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Among a population of patients with type 2 diabetes, researchers assessed the similarities and differences between SGLT2 inhibitors.

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As health care continues to evolve, independent community pharmacists must be flexible and innovative in their business practices to adapt.

Jon Copeland, CEO and president of AAP, recently joined 

®, to discuss key trends affecting independent pharmacies in 2021.

In the episode, Copeland dives into the following influential factors.

 In the past year, consumers have come to rely on technology in many respects, including keeping up with consumer demand and offering more services. Copeland walks us through these digital trends and suggests tools that pharmacists can incorporate into their digital offerings.

 Amazon’s most recent dive into the pharmacy space has made big waves. Copeland provides advice on how to effectively compete with larger chains and online services like Amazon.

Pharmacy benefit manager (PBM) regulations and reimbursement

: Copeland explains the effects of vertical consolidation of PBMs and health plans in the industry and gives an update on the legal battles surrounding PBM reimbursement rates.

 Building a relationship with a co-op can help pharmacies reach their goals and stay ahead of quickly shifting consumer and retail climates. Copeland discusses the benefit of collaboration and partnership with a large network of peers.

As independent pharmacy forges ahead in 2021 with new responsibilities and challenges, innovation is key.

 to hear Copeland’s tip on how to reach your 2021 business goals.

In part 1 of our podcast series with American Associated Pharmacies (AAP), AAP President and CEO Jon Copeland dives into key pharmacy industry trends. 

Reach Your Business Goals in 2021

 from the National Pharmaceutical Association. 

 Hello and thanks for listening to Over the Counter, the podcast from 

In this special episode, Brian Nightengale from AmerisourceBergen, returns to speak with Dr. Lakesha Butler, immediate past president of the National Pharmaceutical Association (NPhA), and Dr. Ryan Marable, current president of NPhA.

The topic is closing the healthcare gap, where experts will tackle the social determinants of health (SDOH), improving access to care and the pharmacist role in addressing these disparities in health care to improve care for diverse populations.

 Hello, everyone, and thank you for tuning in to our ThoughtSpot 2020 podcast in partnership with 

 I'm Brian Nightingale, president of Good Neighbor Pharmacy (GNP) and today I am joined by Dr. Ryan Marable, president of NPhA and Dr. Lakesha Butler, immediate past president of NPhA. Thank you both for joining me today. Really appreciate your time and very much looking forward to the conversation.

 Absolutely. I'm really excited to have the opportunity to learn from both of you really and to discuss the important role that pharmacists in organizations like NPhA and others can play in increasing awareness and addressing the historical and cultural barriers of under resourced communities. And certainly to promote racial and health equity, and hopefully advance the standards of pharmaceutical care amongst all practitioners for the communities that we serve.

So again, really excited for this important conversation today. And I appreciate you joining. But really, before we dive into the key topics at hand, perhaps both of you can share a little bit about your background, your current position, and certainly the important mission of NPhA. So Dr. Butler, let's start with you.

 Sure. I wanted to start off and say I really appreciated the use of the word under resourced and we'll tap into that a little bit later because we don't use that very often. But it's the idea of being under resourced.

And so NPhA was founded in 1947 by Chauncey Cooper. During this time NPhA was, unfortunately, members such as African Americans, who were not accepted into majority organizations. And so this was a time where this type of organization was needed.

The mission we're committed to is serving underserved and under resourced areas. We represent the views of minority pharmacists on critical issues affecting health care and pharmacy. We promote racial and health equity, as you've mentioned, as well as advancing pharmaceutical care amongst all.

I'm a lifetime member of NPhA and began my journey of involvement as a pharmacy student. I was a member of the student National Pharmaceutical Association at Mercer University. And that was where I found my passion.

As a pharmacy student, I decided to get involved in an organization that mission was serving the underserved because I knew that's what I had a liking for. And honestly, during that time, I was able to really find myself through the service and serving others.

And I realized that I wanted to go into ambulatory care, academia, but want it to be in communities that really were under resourced, and that needed additional education. And so after graduating from Mercer, I completed a pharmacy PGY-1 residency in ambulatory care specialty at University of Illinois at Chicago. And within this time of my residency, once again, getting greater exposure to academia and knew right off the bat after that I wanted to pursue a career in teaching and so went on board at Southern Illinois University, Edwardsville as a clinical assistant professor and then moved through the ranks of becoming a full professor at SIUE.

