In a recent interview with Inside Pharmacy, Nancy J. Gagliano, MD, Chief Medical Officer, MinuteClinic, and Senior Vice President, CVS Health, discussed trends in healthcare delivery and the impact of retail clinics on patient access to care.
How are retail pharmacies evolving to accommodate changes in healthcare delivery?
NJG: The world is changing and I think only for the better. We look at healthcare as a broader responsibility where, traditionally, healthcare was thought of as a predominantly physician-owned space. But, as a society, we are coming to the realization that the solution to improving the health of American citizens really lies within each and every one of us, and that retail pharmacy is an important component to improving the healthcare delivery system.
There are a couple of areas in particular to highlight. For example, it is terrific if a physician writes the correct prescription for the patient’s condition. But if the patient does not understand how to take it, does not fill the prescription, does not take it for the right period or duration, or stops taking it, the adherence can have a dramatic impact, not only on that individual patient but on the order of magnitude of billions of dollars of healthcare expense across the nation.
We have estimated that nonadherence to medication in a patient who has high blood pressure, for example, is associated with over $2000 in additional costs to the healthcare system compared with a patient who is adherent.
Pharmacies obviously are a great place to help with adherence, understanding, and education. At CVS Health, we have a program that we call First Fill. If a patient is on a brand new medication, the pharmacist will provide education to make sure that the patient understands the impact and the reasons they are taking the medicine, and lets the physician know if the patient does not come in for their First Fill prescription. Also, once a patient starts a medication, if he or she does not come in for refills, we will reach out to the patient, let them know that they are due, and encourage them to stay adherent.
We have also realized that a patient with a chronic condition actually comes into their retail pharmacy more often in a month than they would to see their physician. A typical patient with diabetes may only see their provider once every 3 months or so, whereas patients with diabetes who use CVS will often be in 6 to 8 times a month, obtaining refills and other needs.
There is a terrific opportunity for patients with a chronic condition to develop a nice, strong relationship with their pharmacist as another person in their healthcare delivery team. There is an opportunity for retail pharmacies to become an important player in the healthcare delivery system.
What is the role of retail clinics in this capacity?
NJG: A retail clinic has a number of opportunities to support the healthcare delivery system. We are facing a dramatic shortage of primary care across the country, with an estimated 40,000 primary care physician (PCP) shortage expected in the next decade. Retail health can provide access for general primary care needs for conditions such as sore throats and earaches, as well as vaccinations.
When we start thinking about how we fit into the role of a retail clinic in a retail pharmacy, then you can think about a broader system where you could imagine a patient with high blood pressure being seen at the pharmacy by the pharmacist, getting educated about their medication, and then, using a MinuteClinic a couple of weeks later to check their blood pressure to make sure they have responded appropriately.
MinuteClinic would then send the results to the patient’s PCP. If everything is great, no follow-up is necessary. If his or her blood pressure continues to be elevated, or the patient has side effects, then MinuteClinic would send the patient back to the PCP. It is truly an extension of primary care, right into the community in a convenient location.
How are the changes in retail pharmacy impacting the consumer?
NJG: People would agree that the goal is to impact the consumer in a very positive way.
The concept that CVS Health has made the important decision to eliminate cigarettes and tobacco products from its retail locations demonstrates a commitment to healthcare, and sends a very clear message to the consumer that their healthcare is very important to them.
Retail pharmacies are really looking at opportunities to make it easier for patients to take care of themselves; simple things such as a drive-in pharmacy pickup. That type of concept makes it easy for the patient to get their medication and then stay adherent. Engaging pharmacists in education and adherence activities helps the consumer. It makes it easier for them to have access to information, guidance, and reinforcement to take their medications, as well as access to additional expertise.
We are all very much aware that although the physician is the center of the patient’s care, having other access points to support the patient’s care can only help the consumer. Anything that we can do to make it easier for the patient to access knowledge, their prescriptions, and other healthcare delivery mechanisms is only going to have a positive impact on the consumer.
What patient group have you seen take the most advantage of retail clinics?
NJG: There are a couple of different groups we have seen take advantage of retail clinics. Fifty percent of the patients who come to retail clinics do not have a PCP. Clearly, it is people who may be insured, because 85% of our patients use their insurance. They may be insured, but they are somewhat disenfranchised. They either do not have a PCP or they just moved into a community, and are on a wait list for a PCP.
In addition, 50% of the patients who visit us, come evenings and weekends. Folks are using us as an alternative to an emergency room when their PCP’s office is closed. Along that line, we are often seeing people who are extremely busy, and taking time off from work or getting to see their PCP is very challenging to them. Folks who have more of a consumer focus on access and convenience are often the users of our retail clinics. About a quarter of the patients who come to us are pediatric patients. The core population is adults. We tend to see more folks here in the employed age. We do see older patients, but it is a smaller percentage.
What additional services do you see available at retail clinics in the future?
NJG: I think you will be seeing more in the spectrum of wellness services and chronic care support.
For example, with the Affordable Care Act and accountable care organizations moving more toward a population health focus rather than acute illness and fee-for-service–type of financial models, the focus is geared more toward early intervention. We would, obviously, rather have somebody lose 10 lb before they became hypertensive or had diabetes.
Focusing on the early stages and the risk factors, MinuteClinic, for example, launched a program for smoking cessation, which combines coaching and prescription medication, as well as medication advice, because nicotine replacement is recommended and does not require a prescription.
We also launched a weight-loss program that is based on the DASH diet, a dietary approach to stop hypertension, a very healthcare-based diet. In addition to that, we have added services to screen, monitor, and support chronic disease.
How is the healthcare team inside and outside the pharmacy coordinating patient care?
