Specialty Meds: Navigating Barriers

In this episode, listen in as our expert panel discusses the challenges and solutions for ensuring access to specialty medications, including how social determinants of health play a role and strategies to overcome barriers caused by these factors.

Our panel for this conversation includes: 

• Laura Sosinski, PharmD, MBA, BCPS; Pharmacy Manager, Walgreens Specialty Pharmacy; PGY1 Community Pharmacy Residency Director
• Patricia Romero, PharmD, CSP; Pharmacist, Walmart Specialty Pharmacy 
• Rachel Popp, CPhT; Patient Panelist; Contact Center Specialist, Walmart Specialty Pharmacy
• Jake Galdo, PharmD, MBA, BCPS, BCGP; CEO, Seguridad, Inc; Managing Network Facilitator, CPESN Health Equity
• Meredy Ayers, CPhT-Adv, CHW; Development Specialist, Bremo Pharmacy

None of the speakers have anything to disclose.

TRC Healthcare offers CE credit for this podcast episode. Log in to your Pharmacist’s Letter,Prescriber Insights, or Pharmacy Technician’s Letter account and look for the title of this podcast in the list of available CE courses. 

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The clinical resources mentioned during the podcast are part of a subscription to Pharmacist’s Letter and Prescriber Insights: 

• Chart: Guide for Helping Patients Afford Their Medications
• FAQ: Facts About Biosimilars

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Transcript

This transcript was automatically generated.

[Intro Music]

[Music Bed Starts]

JAKE GALDO (00:08):

"And so, when we think about the nuances and the stratifications and how we classify specialty… I do think that Laura did a really nice job of describing it… it’s high cost, and then something else. Is that something else, “that needs to be ‘stabby stabby’,” is that something else, “needs to be in the fridge?” Like, what is that something else? No one knows! That’s what makes it so special, literally and figuratively."

LAURA SOSINSKI (00:28):

"It's all one team, cause at the end of the day the prescribers want their patients to get their meds too. We all have this same goal, let’s get our patients their meds in a timely manner, and hopefully help whatever underlying condition they’re struggling with."

NARRATOR (00:45):

Welcome to Medication Talk, the official podcast of TRC Healthcare, home of Pharmacist’s Letter, Prescriber Insights, RxAdvanced, and the most trusted clinical resources.

[Music Bed Stops]

On today’s episode, listen in as our expert panel discusses the challenges and solutions for ensuring access to specialty medications, including how social determinants of health play a role and strategies to overcome barriers caused by these factors.

Our panel for this conversation includes: 

Dr. Laura Sosinski, a pharmacy manager at Walgreens Specialty Pharmacy
Dr. Patricia Romero, a certified specialty pharmacist with Walmart Specialty Pharmacy
Rachel Popp, who is with us today to provide her perspective as a patient who has been treated with specialty medications
Dr. Jake Galdo, a pharmacist and managing network facilitator with CPESN Health Equity
and Meredy Ayers, an advanced certified pharmacy technician and development specialist at Bremo Pharmacy. 

This podcast is an excerpt from one of TRC’s monthly live CE webinars. Each month, experts and frontline providers discuss and debate challenges in practice, evidence-based practice recommendations, and other topics relevant to our subscribers.

The full webinar originally aired on June 20th, 2024. 

[Whoosh Sound]

[Music Bed Starts]

NARRATOR 2 (01:55):

And now, the CE Information.

[Whoosh Sound]

NARRATOR (01:59):

This podcast episode offers Continuing Education credit for pharmacists, pharmacy technicians, physicians, and nurses. Please log in to your Pharmacist’s Letter, Pharmacy Technician’s Letter, or Prescriber Insights account and look for the title of this podcast in the list of available CE courses.

None of the speakers have anything to disclose. 

[Music Bed Stops]

[Whoosh Sound]

Now, let’s join TRC Editor, Dr. Flora Harp, and start our discussion!