In addition, my title as well is director of diversity, equity inclusion. During my teaching, I have once again found that the area that I'm most passionate about is equity, in addition to diversity and inclusion, and so, all parts of my job, whether it's teaching, service, scholarship, is blended around that topic of diversity, equity and inclusion.

So that that's kind of my pathway. As I have gone through the ranks in my career, I have found ways to serve the community, but also serving in greater capacities, and hence the previous service as president of NPhA. I do believe that serving is where you can make great impact; that that serving it doesn't have to be in a leadership role, but oftentimes, we can have a greater level of impact as leaders. That was my desire, to have a greater impact through leadership.

 That's great. Thanks for sharing that wonderful background. And I look forward to to hearing more. So. Dr. Marable, how about you?

: Absolutely. So just to pick up right where Dr. Butler left off as far as providing some context for the NPhA.

NPhA is one of the oldest predominantly Black professional pharmacy organizations established for pharmacists and other pharmacy professionals here in America. And our members, what makes us unique – yes, we are predominantly Black organization; however, our members are not only serving within these communities, but we're active participants.

We live, we invest, we work, we play, and we represent people nationwide amongst the people. I thought that was a very unique aspect of our group, is that not only do we work professionally within these areas, but we're a part of them, and we're active in them, so it's something that's very important.

But just a little bit about myself. I am a recent, relatively recent, graduate from the James L. Winkle College of Pharmacy at the University of Cincinnati in 2013. But just to kind of take it back a few steps. My first experience, which led to my passion in life, was within a small, independent pharmacy. It was a father and son team, the son was the manager and developer of the location. And the father, who was also a pharmacist, they work side by side. And I just thought that that was just such a concept because it was in an under resourced and underserved area within Dayton, Ohio, where I'm from.

Just seeing the level of rapport that those pharmacists have with the patients, and the level of respect that they each received, based in the fact that they were providing a service and care for the people within their area, I just thought that that was something that I could perform, or something that I could do because it was a model of behavior, or action that I felt like I could achieve and it somewhat lit a flame in me to move forward with.

That drove me toward the University of Cincinnati. And because of that experience within a community pharmacy setting, I was full speed ahead to become a community pharmacist.

For the first 7 years of my career, I was in the community pharmacy space as a staff pharmacist. I also spent 2 years as a direct patient care pharmacist, working with the diet, diabetes and hypertension coaching program within Kroger pharmacy, which is here in Cincinnati.

Then recently transitioned over to management and served as a manager for 2 years, which was a very enriching experience, it was actually pretty much the end goal for me. However, I would say after that 2-year experience, I felt a little boxed in, so I wanted to do something that would expand my horizon as far as my impact with people.

That transitioned over to my current role within the industry space. I'm currently a drug information associate with Eversana within their medical communications department, so it's very been very enriching.

How did I get involved as far as being an advocate for the profession? I would say my journey is very similar to many pharmacists from around the country. Just from the day-to-day tasks and in providing service during your workday, there can be times where you can feel burnt out. In order to prevent that, I felt that it was very important to remain engaged within the profession and networking with other individuals who have goals similar to mine as far as addressing barriers to care and access amongst the most vulnerable people within our various populations.

And that is what drove me to NPhA. It initially started off with my experience with the student affiliate during my time at the University of Cincinnati, and then that transitioned over on the professional side with NPhA. So it's been a very awesome 7 years as a pharmacist, and just looking forward to continuing that precedent during my time with NPhA as President.

 That's great. And now you've got the gavel, so looking forward to that.

First of all, great to get to know more about you, thank you and for sharing. You both talked a lot about communities and communities that you serve. And of course, that's what the profession is all about.

So let's dive into, certainly the patients in the communities that we serve, and, in particular, the role of SDOH in access to care.

There's a lot of diverse communities - our GNP network, we have over 5000 of those independent community pharmacies really across a broad geography in the US: rural settings, urban settings, certainly suburban settings as well. And, of course, they serve patients across a very broad socioeconomic and demographic spectrum.