NJG: Adherence is one example. If you think of the healthcare team as being the provider and the office nurse—or the patient care medical home initiating a patient on medication—and the pharmacy as the place where electronically prescribed prescriptions arrive, there is tremendous opportunity for the pharmacist to close the loop with the care team and inform them that the patient has not picked up their script and/or to reinforce the importance of adherence.
We are also launching a new project called bedside delivery, which we are piloting with a couple of healthcare systems, where either a pharmacist or a pharmacy technician goes to the hospital before the patient is discharged and ensures that the patient has their discharged medications, and understands them before they leave.
Obviously, if a patient is hospitalized and sent home, it is vitally important that they take the new medications that have been prescribed as part of the hospitalization. If a patient goes home and does not stop by the pharmacy or does not have their new medications with them, obviously, that puts the patient at risk for having a relapse or not improving.
We believe that approximately two-thirds of hospital readmissions are related to not taking medication appropriately and not having good access to appropriate care in the short period of time after hospitalization. A program that has a pharmacist or pharmacy system supporting the patient, getting their prescriptions before they go home, helps to support the healthcare team, ensuring patient care.
How would provider’s status of pharmacist impact their role in retail pharmacies?
NJG: This is an area that we want to get some additional input, but, in general, there are certain things that if a pharmacist could, he or she can create additional opportunities for care to be delivered.
Right now, for example, vaccinations are often administered in pharmacy settings. Sometimes they are given under the orders of a physician. If we are looking at population health, we know we want to get as many people vaccinated as possible for influenza, for example. When more people in a society get vaccinated, it creates herd immunity, which decreases the likelihood in society of an epidemic.
We want to make it easy for people to get the care that will help them and society. There have been some studies that have shown that a pharmacist involved in providing education about diabetes, or being able to do a hemoglobin A1C and provide education to the patient about their level, improves the overall quality of the patients or management of the patient’s diabetes.
Allowing pharmacists to have a more active role in healthcare provides additional healthcare resources and can definitely improve healthcare across the country.
How do pharmacists interact with clinical staff in the MinuteClinic?
NJG: It is a complicated issue because there are privacy rules related to how the pharmacist and MinuteClinic staff can interact. We have to make sure that the patient’s information is kept private and we have to abide by regulations.
That being said, there are opportunities to enhance care by having a MinuteClinic within a pharmacy. Obviously, if a MinuteClinic practitioner is seeing a patient and has questions related to the medication, there is a pharmacist available that can answer the questions.
Patients can choose to have their prescription filled at that pharmacy or wherever they prefer. If the patient chooses to have their prescription filled at that same CVS, he or she can easily get their medication, and therefore, have a higher likelihood of taking the medication prescribed. In addition, sometimes the patient will ask the pharmacist a medical question that is outside their scope and the patient may not have a PCP, for example.
The pharmacist would always refer the patient back to their PCP, but if a patient does not have access to one, the MinuteClinic, being at that location or nearby, can allow the pharmacist to easily refer the patient for the care that they may need. There are a number of ways where they both can work together.
Do retail clinics contribute to disruptive healthcare innovation and how so?
NJG: I definitely view retail clinics as a disruptive healthcare innovation in a number of ways. (1) Traditional healthcare is based on the model where the patient goes to the healthcare system. (2) The patient sets an appointment, and then goes when there is availability to accommodate the patient, not necessarily at the patient’s convenience. (3) Healthcare systems are designed to provide a high level of overhead that makes the healthcare system traditionally very costly.
There are secretaries who answer the phones, scheduling systems, referral coordinators, billing coordinators—an assortment of infrastructure to support traditional healthcare.
The MinuteClinic model is designed to do a few things. It is a walk-in model and that model is therefore designed on patient choice and patient convenience. A patient comes when it meets his or her needs.
It is open evenings and weekends, which is also quite innovative and disruptive, and the model is based on guideline-driven healthcare.
The services are developed and the list of services that are available to the patients are services that can be given and provided in a very safe, high-quality manner that is based on research and standards, and those are embedded into the electronic medical record so that if a patient comes from a MinuteClinic in New Jersey with a sore throat, they will get the exact same care as a patient who was seen in California.
This level of healthcare standardization allows for high quality, safety, and efficiency. It is disruptive in that it creates access, it is low cost, and it is very high quality.
How do you think this model will evolve or change in the next 5 or 10 years?
NJG: I think as healthcare evolves and certain different aspects of it can be a little bit more standardized, those services can then be added to the MinuteClinic model.
One of the things we do is point-of-care testing right in the clinic: We can do rapid strep tests; we can do a cholesterol test. There is also a significant collaboration and affiliation with healthcare systems. As payment models change and population health grows, we are getting high-quality, cost-effective care, which is really the underlying focus, and the relationships between retail systems, retail clinics, and the healthcare system will naturally grow.
Retail clinics will become more of an extension of the healthcare system right into the community where a physician can say, “It’s 5 o’clock,” to a patient, “go to MinuteClinic. I’ll get the note in my electronic medical record tomorrow. If they see any problem, they’ll let me know.”
There will be much more of a collaborative partnership between retail clinics and the health system. Then, finally, a very exciting area will be the growth of telehealth and different ways we can see patients in retail through telehealth opportunities.
What key opportunities and challenges lie ahead for retail clinics?
NJG: I think the opportunities with the Affordable Care Act and more patients becoming insured, in addition to the fact that we have a primary care shortage and an epidemic of obesity, diabetes, and other chronic illnesses, the need for healthcare is definitely paramount.
I think that on top of consumerism where patients have higher expectations of access, there is a dramatic opportunity for retail health to grow and expand to meet these needs. MinuteClinic is growing at a rate of about 160 new clinics annually with the expectation that by the end of 2017, 60% of Americans will have access to a MinuteClinic.
When you think about that, the opportunity then really becomes that MinuteClinic can have a national impact on healthcare.