Consumer Expectations for Pharmacy Turn to Services, Personalized Care

Aislinn Antrim: Hi, I'm Aislinn Antrim with Pharmacy Times, and I'm speaking with Troy Trygstad, executive director of CPESN USA, about the future of pharmacy and how patient perceptions of pharmacists have changed over the last couple of years. There was a lot of discussion over the last two years about how patients are more aware than ever about the role of the pharmacist. And now that we're about two years into this thing, how have you seen consumers’ opinions about pharmacists change?

Troy Trygstad, PharmD, PhD, MBA: I think the biggest one is the mainstreaming of what was previously thought of as maybe a couple pharmacies might have done some neat things. Right? So certainly, most of the public had gotten used to getting their flu shot at a pharmacy, and you basically had a third who would get it in a physician practice, a third in the pharmacy, and third somewhere else some other way. And, you know, the latest numbers are that the strong vast majority of booster shots are coming out of the pharmacies. Now that COVID is a conventional vaccine, most flu and COVID people think of the pharmacy, but there were pharmacies that did a really good job with non-flu vaccinations, maybe travel vaccinations, because of that shift in consciousness of the consumer.

Other types of vaccines are taking off as well, right? So, it's also accelerated point of care testing. There were pharmacies that did point of care testing before. Like for us, we had I think, 600 pharmacies that had a CLIA waiver, and that was about 1/6 of our pharmacies. Now, over 2000 of them have CLIA waivers, which is over about two-thirds of our pharmacies. So, it's scaled, it’s accelerated it, and I think the public now thinks of testing, even the infusions with monoclonal antibodies, and all sorts of vaccinations as mainstream, they expect those things from the pharmacy now. Pharmacy does that, so maybe I want to get it there. And so convenience is king. Accessibility is king. And trust is king. And pharmacies have all three of those. Absolutely.

Aislinn Antrim: As you kind of said, many consumers also became more aware of the various services that pharmacists provide, beyond just dispensing medications. How did you see that aspect of pharmacy really evolve quickly over the last couple years?

Troy Trygstad, PharmD, PhD, MBA: You know, interestingly enough, the two greatest accelerants outside of the pandemic, I think for a services-based pharmacy or pharmacy that does a lot of services. The first was the appointment-based model with med synchronization because it created this known day and oftentimes known day and time that you would see a regular group of patient in the pharmacy, which allowed you to prepare for seeing that patient that allowed you to follow up in a consistent way. When we got into the pandemic, pharmacy sort of necessarily doubled down on that concept. But for everybody pre-pandemic, there weren't a lot of appointments being made in a pharmacy. Right?

But now every pharmacy has a more or less fully or semi-fully integrated scheduling system. And that's a big deal because the promise of community pharmacy was accessibility and affordability and, you know, trust and frequency. But the downside was the upside. And that was that anybody could show up at any time, even if it was Monday at nine when you open and you were backed up. And I was like, I can't get in a 15-minute session or a 20-minute session with a patient. And so now that it's the duality of walk-up accessibility, with carving out services that are scheduled, now you're hitting both things that consumers like somebody being ready for you to have a meaningful one on one uninterrupted amount of time for something. And hey, I got a question. I happen to be, you know, here for something else. And so those two things are pulling base model from synchronization. And then the sort of doubling down of that concept with scheduling tests and vaccinations and everything that we've been doing in the pandemic, right.

Aislinn Antrim: Definitely. And leading into my next question—scheduling platforms have become kind of the new normal for patients looking to get vaccinated at pharmacies or some counseling, lots of things like that. Do you expect to see this branching out into other aspects such as more counseling, blood pressure testing, or other services like that?

Troy Trygstad, PharmD, PhD, MBA: You know, it's interesting because I was talking with a pharmacy pre-vaccine availability but post-testing availability. And they had been doing testing and implemented a scheduling system. And I was having a conversation online, we were meeting for another reason. And we were talking about the scheduling system they had implemented. And I said, “So when testing goes away, do you feel like you're going to stop this? Or are you going to, you know, use it for other things?” She's like, “Oh, my gosh, I don't even know what we’d do without a scheduling system now. Like, I've got all sorts of things I'm putting in there. Now I have synchronization patients in there, influenza vaccinations, COVID vaccinations, if we ever get them, we'll put our blood pressure service in it.”