And so, one of the things that we sometimes struggle with when we're developing programs to support these pharmacies is really the role that the various SDOH play in how care is provided, and also importantly, how care is received across various geographies and communities. And ultimately how that impacts patient outcomes within these diverse communities.

So Dr. Marable, how does NPhA, view the role of SDOH and why do you think they're so important for pharmacists to have a better understanding of?

 Thank you, Brian, for laying that question like that.

I feel like it's definitely something that you have to take a step back and view from a wider angle. The term, SDOH, just to provide some additional context, are conditions in the places where people live, learn, work, and play, that affect a wide range of health risks and outcomes.

So just in general, we often associate, as pharmacy professionals and healthcare professional in general, we often view an individual's behavior as the major driver behind how their health outcomes will be determined. However, that's typically only about 10% of how that person or that individual, their health will actually really play out.

So you'd have to think about what is that other 90%? What is actually creating a much more significant impact on their health. And that's where those social determinants come into play. It's those things that individuals, those things that groups of people and various populations, that they can't control. So those things can present themselves in a number of different ways.

That could be educational access, and quality of that education. That could be an individual's particular neighborhood or their actual environment. So you have to think, if you're an individual living in an area, if you have poor infrastructure, if you don't have access to transportation, it can be difficult for you to access your actual primary care physician. Or you have difficulty getting to a pharmacy or there may not be a pharmacy within 15 or 20 minutes. You could have the strongest intentions in taking care of yourself and addressing the health needs that you may have. But if, for any particular reason, you don't have that access based on your community's infrastructure, you're going to be behind, and that can greatly impact your overall health.

Also, this is one area that I never really thought about until diving a little bit more deeply into the topic was the social and community context. So how does an individual's ability to be included within their overall community, how can that impact their feeling in their perception of how their health should be played out?

You often see this in the forms of civic participation, levels of discrimination, mass incarceration. This is often evident in the topics of criminal justice reform. You also have areas of workplace conditions. If you have poor workplace conditions, that can even spill over into one's treatment or their overall care.

And then of course, you have economic stability. So if you have individuals who have employment issues, or food insecurity, or housing stability, these are all just different areas that as individuals, we just don't have as much control over. And that can ultimately play into your health.

And outside of that, once an individual is placed in those types of situations where these areas are gone unchecked, that could put an individual in a position to where they're basically going from being in a position to thrive, and then they're forced into survival mode.

Often what is seen in an individual or a group of individuals, they're just basically trying to make the best out of a situation. It comes into play of identifying the most nutritional based foods. If they can't afford that, or if they can't identify the quickest way to get it, they're going to do whatever they have to do just to survive. And that just puts an individual in a position where their health could be put in jeopardy.

 Yeah, so it sounds like what you're saying is when we as pharmacists are caring for a patient, in many instances, what's in that patient profile or in that chart represents only about 10-15% of what actually you need to know to be able to understand their healthcare environment and some of the barriers to appropriate care.

And that's a pretty startling number when you think about the lack of information that a caregiver and a pharmacist have in front of them. So, Dr. Butler, maybe you can transition that into education and are pharmacy students starting to learn more about the importance of those factors. And is there a role for the pharmacist in capturing that information and making care plans accordingly?

 Absolutely, Brian. Dr. Marable did a great job of setting up the foundation of the importance with SDOH and factors that contribute to it. Ironically, I am, and this is the honest truth, I'm teaching this tomorrow to my students where we are discussing SDOH, and specifically how that plays with systemic racism.

I know we'll talk a little bit more about that later, but I think it's important to reiterate what Dr. Marable said about this iceberg: that we only see the surface when we are interacting with patients or when we're looking in their charts and coming up with health care plans for them.

And so, yes, the importance of relationship with the patient becomes critical in order to understand and have a better sense of how these factors are contributing to their health outcomes. I oftentimes think of some of my real patients that I take care of and many of them, because of where they live - I serve predominantly African American patients that live in under resourced areas - so when it comes to finding places that, for instance, grocery stores, those are limited in the areas that they live. However, fast food restaurants are in high demand and in high numbers that exist in those areas.

This idea of problem patients that aren't showing up for their appointments, or they're not getting their prescriptions filled. We may view them as problem patients, but digging deeper to understand why. Anytime I see a patient who's not taking their medications how they should be taking it, I know that there's a much deeper story on why they're not taking it.