[Whoosh Sound]


*********

FLORA HARP (02:24):

I thought I'd kick us off by reviewing a patient case and getting our panelist thoughts. So let's consider this scenario. A patient has severe eczema which is an inflammatory condition that often results in rashes, itchy skin, and dry skin. And for this particular patient their eczema was so severe that it kept them up all night itching and they had to deal with rashes from head to toe. The patient was prescribed an injectable medication that was considered to be a specialty med by their payer. The payer required a prior authorization or a PA so the pharmacy and the provider work together to submit this. The PA was approved and the patient experienced life changing improvements with this medication that for them was highly effective. Things were going great until a year goes by and the prior authorization expires. Upon resubmission of the paperwork required the PA was rejected because… clarity no longer met the criteria… I wanna turn things over to Patricia and get your thoughts on this. Is this a scenario that you've ever experienced and if so how is it handled? Or how would you approach the scenario if it were to occur in the future?

PATRICIA ROMERO (03:35):

Thanks Flora. Yeah, so, unfortunately, the situation does happen. PA's are required to be renewed most often on an annual basis. So it is important to make sure that patient is maintaining follow-up with their prescriber…to ensure that their progress on treatment is being documented it appropriately and thoroughly. That way when you go to resubmit for a PA, that clinical information is on there and they can review it. You also wanna make sure that you are keeping track of what's been tried and failed in the past and how this medication is improving the patient's symptoms currently. Another thing that's good to have documented is when the PA is gonna expire. So that way the PAs can be worked on proactively as opposed to waiting until it expires to then work on them. And also if patient has a new insurance plan, a new PA would probably be required as well. So, that's something to keep in mind. 

FLORA HARP (04:39):

Great points. I'm gonna see, Laura Do you have any other impressions about the case any thoughts…

LAURA SOSINSKI (04:45):

Yeah. Other things to kind of add and think about. Obviously the patient is doing better because they're on this medication. So making sure when we resubmit a PA, that you have that clinical documentation…that Dr. Romero was talking about included, so don't just check all the boxes, make sure you're including a clinic note. Unfortunately some insurance companies will still… decide to deny the PA in those cases, we may have to go down the appeals route, which is not fun but that may be the route we have to go through with insurance. Maybe the insurance formulary changed and we have to change to a different injectable. Maybe we have to change to a biosimilar. So there's other unfortunate options out there so it's gonna be almost a game to play to see what the insurance wants and prefers sometimes.

FLORA HARP (05:39):

And so Rachel to hear your thoughts on the case and and just from a patient perspective, all of those things that are happening behind the scenes that you don't necessarily get…much exposure to, kind of what what are your thoughts on that?

RACHEL POPP (05:55):

Thank you Flora. Unfortunately I have been on the receiving end as the patient. Whenever I was going through the cancer treatments, we went through the route of okay we obtained PA We're gonna start my treatments on the medication it worked It was amazing. But some plans apparently and I didn't know this their payers only last for up to eighty four days, ninety days, so once the treatment would be completed I'd be doing great. I'd go in for my next appointment only to find out the PA had been denied, so my treatment would then get delayed and I personally had no idea what was going on in the background. I didn't know what was going on on the pharmacy side or my plan side. I wound up going through probably four different treatments…just because the prior authorizations kept getting denied. Until about like seven months down the road I got put back on the same medication I was on in the first place. And it was extremely confusing and honestly very defeating dealing with it.

FLORA HARP (06:50):

For sure I can't, I can't even imagine. And you know we're gonna get into more of the details about these challenges and hopefully strategies to overcome them. But I do wanna shift the focus over to the basics. What even is a specialty medication and how do they compare to traditional medications? And Laura I was hoping maybe you can help clarify that for our audience. 

LAURA SOSINSKI (07:11):

Yeah. So generally speaking, to keep it as black and white as you can I like to think of specialty medicines as anything that's usually high dollar that is treating some kind of complex chronic condition. So in this case you know in the patient case we had, the eczema, that's a chronic condition and it was pretty complex, the patient couldn't sleep at night and injectables tend to be high dollar. So trying to keep it as simple as possible, high cost, complex, and chronic.

