s most powerful drug store and big-box chains.
How does any regional drug chain forge seemingly unbreakable bonds to dozens of far-flung communities and generate enduring, cross-generational loyalty among the consumers within its reach? For Lewis, long-term success has been the byproduct of decades of patient relationship building and a nimble, willing-to-try-anything approach to marketing and merchandising. The chain promotes a family-friendly, community-involved image and prides itself on the neighborhood activism of its employees.
Those efforts have made Lewis virtually indispensible in many upper Midwest communities — both with generations of consumers who depend on the 54-store chain for pharmacy services and a broad range of everyday household needs, and with local health providers who have come to rely on Lewis’s pharmacists as extensions of their own patient-care activities.
Lewis always has put a premium on a close connection between its pharmacy and front-end staff and the customers they serve, Griffin continued. “Personalized [customer] care is one of our hallmarks. One thing we’re finding out is that’s important to people, even among millennials,” which has emerged as one of Lewis’s strongest consumer segments, he said. “There was a period when that wasn’t important, when the big boxes opened up and the message was just price, price, price,” Griffin added. “Now, people value the home team and the home businesses.”
A great niche
Hewing close to the shifting needs and shopping patterns of its customers, and promoting a family-focused image and a deep connection to the communities it serves, the company has fended off or held its own against waves of competitive challenges from much bigger chains.
In its central Sioux Falls operating area, for instance, Lewis faces off against four Walmart supercenters, three Target stores with CVS pharmacies, and at least five Walgreens locations in a trade area of roughly 250,000 inhabitants, Griffin said. Lewis also can attribute its success to ongoing efforts to “read the marketplace, and be out front with expectations of the clientele,” Griffin added.
To stay abreast of shifting consumer needs and expectations, Lewis conducts ongoing surveys and focus groups. “Our niche, how we fit, is we’re recognized as a high-value retailer. We don’t try to be a Walmart or Costco, but we’ll offer 80% of what they offer in their large stores. And we offer convenience that’s unmatched,” Griffin noted.
‘Prudent’ but determined growth
Griffin describes Lewis’s expansion strategy as “prudent.” The company is building three new stores in its home Sioux Falls market, including a new, 25,000-sq.-ft. Lewis Drug store that will replace a larger, 25-year-old Lewis store downtown; a new 7,000-sq.-ft. unit near the site of its very first store that will cater to the growing population of downtown Sioux Falls residents where they live and work; and another large-scale drug and general merchandise store in partnership with Sanford Health, adjacent to a large Sanford clinic.
Besides its development pact with Sanford, Griffin added, “we finance internally, and therefore our growth is controlled. And it’s been pretty successful: I think we’ve closed one store in 75 years.”
Internal development aside, Lewis has generated the bulk of its expansion through the purchase of independent drug stores within its operating sphere in South Dakota, Iowa and Minnesota.
There are strong incentives for independent drug store owners — particularly those nearing retirement — to join Lewis, Cross added. “What they’re looking for is a company to take away all the administrative headaches, all the human resources issues they have to deal with, all the compliance and contracting issues, … and just let them practice pharmacy,” he said.
“That’s really our selling point: ‘You don’t have to work a 10-hour shift and then come back and work four or five hours at night trying to do your books and work on contracts and all those things. You can practice pharmacy and let us take on all the headaches,’” Cross said.
Griffin added, “There are quite a few of those independent folks still out there. That’s been our growth opportunity for the most part — being able to partner up with independents and have them work as long as they want while we take over the ownership.”
Lewis’s ongoing efforts to court independents points to a determined, if carefully controlled, growth plan. “We definitely are looking for expansion,” said Bob Meyer, SVP of merchandise and marketing. “There are a lot of smaller communities of 1,500 to 5,000 people [where] there’s ample opportunities.”