As Dr. Marable mentioned, survival mode makes you create priorities. So sometimes healthcare is not necessarily a priority when you have to pay bills and you're concerned about medical bills that you may incur from going to the hospital and so not going to the hospital just seems like the easiest thing to do. So, therefore, healthcare may not be the priority.

Also transportation. Dr. Marable talked about that. But I see that very often. If you're depending on public transportation and if you missed your stop, that could actually delay you, or get you completely off track with getting to work on time. And that can snowball into lower performance at work and potentially affecting employment rates.

Also, we talked about housing. Housing, depending on where you are, there may not be sidewalks. We know that with healthcare, physical activity is important to decrease our risk for disease states such as cardiovascular disease, diabetes, and if there aren't sidewalks to walk on, or if you don't feel safe to go out and walk, then that can contribute as well to a decreased level of physical activity. And so finding optional ways or other ways, alternatives, to increase physical activity - I oftentimes will say, well go up and down the stairs in your home; going down into your basement and maybe doing some exercise there; parking further away when you're at certain places - that takes time. And that takes a genuine interest in your patient, a genuine relationship building with the patient in order to uncover this huge iceberg that's contributing to what we're seeing on the surface.

 Those are great points. I think you're talking about structural and societal barriers and things that that can create issues that show up at the point of care that the care provider has no idea about. And then I can imagine that lack of awareness of what happened from the time that person left their home to try to get to their appointment or the pharmacy, and that, again, due to just either outright racism or unconscious bias, the automatic thought might be, well, they just must not care. So why should I care? Right?

 To kind of tie into the pharmacy, your role in this a little bit. I've been in other conversations, where there's a whole conversation around trust and mistrust.

How can care providers or pharmacists that are white and that may not understand or be aware of a lot of the challenges and issues that we're talking about – what should we do to better build that trust so that we can create that better relationship that you're talking about?

 Absolutely. I think the first step is that interpersonal work: truly finding ways to educate ourselves on what might be contributing factors to these decreased health outcomes. It does take a deep dive into historical context. And we know that we're here today because of history. And there have been hundreds of years of marginalization of underrepresented, marginalized or minoritized communities.

And because of that, we have biases. We all have biases, because of what we've been taught, what we've been told, what we see in the media, and specifically, when we think about our white colleagues, because of the historical context in our country, there is an innate feeling of negative bias against individuals that are of color.

And so because of that, oftentimes, biases are considered to be unconscious most often, especially in the healthcare field. But we have to take a deeper dive and really understand and self-reflect on what is our socialization? How were we socialized, as individuals, when we grew up in our home; what were some messages that we received, about minority patients that we take care of?

Those socializations really stick with us until we decide to disrupt the cycle. We continue to stay in that socialized cycle based on what messages we received internally and inside our home and externally, until we decide to educate ourselves. And that's why I say that interpersonal work is so important.

I think the other piece is listening and seeking to understand your patient. So those open-ended questions, and I like to use the term cultural humility instead of cultural competence, because cultural humility says that I'm coming as a pharmacist to the table, certainly with knowledge in in medications, disease state management, but that patient is also coming to the table with knowledge about themselves. And so I'm here to also learn from them about what factors, or that, once again, that iceberg that we need to uncover, to understand the patient at a deeper level.

Another approach would be avoiding further marginalization when communicating, and that is verbally and non-verbally. So non-verbally, we don't want to stand up over a patient if we have an opportunity to be eye level with them. Sometimes, I recommend taking off the white coat if possible, because the white coat - we've heard of the white coat syndrome with high blood pressure - but that resonates across the board with many patients as a power dynamic. And this level of feeling like they're being judged.

The other piece is the terminology that we use. If we're stating that someone is at a greater risk for diabetes because of their race, that's not necessarily true. That's a level of marginalization. Because of the color of your skin, you're saying that you have this condition, that’s something that they could not control. And so that's a further marginalization when we're communicating to them. We want to avoid that.

Because honestly, race is a social construct that was made up. And we know that there are not many differences between individuals based on race. And so really, those differences or those disparities are due to those SDOH that we've talked about that stem from the systemic and structural racism that we've outlined.