FLORA HARP (07:44):

Great. Laura, thanks. Yeah, it is confusing because different entities define it differently. And so that is a great way to think of it. Can you provide like some examples of specific specialty medications that you're commonly dispensing or dealing with and the conditions that they treat. 

LAURA SOSINSKI (08:00):

Yeah. So currently, other things would include a lot of cancer meds. Those tend to be oral ones, so a lot of times people automatically think injectables only. But there are a lot of oral meds currently a newer fancier med for demodex blepharitis, which is actually an eye drop that's been a specialty med that we've been seeing a lot of... asthma, COPD, when we think of sickle cell, autoimmune disorders, multiple sclerosis, the conditions can just vary. 

FLORA HARP (08:33):

Yeah, and it's definitely, again, back to the challenge of everybody defines it differently. Meredy, I'm wondering if you can address this question that I have here which is... how do you even find out if a medication is considered specialty if you're filling it at a local community pharmacy?

MEREDY AYERS (08:52):

The simplest way that we find it at the community pharmacy is the simple rejection from the pharmacy benefit manager. The patient can find out prior to coming to us utilizing their formulary or the preferred drug list and the general public doesn't realize that. So of course when we run a claim we will see it at the time of service. 

FLORA HARP (09:11):

Yeah. Great. And I don't know if you're seeing more stuff team medications in the community pharmacy, I know it's one of the fastest growing pharmaceuticals with around eighty percent of new drugs that come to market being specialty. However, despite the fact that they make up the majority of new FDA approvals, they still account for just three percent of prescriptions, but they still account for over half of the drug spend in the US, and so that's why there's a lot of focus on these medications. The average annual cost of one specialty medication used chronically is over eighty thousand dollars. Compared to six thousand dollars for a brand name traditional medication. And so I was wondering if we can talk next about some of the main pathways for patients to access special medications and Patricia, hoping you can elaborate on that a little bit more…

PATRICIA ROMERO (09:59):

I feel like one of the… easiest way to get the prescription sent in is taking advantage of the manufacturer hubs. A lot of the specialty meds do have a manufacturer hub that they can fill out that referral form, send it into the hub, and…they'll start the benefits investigation, see depending on the patient's insurance plan who their preferred specialty pharmacy is. If the patient does need co pay assistance they can indicate that on that form to start getting that process in place. I think it's the fastest way to get patient on therapy.

FLORA HARP (10:35):

Rachel, I'm wondering if you can share your own experiences in getting prescriptions for specialty medications…filled in different places…

RACHEL POPP (10:45):

Thank you Flora. Actually initially whenever I got prescribed the medications, I was under the impression and through my prescriber as well that they were just normal medications grab him from the pharmacy, bring them to the center to get the infusion done And…nah. That wasn't the case at all I had to be routed from the retail pharmacy that I went to, to a third party pharmacy…that got routed to another specialty pharmacy that my insurance wound up not accepting, and then I got routed again At this point it's two months down the line... so it's a little confusing getting implemented into it but I think Patricia has a good point. Going through the manufacturer was the easiest way to do it and the most informative way too because they have a built in support system that helped me tremendously on my journey through this…

FLORA HARP (11:30):

Very interesting. Yeah. So if a payer classifies a medication as specialty or even a manufacturer I guess does this always mean that it has to be filled at a specialty pharmacy, Patricia, is that something you can answer? 

PATRICIA ROMERO (11:46):

Yeah, so when you get that rejection, a lot of times I see it as must fill at specialty. Most of the times it does need to be filled at specialty. There can be…sometimes an insurance may allow like a grace fill to fill at retail or community pharmacy I have seen that as well. It's gonna depend on whether the medication can actually be ordered, because a lot of times they can be limited distribution drugs. So the the community pharmacy may not have access to it. And then after that one time or grace fill, most likely they're gonna have to go to a specialty pharmacy at that point.

