2022 has seen chain pharmacy operations getting back to a more normal footing. Key elements of the COVID-19 pandemic response will remain and, in fact, should prove to be very useful as standard tools within the pharmacy workflow.
Overall the trend is to look for efficiency gains everywhere, as pharmacies balance prescription volumes with clinical activities. Chains are doing their best to address challenges such as pharmacy benefit managers’ (PBMs’) continual tightening of performance requirements associated with DIR (direct and indirect remuneration) fees, reimbursements for clinical services that aren’t remotely commensurate with the service and pharmacy costs, and a consolidation among technology vendors that can unsettle long-standing partnerships that chains have developed.
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Clinical Services Growing
Over the last few years, COVID drove a major increase in resources dedicated to clinical services. While areas such as medication therapy management, health screenings, and even vaccination programs were common, COVID necessitated testing programs beyond the scale of anything pharmacies had implemented before, and then a steep ramp-up in vaccination capacity. While the massive effort necessitated by the COVID response did in some cases sideline longer-standing clinical services, according to our interviews, it had two significant benefits.
First, it put chain pharmacies to work in close concert with a range of offices across all levels of government. This was a perfect opportunity for these pharmacies to show just how effective they can be in public health efforts, as well as in patient care more generally.
Second, and on the technology front, some of the key tools that supported the testing and vaccination workflows will continue to be valuable, such as technology for scheduling.
In fact, remote services and telehealth should gain in importance as both pharmacies and patients are becoming more and more accustomed to using video conferencing, for example, and the technology and bandwidth for remote interactions continues to improve. These will be tools that pharmacists can use to expand the scope of the profession, notes one chain.
While the resources demanded by the COVID response were extraordinary, it also turned out to be a golden opportunity to identify inefficiencies in critical processes. Patient-facing technology for scheduling visits and collecting required paperwork ahead of time was particularly important, and its widespread adoption by pharmacies and acceptance by patients should yield dividends for some time to come.
For example, chains found that the volume of immunizations required that they find a way to collect informed consent and health questionnaires online. It was clearly not just inefficient, but a public health hazard as well, to have a waiting area full of people at COVID immunization clinics going through forms on clipboards. The circumstances demanded that, as much as possible, when the patient arrived at the site you had as many of the preliminary tasks out of the way as possible.
This was, in general, a brand-new tool for pharmacies and a new experience for patients. It is a prime example of a technology and a process that will continue to pay dividends for pharmacies.
Building on Scheduling Technology
Patient-facing scheduling technology will continue to be mission critical. As one chain put it, web- or app-based self-service scheduling can now be the norm for all vaccines and for other appointment-based services as well. It should be a key source of efficiency gains as pharmacies seek to provide not just COVID testing and vaccines but also to help patients catch up on other vaccines, such as those for shingles, pneumonia, and flu.
These broader vaccination efforts will get a boost from pharmacy access to state immunization registries, another element of the vaccine process that one chain notes changed for the better during the pandemic response. It is now the standard of practice for pharmacists to access these registries for the rich data they provide on patient status across a range of immunizations. The pharmacist can easily have the information he or she needs to minimize errors and identify immunization gaps that can be addressed with a patient.
Reaching Those Most in Need
The widespread adoption of both scheduling technology and registry access is making an impact on the ability for pharmacies to better serve those patients most in need, according to one chain. For example, when a chain sponsors off-site clinics in assisted living or long-term care facilities, or for people in other settings with a high social vulnerability index, the scheduling tool is useful to allow facility staff or a caregiver to register patients for the offsite event and complete the required paperwork.
One beneficial wrinkle in scheduling technology is the ability to create unique, private URLs for offsite events. This means a closed schedule, which was critical for COVID vaccine scheduling to prevent appointments from filling up with people from outside the intended population. Of course, that’s not likely to be an issue now, but it can still be a good feature since it allows a pharmacy to create scheduling parameters that are tailored to a specific event.
Connecting via Texting and Apps
Texting is currently the preferred communication channel, according to our interviews. The word is that patients do not want phone calls, and it’s been clear for some time that pharmacies need to limit staff time spent on the phone to only the most necessary situations. While text messaging is convenient and efficient, you can also expect chain pharmacies to work toward greater adoption of smartphone apps by patients. One chain said that the goal is to nudge patients from texting over to the app in an effort to both improve pharmacy efficiency and increase the service level for patients.
Apps have moved beyond simple prescription status text messages to providing patients with a list of prescriptions, in-depth health content, and more. In the end, the app can cover all the areas that text messaging does, but texts cannot do everything an app can.
Overall, there’s a need for consistent and systematic communication between pharmacy and patients. Both pharmacies and patients have a strong interest in easy patient access to prescription status, whether it’s a refill due, a request to the prescriber for more refills, or a prescription ready to pick up.
Intelligent Phone Systems
Certainly, each phone call into the pharmacy that a staff member answers can easily take a couple of minutes to resolve, and there’s quite a bit else that can get done in that time. However, the goal, according to our interviews, is not to eliminate the phone as an option. Instead, it is to automate the phone interaction and make it as much of a self-service event as possible, limiting live phone calls between patients and pharmacy staff to only the most important interactions.