You know, if it quacks like a duck and walks like a duck, then it's probably a duck. And I think what we're thinking about now is these pharmacies are clinics, right? In their own right, they’re pharmacy clinics, and clinics have clinical documentation and they have scheduling systems, so that you can, you know, evaluate and monitor what's going on. And so, I think, I think if you're asking if scheduling systems have pierced the veil? Yes, definitely. I don't see people backing away from that, and I see people doubling down, tripling down on using these systems to think about how it is they manage all sorts of product and services-based workflows.

Aislinn Antrim: Absolutely. And how does this shift into more holistic care? Like you were saying, it's essentially a clinic, so how does that fit in with the traditional roles of pharmacists, which they still have to balance amid all of these other new responsibilities?

Troy Trygstad, PharmD, PhD, MBA: You know, on the CPESN side, we often say, you know, you're not just a dispensary. You're a health care service provider that's using the event of dispensing as unique way of engaging a patient that nobody else can in this system. There's a lot of folks that want to get into the pharmacy space for engagement reasons, not for pharmacy itself, because pharmacy is become a tougher business to produce a margin on. So, it's not about running away from the dispensing, it's about what is it you're layering in with the dispensing, that makes it better patient care, more sustainable practice, and that there's a lot of entities out there— primary care management, telemedicine—that would love the almost guaranteed engagement of that dispensing event. And so the thing is no longer the thing in the bottle, the thing is the service, the bottles, the thing that makes the patient come to you and sort of creates the premise for the visit.

Aislinn Antrim: That's a great way of thinking about it. And have you seen the physical pharmacy spaces in the buildings and how they fits? Have you seen that evolve to fit in with these new expectations?

Troy Trygstad, PharmD, PhD, MBA: No, bricks and mortars takes a longer time than workflows, and takes a longer time than, you know, specific services. But the thing that sometimes can take the hardest time, the longest amount of time is mindset. Right? Which is on kind of the opposite side of bricks and mortar. And, you know, while bricks and mortar continue to evolve a little bit, I think part of the reason that we haven't seen bricks and mortar change a lot is that the patient mindset is now, maybe I don't need a fancy brick building with a traditional exam room to receive health care. Right? So why model what is arguably a relatively inefficient and sometimes ineffective system or set of systems that are out there for services, maybe you're already in a better position with accessibility, being kind of mixed retail for some of these places being mixed with other things.

I think we're going to see a lot more primary care coming into the pharmacy, incidentally, and using existing spaces, private spaces, but I think the mindset of the consumers is changing back to the first question—that maybe I don't need to change a lot of pharmacy bricks and mortar to be accommodating to a patient. Now, the other mindset, of course, is on the other side of the counter, if there's a counter, right, which is the staff and again, that can take longer, but all of it being accelerated by the pandemic on the consumer side as well as behind the counter and staff side. But if you’re really effective at it, you can I mean, that's, that's in the minds of the staffers, right? So how you greet folks, how you engage them, how you screen them, how you talk about services, how you present those services, how you market those services. Do you think the primary flow is the dispensing or is the primary flow the service and the dispensing around it? All of those sorts of things are all in the minds of the staff. And so, if I'm leading an organization, I'm kind of starting there first. I can only control consumer mindset so much, that's a larger kind of tectonic evolution, and I think the pandemic has been, you know, sort of had a positive effect.

But, you know, bricks and mortar. Honestly, I feel like it's a little bit of a 2020 way of thinking, I mean, 2000 to 2010 way of thinking, rather than 2020. Definitely not 2022, post-pandemic.

Aislinn Antrim: Absolutely. And how are technicians involved in this new pharmacy environment and these new expectations?

Troy Trygstad, PharmD, PhD, MBA: You know, at CPESN we have what we call pharmacy services and support staff training. And there's a reason we don't call it technician training. We would love to see—sometimes a lot of this is mindset, again—we would love to see in a reasonably short timeframe that the pharmacies we're working with almost sunset the term technician. There's a whole new world of skillsets and titles and roles and accountability and responsibilities.

We break them down into four areas, as far as non-pharmacist staff. So, the first one should be the appointment based model. Second one is patient engagement, whether it's your courier dropping off meds, whether it's your former technician at drop off, your cashier that's now doing other things, and we're not going to call them a cashier either. It's patient engagement for everybody. So, the second one, patient engagement. Third one, practice management. So, we just talked about how this starts to look and feel like a clinic or a practice. Yeah, it's the pharmacy practice. Well, guess what, if you're going bill for monoclonal antibody infusions, you're going to figure out how to do testing billing, you're going to figure out how to do that scheduling system, you're going to figure out how to send blood pressure to the data validator, you're going to do a lot of this stuff. It's practice management, right? So, it's medical revenue cycle management, it's pulling reports on patients that have gaps, these types of things. And then the fourth one, which, interestingly enough, I think pharmacy, especially on the independent pharmacy side, is mostly bereft, that is business development.

