Pharmacy Should be ‘Special’ for All Patients

Specialty pharmacy has become an even more robust industry than was predicted during it’s somewhat quiet birthday back in the mid- to late-1990s. At that time fewer than 30 specialty medications existed but the foundational trends were clear.

There are currently more than 300 specialty medications on the market, spending is trending toward more than 50% of the overall pharmacy budget, and even more are coming as the majority of therapies in the pipeline are now classified as specialty medications. With the specialty market growing, prices increasing, and the special high-touch patient services model required to support rare and complex diseases expanding, specialty pharmacy has indeed become very special.

The question that should be getting asked louder and louder is, why are we leaving our common chronic therapy patients behind? If high-touch services improve adherence and outcomes, don’t all patients suffering from a chronic disease deserve the “specialty treatment?” Is it fair that only patients fortunate enough to have access to an expensive biologic therapy get expanded support?

At least part of the answer is that as pharma has focused on the more lucrative rare and complex disease states, the level of support from pharma and pharmacy for patients suffering from conditions such as type 2 diabetes, heart disease, depression, stroke, arthritis, asthma, and COPD has waned considerably, despite the fact that these patients still account for the vast majority of sickness, disease, and cost of care.

This becomes tragic when you consider that there is an abundance of very effective and much less expensive therapies available (a list that now includes biosimilars) that are not being fully optimized, and tragically ironic, when you also consider that many of these therapies could potentially mitigate the need for some of the more expensive specialty medicines. Could it be that if we applied the high-touch model to the support of patients who are on common chronic therapies, that we would see similar adherence rates and equivalent outcomes?

The crux of the challenge is that the much lower margins on most of the common chronic therapies won’t support a high-touch model. Specialty pharmacies very proactively reach out to new patients to begin building a consultative relationship as soon as the prescription is received.

This serves as the beginning of an ongoing relatively intense monthly (or higher frequency) effort to engage the patient with education, coaching, motivational interviewing, symptom tracking, improvement tracking, reminders, logistical, and insurance-related assistance to maintain adherence and assure the best outcome.

This approach has proven to be quite effective, and unfortunately, is a far cry from the attention a typical type 2 diabetic on generic metformin is going to receive. Unfortunately, even if the financial resources were available, there aren’t enough human resources in pharmacy to provide this level of engagement to the millions of patients who suffer from common chronic diseases.

With the costs of a high-touch model for common chronic therapies and the need for substantially more human resources being prohibitive, it is past time that we look to technology and develop a “smart-touch” model of care. Although physicians, fueled by the emergence of telemedicine and virtual care, are beginning to embrace the idea of using augmented intelligence (AI) to dramatically improve their ability to scale, lower the cost of care, and operate at the top of their license, there is not much in the literature that is focused on the pharmacist’s ability to do the same.

It goes without saying that both working together is the ideal, but the systems generally are not quite there yet. In the interim, leveraging the ability of AI to engage patients, build a digital relationship, and execute the majority of the high-touch model currently reserved for specialty medicines is very much within the scope of what this technology can do for pharmacists.

“Non-adherence costs Americans $300 billion annually and may cause up to 125,000 deaths. Reinforcing medication counseling points is a way AI can deliver immediate value,” said Nancy Butler, PharmD, RPh, and pharmacy director with K Health.

Butler goes on to share a compelling example of how it could work:

“A patient with uncontrolled diabetes who has just been started on a new medication regimen and instructed to test their blood glucose levels 3 times a day will download an app that will give them customized feedback and instruction each time they test and enter their glucose levels or results. Patients will also be able to enter pertinent information into their profile, such as acute illness, possible side effects, over the counter medication and more. As patients become more conversant with the disease state and health improvements are made, updated treatment plans will be reinforced by AI. Data derived from patient entries will be collected, analyzed, and reported to the health care team. The team can use those data to make adjustments to the treatment plan. Now the pharmacist will know in real time whether the patient is adherent, physically active, and the current glucose readings. There will also be robust data to perform all sorts of innovative retrospective studies relating to patient involvement, treatment changes, adherence, and more.”

Because AI can engage the patient with unlimited reach and frequency without additional cost, Dr. Butler notes what she would want to know if the AI was able to get the patient to engage daily in a contextual and comprehensive way.

“A pharmacist would want to know if the patient was adhering to both the pharmacological and non pharmacological treatments they have been prescribed, and other information pertinent to health and treatment: diet, exercise, over-the-counter medication use, substance use, and habits that might affect health or interact with their medication.”

All of which should be integrated into the pharmacy’s software and reported in the patient's profile in the form of a dashboard, according to Dr. Butler. This would enable a 360-degree real time view of the patient, enable real-time interventions, and save “the pharmacist hours spent on the phone, calling to clarify medication, or unanswered refill requests.”

There is long-held confidence in the tech community that AI done right can ultimately be trained to more efficiently handle or assist with 80% or more of the tasks a clinician needs to do remotely, and to do it with almost unlimited scale. So, the benefits don’t end with the patient, as Butler notes the huge role that AI can play in ensuring that pharmacy is adequately staffed to handle a higher workload more efficiently.

“The first step would be AI tracking how long it takes to complete tasks in various stages of workflow, such as data entry, order verification, product preparation, product verification, consulting, assisting patients who are picking up their medications, inventory management, vaccine administration, over-the counter recommendations, incoming phone calls, care plans, warehouse order receipts, and other administrative tasks,” she said. “Then, AI will analyze the data and generate a report on pharmacist and support staffing needs and workflow prioritization. Ultimately, the AI will help answer questions like: When to schedule an in-store vaccine clinic? How many pharmacists are needed to safely operate the pharmacy? The recommendations will improve with more data. More intelligently allocating resources will improve medication safety as well as the mental wellbeing of the pharmacy staff.”

What Butler so eloquently describes represents a very powerful collateral benefit for digital health companies that is achievable today with a smart-touch model of engagement. So, last and certainly not least, let’s get back to the patient and how they may respond to the idea of a digital-first, smart-touch relationship with a pharmacy instead of the high-touch human dependent model? Good news here as well.

The literature is ripe with evidence that not only will patients engage with a digital entity, but that they may actually prefer digital engagement over human engagement on a day-to-day basis. This has been found to be particularly true when a patient needs to share sensitive information, such as bowel, bladder, sexual dysfunction, or behavioral health issues.

Patients report feeling less judged, less intimidated, and generally more comfortable with a non-human entity when discussing these very personal issues. The benefit of scalable conversational AI technology appears to be 2-fold in this regard.

Patients trust the technology enough to be open and honest with it, and it is readily available in real-time when they are actually going through something that may impact their health as opposed to 3 months into the future when they are in front of their pharmacist or physician and don’t remember the issue or believe it was important. This puts pharmacists and the health care team in position to be at the point of attack in understanding what is going on clinically in real-time and dealing with it in real-time with the most clinically appropriate intervention.

This amazing opportunity for the clinical team should greatly underscore the idea that the big win with AI is not to replace humans—it is, in fact, quite the opposite. It is beyond critical to have humans in the loop, knowledgeable about the circumstances, and ready to intervene in real-time when clinically appropriate, with the best possible intervention—thus the term augmented intelligence.

The AI, simply put, is there to support and expand the QHCP’s capabilities, not to replace them as the care provider. As has been heard and read millions of times since the terrible heyday of the pandemic, patients are now increasingly comfortable with a permanent seismic shift to virtual, remote, and digital engagement. This sea change offers a transformational opportunity to use augmented intelligence and digital engagement to make pharmacy special for all patients.