What we should look for then is a more intelligent phone system that will move beyond the classic and not terribly well-loved IVR (interactive voice response) menu. Ideally, the phone system will identify a caller and provide a smart path of options designed to find the right answer without needing to connect to a pharmacy staff member. This could be driven by artificial intelligence.
There are phone systems out there right now that promise to bring greater automation and intelligence, and there are chain pharmacies that will be testing this model this year to see if the theory is backed up by solid data and a strong return on investment.
Pharmacy Needs, Technology Solutions
One challenge in chain pharmacy is ensuring that pharmacy staff can communicate their needs effectively and that developers can set appropriate expectations for a timeline and feasible features. This was particularly acute amid the all-out push to build the technology capabilities needed for pandemic response. And although project timelines may be getting back to normal, it remains a fact that most pharmacists and other patient-focused staff don’t speak “engineer,” and developers are not experts in pharmacology, patient care, and the details of pharmacy workflows.
Automation and Efficiency
Dispensing automation in central fill is an area that can be important to driving efficiency in pharmacy processes, according to one chain. In this case, central fill accounts for about 50% of prescriptions. This chain is using central fill for both new and refill prescriptions, with daily deliveries from central fill locations to pharmacy sites. Pharmacies still maintain a formulary on site that permits dispensing for walk-in patients. The idea is that moving as much dispensing as possible out of the pharmacy is a way to safely and efficiently maintain high volumes while allowing on-site pharmacy staff the time to focus on patient engagement and high service levels.
Payment Model Challenges
PBMs remain a major issue for chain pharmacies. The pressure here is intense. With each contract renewal PBMs seem to increase the expectations without any commensurate increase in reimbursements. In fact, DIR fees are structured in a way that does not reflect reality, with adherence tiers reaching 90% and higher required to allow a pharmacy to recoup as little as 3% of DIR fees. That amount available to recoup is small, but more importantly the adherence threshold is nearly impossible to achieve.
In the face of this, there’s the fact that, as one chain sees it, clinical services, rather than filling prescriptions, are going to be the way that pharmacy stays relevant. The scope for the services is only increasing, as pharmacies leverage telehealth for remote counseling or medication therapy management. And, as one chain notes, payers are coming to expect pharmacies to provide a range of clinical services.
But, again, the contracts that PBMs are offering don’t even begin to provide an appropriate level of reimbursement. It is certainly the case that pharmacies have a wide range of performance metrics available to them, but it can still be a challenge to measure and report on the real impact of services in a timely manner. In one example, a chain pharmacy noted that adherence metrics were up to two fllls out of sync with dispensing, making it very difficult to connect the dots and demonstrate the pharmacy’s impact on outcomes.
Consolidating Tech Vendors
Another challenge mentioned by a chain is the changing landscape of pharmacy technology vendors. There’s been a great deal of consolidation in recent years, with the new owners frequently being investment firms. This can often mean turnover in staff at the vendors that disrupts long-standing relationships; rationalization of product portfolios that ends up de-emphasizing a chain’s chosen instance of a technology that had been offered independently by each of the consolidated companies; and a chain moving from being a major client to the proverbial smaller fish in a bigger pond.
This is all important, as this chain puts it, because chain pharmacy technology projects are of a scope and complexity that work best as real partnerships with strong continuity and a shared vision that extends beyond next quarter’s numbers. When your vendors of record are turning over regularly through no choice of your own, it creates uncertainty and a need for a chain to redirect resources to managing the vendor relationship rather than strategically managing technology resources.
What’s on the Radar?
The trends suggest that chain pharmacies are going to continue to look for every ounce of efficiency in dispensing and patient care workflows. One major opportunity right now is for chains to build strategically on the engagement with patients over the last few years and the new tools that have rolled out to position pharmacies as truly the most convenient source for a range of clinical services available to consumers. That’s one piece of the puzzle. The other is reimbursement, of course.
There’s certainly technology that addresses DIR fees and paltry dispensing fees and all the other ways that PBMs squeeze pharmacy, but it may actually be the connections pharmacy can build with plan sponsors and through political channels that lead to recognition of pharmacy’s importance. That’s because it’s never going to be enough to simply be more efficient or track a set of metrics more precisely.
What chain pharmacies can do is broadcast the message that what they did during the pandemic response was indeed truly exceptional, but it does not have to be the exception. It’s the kind of community engagement and care that they can offer every day. The message is that these are services that require investment in both people and technology, and pharmacy deserves fair payment. CT
Unlock More Content on Chain Pharmacy Technology Trends…
An NACDS report on how pharmacy expertise and accessibility supports healthcare
American Association of Colleges of Pharmacy (AACP) resources on direct patient care.
The opportunities for retail clinics located within pharmacies.
A blog post from Merative (formerly IBM Watson Health) on the value of expanding roles for pharmacists that are improving access to health services.