FLORA HARP (12:25):

Alright.

JAKE GALDO (12:27):

May I jump in? I've been quiet but I'm itching to jump in if that's okay. I think the nuance that we need to highlight here is that it is very very regional. There are state differences. So I'm in the state of Alabama and there's a big payer here, down the street. And that payer may designate drug a to be specialty. So then I'm in Alabama and I cannot dispense drug a but Meredy in Virginia can. And so when we think about the nuances and the the strategifications and how we classify specialty. I do think that Laura did a really nice job of describing it... It's high cost and then something else. Is that something else that needs to be stabby stabby? Is that something else needs to be in the fridge? Like, what is that something else? No one knows. That's what makes it so special. Literally and figuratively. And so then that's like the construct of what the drug is. And then the distribution…is this financial model that it is gonna involve medical benefits because it is a medical benefit drug or is it a space or pharmacy benefit drug. It involves the PBM. How are they intertwined with each other. Is it a vertically integrated company where they just pass it from Peter to Paul or are they separate entities on the bid contract? Again these are all the different nuances. So when we think about this construct of what is specialty it really does fall within the idea of... do I have access to buy it? That's the limited distribution phrase that you've heard us say, or can I actually even sell it to the person in front of me? So with this drug A example I might have access to it in Alabama, but I can't sell it because my primary insurance designates it as specialty. Or it's drug B where I could sell it to the person in front of me but my pharmacy wholesale contract says I cannot buy it, it's only gonna go to pharmacy a or pharmacy b.

FLORA HARP (14:21):

Yeah, great points Jake. And as you were talking out I was thinking to myself how do we explain that to a patient though? How do you explain to a patient…that they have a prescription for a specialty medication and that it has to be filled elsewhere. Patricia…or Rachel if you wanna jump in on how you think that'd be best communicated to a patient.

PATRICIA ROMERO (14:46):

When they do get a specialty medication we introduce them to the specialty concept of okay now you're gonna be getting this medication. We do have to talk to you you know every month or however often it's prescribed for you to take it It's gonna have to be shipped to you, it's not something that you can just run down the street and get it. It doesn't need to be shipped. It's gonna come in a specialized container. It's gotta be kept at a certain temperature. And we make sure that the patient understands all the requirements that go with having that specialty medication

FLORA HARP (15:19):

And Laura I just wanna give you the opportunity if you wanted to chime in on this.

LAURA SOSINSKI (15:23):

Yeah, I kinda wanted to add to a couple things Dr. Romero was saying. But basically the other thing is it's really important that when we're trying to explain to patients what a specialty med is and how we're going to help them through this journey. It's important that we use like patient friendly terms. So I try my best as well as trying to coach my staff the best, not to use terms like limited distribution, because your normal type of person out there is not gonna know what that means. So trying to phrase it in ways like well, the company that makes this drug only allows certain pharmacies to have it. So that's why you're getting called for me in Central Indiana instead of your local pharmacy in Southern Indiana and so on. So trying to make it in friendly terms because the patients can get very confused and it can get very mad when they have someone calling them from a different state calling them from a different part of the state and are completely confused.  So trying to use friendly terms that they can understand.

FLORA HARP (16:27):

I just wanted to see if we could expand on…what can prescribers…and community pharmacy staff do to collaborate and vice versa with specialty pharmacy staff. And so I was wondering Patricia if you maybe wanna take this first and then Laura I'll pass it over to you. 

PATRICIA ROMERO (16:45):

Yeah I mean one important thing that I think can be started on is the benefits investigation because that's gonna really determine where…everything is gonna go and and what can actually be prescribed to a patient…depending on their formularies so just doing a quick benefits investigation starting at the prescriber's office with if they've got a PA specialist or or someone that handles PA, calling up the patient's insurance plan and seeing okay I wanna prescribe this drug to my patient. What is the formulary? What does the patient have to meet in order to get this drug? Is there a PA required? What does that look like? Are they gonna have to try and fail a different medication first?  Getting all that upfront would save save time to getting patient on their medication and and help prevent some of that delay…

FLORA HARP (17:37):

That's a great tip. Laura, do you have anything to add? 