And my aha moment, I had a pharmacy call me and say, “Troy, we just realized that we have essentially greeters at the front of the store.” This is actually not a chain. It's a one store independent. But they do kind of greeters up front and folks up front, at front of store. And I had a conversation with one of my patients that I've had for 25 years, that had no idea that we're doing synchronization and delivery and, and these types of things, right. And so we usually suggest or refer people to this service, we don't do a good job of telling folks that we’re doing it, let alone maybe hospital systems around me or clinics around me or behavioral health entities or the health departments. So, now there's a bunch of health department pharmacy relationships from the pandemic. So, appointment-based model, patient engagement, practice management, and business development. If the pharmacy owner, the pharmacist in charge of the pharmacy manager, or even any of the pharmacists or what we think it was practitioners are doing any of that stuff, it's not a real smart thing, right? I should have staff around me and should be training people up. So, the other thing we'll say is don't train your non-pharmacist staff—develop them. And if we can eliminate the lexicon of calling somebody a technician or a cashier, let's maybe do that too.

Aislinn Antrim: Interesting. And how has the pandemic expanded the role of all pharmacy support staff, as you were saying?

Troy Trygstad, PharmD, PhD, MBA: Well, the last three shots that my family's gotten have come from a non-pharmacist, right? In three different places. And so, data entry specialist, inventory manager, supply integrity, who's reporting on temperature in the freezer, what type of freezer, right? So again, I mean, I could go on and on and on. There's probably 60 different roles that have emerged, that whether it's a pharmacist practitioner or non-pharmacist, it's a role with a distinct responsibility and accountability associated with it that doesn't really exist in a dispensing only pharmacy. Right.? And so, there's so much of that evolving and rapidly now that I just, I think we're going to be looking at pharmacies and, physically, they will be relatively the same. They'll add some things to the consumer. But behind that counter, how those teammates work and interact with each other, and what they're doing, has been looking and will continue to look quite different.

Aislinn Antrim: Wonderful. With all of these changes in mind that we've been discussing, where do you think the pharmacy field is headed?

Troy Trygstad, PharmD, PhD, MBA: Well, it can go one of two directions, we're at a bit of a fork in the road, because a lot of pharmacies that I'm familiar with had the best year they've had in a long, long time. And something happened that academics and others have been saying for 30 years that they never believed would actually happen, which is the majority of their profit margin comes from services.

Let me repeat that. Most of the pharmacies I interact with now—the majority of their pharmacy profits come from services. Not their revenue, their profits, because they can do services. Right, they can do services at a higher margin. Because it's not product in and product out. And we have this, you know, I've got hundreds of pharmacies that have done more than 10,000 vaccines, right? So, you can do the math, and they're doing testing, and they're doing infusions. So, they've kind of had the best year they've had in a long, long time.

But what happens if that all goes away, is the underlying reimbursement for dispensing just gets worse and worse and worse, narrow networks and being locked out of networks and patients keep getting worse and worse underneath that. And so in one way, it could be this evolution. And actually, what happens is the, the product part becomes relatively insignificant, that really is all about services, because at the end of the day, five years from now, 90% to 95% of the fills are going to be 15% to 20% of the spend. So, 90% of my fills, or more 90% of my fields are less than $4, less than a nickel to buy. And we move to more of a dispensing service payment for service payment. And services like vaccines and blood pressure management, these other types of things, then what happens is the global revenue of the pharmacy goes down, but the profit margin goes up because the services are what’s bringing home the bacon. So that's one way it could go.

The other way it could go is we just regress. We don't advance from the things that happened over the last 18 months. And community pharmacy as we know it kind of withers and dies. It doesn't mean there won't be pharmacies out there, but they'd be staffed probably by pharmacist extenders. Most of the control of the prescribing of the dispensing and other types of things will be more kind of centralized or even mail order, even, if you've got primary care. And next to a pharmacy, most stuff is going to go to kind of a mail order circumstance. And what we're really talking about is the continued commoditization, where it really doesn't matter where you get your pill bottle and the pills that go in it from. So, obviously, I think the former is a better path. But I don't see a middle road anymore. We've kind of been riding the fence, and it's going to be one or the other coming out of the pandemic.

Aislinn Antrim: Very interesting. Well, hopefully option one there prevails. Thank you so much for talking with me about all of this. It's so interesting.

Troy Trygstad, PharmD, PhD, MBA: It's great to be here. Thank you.