LAURA SOSINSKI (17:42):

Yeah. So I think another thing that's huge is remembering that we're all part of the health care team. So how can we close a gap? How can we make relationships with the providers in the offices that we know are prescribing these medications? So is that you know finding out the…extension that the nurse who does the PAs at this office, knowing their name and them knowing your name? We have a lot of those scenarios at my pharmacy... where we know this office, the nurse is this name, at this extension. And they know like this pharmacist works on these meds. Or if they have this issue they need to ask this person. So trying to make relationships…whether that's you know going to the doctor's office talking to them whether that's doing community events so patients see you and know. Right now the pharmacy I am in does a lot with the LGBTQ plus community. So we do our best to go to pride events and do all of that. So showing people like hey we are here... how can we help you? How can we bridge your gaps? So one word-of-mouth, but also knowing it's all one team. Because at the end of the day the prescribers want their patients to get their meds to. We all have this same goal... let's get our patients their meds in a timely manner and hopefully you know help whatever underlying condition they're struggling with.

FLORA HARP (19:01):

What are some other common barriers... Laura I'll direct this to you. That you see that your patients are encountering when trying to get access to specialty medications…that we might not have already talked about. 

LAURA SOSINSKI (19:17):

Do you have all day? Is the real question. 

Um, there are a lot, I actually teach social determinants of health at a college of pharmacy. So I could talk to you all day, but there's many. So whether that…One the insurance access. So do they have insurance? If they do have insurance how much does it cover? How much money do they make? Do they qualify for grants? Are their grants open? So one big thing is just cost, what's available to help the cost? Cost is huge. 

Next would be I would say where are they going to get the med? Is it available to be shipped? So in Indiana we have lots of areas that are rural health care. I have tried to FedEx meds to patients multiple times…FedEx can't get there... FedEx doesn't know where the address is. Constant barrier can't even find where a patient lives.

Getting to your provider in rural areas, how are you gonna get to your provider for follow ups so that you don't have that break? So you can get your PA renewed. That's a huge barrier. 

Other barriers would be languages. And we have lots of patients who speak different languages, I speak…decent Spanish that I can get through most of our Spanish speaking calls and when it gets a little complex that's when I get squirmish and have to tap out and get someone to help us but it's not very authentic when you have to talk to someone on a three way call with an interpreter and that can make you lose the trust of your patients sometimes. It's great we have those services but again that's a huge barrier when it's not face to face with your patient. 

Religious things can be a massive barrier, especially when we're thinking about blood type of…um disease states when we're looking at cancers and if patients can receive blood transfusions and things like that, honoring people's wishes with that. 

I have a lot more but looks like Rachel would love to chirp in. 

FLORA HARP (21:25):

Yes, Rachel please chime in. 

RACHEL POPP (21:29):

Thank you. Laura, you actually brought up a really good point that was actually one of the significant barriers for myself. When I was going through my treatments I actually lost the use of my voice. So I was not able to make phone calls or anything and not a lot of specialty pharmacies have the ability to use the TTY systems which is the text tone. So I didn't have a means to communicate at all I had to go through a third party I had to stay on the phone with my doctors So a lot of the times, our disabilities and our abilities are a huge impact and a huge barrier whenever it comes to getting these medications as well.

FLORA HARP (22:04):

That's a really great point Rachel. Jake, it looked like you wanted to chime in…

JAKE GALDO (22:10):

The overarching question is like what are the barriers? And I think that when we consider the barriers around patients, access to care is one social determinate health. But when we define the the health inequities that we face it is more than just our ability to get access. It's the food we eat or don't. The air that we breathe or can't. The places we live or don't live. The water that we can drink or not drink. But I think the best way to catch all of this is again related back to patients, the people that we're caring for. 

I love this story. The CHW technician was doing a patient visit. And so to Laura's point they knew what unmarked house to go to, they didn't have to worry about FedEx finding it like they knew where it was, they were there. They were in the patient's house and they were talking to the patient and they were like, why aren't you taking your meds, I don't care what med it is, specialty or not, why aren't you taking your med? And it was like, well, I gotta buy dog food. So the choice was dog food... medications. And so they were choosing dog food which, fair, good answer. No problem with that. So what does CHW do, called Chewy's. Chewy's has a foundation that they will provide dog food for free. And so the CHW got dog food shipped to the patient's house for free and now the patient is able to get access to their medications. 

And so I think that the biggest…aspect of of this story that I would share is that when we think about health inequities, not to be pharmacy centric, not to be myopic on just pharmacy drug cost, but health inequities are the cost of the household and how that plays into getting the access to care.

FLORA HARP (23:51):

Awesome. Yes. Amazing, Jake, thank you. And you know that was a very innovative…approach to overcoming a barrier, right? And so that leads into this next question that I wanted to make sure we spent some time on which is... okay, so we we know about all these barriers. They're there's a social determinants of health related barriers and then just the barriers that are inherent to specialty medications. But what are some things that could be done? To help overcome them to help improve access for these patients who are on specialty medications. So, Laura I think I'll start with you and then Patricia, I would love to hear your thoughts as well.

LAURA SOSINSKI (24:32):

Yeah. So, I think I'll start with the easy one. Which is figuring out the cost of meds. So I know that doesn't sound easy but that tends to be the one that us pharmacists find easy, that's our jobs. So looking at copay cards for patients, looking at grants, looking at for me serving people who live with HIV, the Ryan White Foundation…tapping into that, using that, using lots of different funds out there. Maybe we have to go the free drug route. And you know maybe we're the ones who are going to have to fill out that paperwork and be the owner of that and stay on top of the prescribers to get the signatures on that. So costs of the med and getting the access to that. That's one way. That's one potential barrier solving. 

Sometimes it's just, sometimes it's food. So…where can you go, when you're local? So some specialty pharmacies ship. Some are local. I'm lucky that mine's all like a local specialty. So I know what's going on I know where things are happening. So we're able to say hey there's a food bank here that's open these days. Hey there's a food bank here. Or hey I actually know a pharmacist who does insulin counseling... and works at this food bank on these days, this will be great for you. 

FLORA HARP (25:55):

Love that. Thanks Laura. Patricia do you have anything to add?

PATRICIA ROMERO (26:00):

Yeah. I would just say…adherence calls also it's something that…is you know a small thing but it can make a big difference patients can just forget, they get busy. So making sure we're staying on top of our adherence calls, connecting patients with those CHWs when they need it Uh you know I've seen where they can get patient connected with local…support groups and that makes such a big difference in some patients lives because of that loneliness that was mentioned earlier. So having that support group, and also…some pharmacies can offer…face to face consultation…via a secure video, we ship nationwide so our patients are not local a lot of the times but we can offer a secure video if patient needs help with like injection training, they're not understanding something, troubleshooting…their therapy and and getting that injection done correctly.

FLORA HARP (27:00):

Great tips. Meredy, do you have anything to add from the community pharmacy perspective?

MEREDY AYERS (27:05):

Yeah. Like Patricia was saying, I kinda like to call it like the peanut butter and jelly effect, stacking kind of the resources on top of that. Like she said like and even Laura mentioned like the food bank on top of the other things, where can you go to get this and top of this? And recommending places for transportation while you're…you're building these these relationships with your communit. 

FLORA HARP (27:32):

Awesome, great... and I just realized we've been saying CHW and so for the the audience who might not know acronym stands for community health worker. We will expand on community health worker shortly. So this question that we received I think is very important to address. So it's, how can we help patients who make too much money to qualify for patient assistance programs but who cannot afford expensive specialty meds that they need to be on even with insurance. Laura, if you could start, and then we can pass it on to others.

LAURA SOSINSKI (28:05):

I'm not gonna pretend to know the answer to that um, because that's hard. There are copay cards out there that can help. Unfortunately copay cards can max out. Copay cards…cannot go to a patient's deductible which then doesn't help them in the long run. You may only be able to use a co pay so many times. So while it's great, it could cause problems in the long run because you could get on a medicine and be on it for three to four months and then your copay card runs out of money and you can no longer be on it. It's really hard…because…you can have great insurance and the drug can still be out of reach out of pocket.

FLORA HARP (28:53):

And then I don't know if Meredy, if you have any additional thoughts or even Rachel just from your own experience, but I'll just open the floor feel free to jump in.

MEREDY AYERS (29:02):

Sure. You can look into like, state provider…plans and that's really where you should use your community health worker to look into different types of plan like those kind of state provider…assistance plans. And those aren't necessarily pharmaceutical plans It could just be…grant opportunities and things like that. And then other options are charities in your area, organizations there's non profit pharmacies in the area, so It may or may not be your pharmacy filling it but when it comes down to it we're here to to help that patient So…I know in in Richmond we have two or three different non profit pharmacies. And then there are some pharmacies that are able to take in donated, with integrity…medications that they're able to dispense. So you can always check-in to see if if somebody's eligible for those to see if it's there. So you know it it stinks when somebody is…just above the threshold that they don't qualify for different types of aid. But they still need the aid. So there's different options out there Just you kinda have to get creative.

FLORA HARP (30:10):

Definitely. Yeah Great tips there. Alright, well, you know we already kinda touched on social determinants of health. Thank you Jake for giving us a introduction to that. And you did mention that statistic that I do want to narrow it on because I think it's very…powerful in that eighty percent of health outcomes are due to social determinants of health while twenty percent are due to medical intervention which would be like the specialty medications for example. Can you talk a little bit more about what that means?

JAKE GALDO (30:43):

Yeah, yeah. So, in Richmond, Virginia, there are zip codes five miles apart and the life expectancy difference is twenty years…So what's going on that the life expectancy is twenty years different within five miles of Richmond, Virginia. And it boils down to the social determinants of health. What if this was Palestine, Ohio? Where there was a chemical spill from a train. What if this is Flint, Michigan? So why do we not live long and we're five miles apart, because there's lead in my water because my infrastructure is not producing clean water. That is more damaging to my health, right now, than if I were to develop diabetes as a Hispanic male over time…So that's where that eighty percent comes from…

FLORA HARP (31:38):

But there are factors right, that are considered to be social determinants of health that do kinda influence a patient's ability to access medications. And we already talked about how challenging it can be it could be to access specialty medications. But if you can maybe talk a little bit more about about that Jake about specifically how do social determinants of health influence a patient's ability to access…medications in general…

JAKE GALDO (32:04):

So when we think about access it is such a big broad word. And it is the physical access of in my hand it is access because of cost barriers, it is access because of cognitive barriers. We have a a colleague and friend in Wisconsin, Milwaukee. And to Laura's point, his pharmacy, he has like eight or ten pharmacies, and they speak over thirty languages…Because they are designed to be in their communities to understand the cultures. You know, I'm a community health worker in Alabama if I come work, with…I know uh, Patricia you're not in Bentonville I'm gonna act like you're in Bentonville, I don't know if you actually are. So I'm gonna come over from Birmingham to Arkansas. And am I a community health worker? No I'm just a worker because I don't know that community. The whole aspect of a community health worker, the whole aspect of addressing health inequities is understanding the community and the resources that those communities have…

FLORA HARP (33:05):

I do wanna follow-up on something you said, Jake, you had mentioned about getting paid for pharmacy delivery services. Is, are you seeing a shift or do you foresee a shift in that a payer would start to pay pharmacies…for their delivery services?

JAKE GALDO (33:21):

So it's all about the business model. It's the ROI. And so can we justify…a cost on a billing model so that we pay for local delivery. And the answer is kinda, yes. But what's happening is that if you look at the the ten k of your publicly traded pharmacies, you you kinda look at what they're selling and it's always prescription sales and OTC sales. And we lose money on eighty percent of our prescriptions at this point. They're loss leaders, we just lose money on eighty percent of our prescriptions. So that's out the window. OTCs I can sell as many Legos and books as I want but it's not gonna offset those prescription sales, right? So we try to diversify our down front. Some pharmacies now report on a ten k perspective, clinical services. Do I do a self diabetes health management education? Point of care testing is more of a clinical service. And so we are human trained within our network of pharmacies…to have a health equity service line, put your expenses around health equity on that service line but also track your revenue for health equity on that service line. And as a clinically integrated network we're able to get network wide contracts with payers. And so I sit in the room and I have those conversations, and we do get network wide payment contracts for the services we render about the products that we dispense. And I think that vernacular that I'm using is very very important because it's more than just the product, it is the service. And oftentimes that's through value expression which is why we use a standardized quality measurement system at our pharmacies. The CPSN Health Equity Network because we just got a recent report card eighty five percent of children have a documented weight in those pharmacies…So if I go to a Medicaid program and say let me help you because our network treats patients differently and they say how? I can express our value. We document the weight of a child at our store every single time so we know the dose is correct…
 
FLORA HARP (35:22):

That's awesome. Those are great examples Jake. And we keep mentioning the community health worker, and so I want to…get some attention…on what is all involved. So you know, one of the things that I keep hearing about pharmacies doing more and more is, in a way to help identify and address social determinants of health, are to get their staff trained to be a community health worker. And Meredy, I'm so glad you were able to join us today, because I know you've gone through the training, and so I'm wondering, as someone who has gone through this training can you spend some time explaining what a community health worker is and what your training entailed?

MEREDY AYERS (36:00):

Your primary responsibility includes educating community members on health issues, promoting preventative care, assisting with accessing healthcare services and resources. So my training consisted of a two hour course weekly for sixteen weeks. And then also I was involved in intense topic discussions during those two hours, intense topic discussions, completed patient case reviews we built…this intense…community resource portfolio, intense. And then during the process I also interacted with my community. So I went and shadowed in my community, diverse resources and discovered more and more about opportunities available locally. The class itself covers core competencies like you're gonna learn health education, cultural competencies, advocacy skills, you learn empathy. Which is really hard to learn, but you utilize it, you kind of get in touch with yourself and really bring that out. It really includes practical training and conducting community assessments. It provides social support navigating health care systems. CHWs really are playing a vital role in promoting health equity. By addressing barriers to healthcare and empowering communities, and we're gonna improve health outcomes by doing this.

FLORA HARP (37:17):

Awesome. If someone was interested in getting trained, what advice would you give them? 

MEREDY AYERS (37:23):

Really look into the courses that are available. There are really great ones out there. I was very specific into finding one that was pharmacy technician specific, because of our health background, that was really really important to me. I wanted to make sure it was accredited for CHWs and then I looked into the credentials that were specific to my state. I'm in Virginia, so after a certain amount of hours that you put into your community you can actually go get credentials with the state of Virginia. And so different states have different credentials, so look into that too, if you wanna go pursue that after you finished your course, for me it was important to find that program. Look into different community…the different information that's available, research the role first, and what it's gonna mean. In your role, what are you gonna do with it and how does it pertain to your current position? Are you gonna be purely a CHW in your community? Because you can do that. Are you gonna be that alone a standalone or like Rachel do you wanna partner with being a pharmacy technician? For me that's really what it was about. And helping our current community and our patient base that we have here. And then start networking in your area and talk about it with other people and let them know this exists and how important it can really help.


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