Educating and empowering patients. So really taking the time, once again, I mentioned listening and seeking to understand, but educating them and empowering them on their disease state.

I have many patients that really don't understand why they're on a medication, and so sitting down, and helping them to understand that really goes a long way. That helps to build trust. Because first off, you're taking the time to educate, and you see them to be important enough to provide them with additional information and helping them to once again be their own advocate for their for their healthcare.

I think those are a few ways or approaches to help build trust among minoritized populations, certainly what we say and how we act, but also that interpersonal work is key.

 And that's such a great way to put it, I think that was great context. The takeaway for me, just from what you just said is, again, it's not the color of your skin that's raising your risk of a disease or an outcome, it's what's behind your life, right, and your SDOH, and that that's a great way to put it.

Dr. Marable, I think let's kind of continue that though, but not necessarily from the patient or the community perspective, but from the professional perspective.

What challenges or barriers do minority professionals face in their day-to-day practice and caring for patients? Whether it's a white patient or a white coworker or provider that you're working with? Does that play into this as well?

 Oh, absolutely. As a minority professional, I will have to draw back to my experience during my time as a direct patient care pharmacist.

So during that period of time, I was working more closely with the help of primary care physicians, and you would reach out to them and ask certain questions and elicit feedback from them. And there could be sometimes, if they have an idea that you may be Black or that you may be of a different ethnicity, that you could get some pushback.

But just some things that I just try to recommend for other minority professionals is just go into it, as far as just establishing who you are and what you're representing, you're here as a pharmacist, and the end goal is to represent the patient. I feel like just in general, to go back toward what Dr. Butler was mentioning, as far as the level of bias, I feel like we all have similar goals that we're working toward as healthcare professionals, but those biases are, they're just natural things that occur within us.

The only difference is that we all have a different perspective or a different lens that we're viewing the goals through. And that lens is produced through our life experiences. The things that we go through as individuals, the experiences that we may have seen friends and family go through growing up, cultural stories that you may have heard of growing up, that really shapes us, and it doesn't really go away. And if, once you become a working professional, you're a pharmacist and you're practicing within your respective field, if you don't address that, and if you don't acknowledge it, then it can get out of your control. And that can be manifested in your communication with other health professional.

If I had to make a point toward other healthcare professionals and pharmacists, specifically, I would just encourage each person to identify what their specific biases may be, do some level of self-inventory, and just try to make those changes.

And being committed to making those changes I think is very important, because as you're making these types of changes, as you're seeing that you have these levels of biases, and you see other individuals around you who may have similar biases, if you start to call individuals out, or if you voice your opinions, you will probably receive some pushback.

If you're committed to making that change and changing your environment and the individuals around you, there's going to be an even greater importance that you have a very strong foundation and knowledge and understanding of exactly what those biases are and how you can address those changes for other individuals as well.

Additionally, it's going to be important not to wait for someone else to educate you. For example, within your professional workplace, you may have a mandatory in-service or training event, but you cannot wait for those things to happen. You're going to have to do some legwork and go out there and really try to find those resources that can create that knowledge base for yourself.

NPhA, we have anti-racism resources on our website

Office of Minority Health has a tremendous amount of resources

. And even if you wanted to dive a little bit deeper and identify wealth inequalities and information, the 

Federal Reserve also has so many resources

 that'll allow you to paint a much wider picture. So if you are challenged, and you are, reaching out to members within the professional community and you're addressing those levels of biases in order to create that true change that you want, you'll have that knowledge base and you'll have the resources that not only prepare other individuals, but it also helps to keep you strong in your quest to commit to that change, and changing others.

 And I just wanted to piggyback on a couple of things Dr. Marable mentioned, which were great.

It's important to start the work, right? We have to understand that we all, as Dr. Marable mentioned, because of our life experiences, we all have a lens that we're looking through.

If we take the stance of being colorblind, that that's not going to solve the problem. If we take the stance that I'm just going to treat everyone the same, that is not going to solve the problem as well, because everyone is not the same. We've talked about how where we live, work, play, it varies, those social determinants of health, again, creeping back up. And that creates differences, disparities, and because of that, we cannot treat everyone the same because we won't see movement.

Our final episode in our ThoughtSpot 2020 podcast series features NPhA president Dr. Ryan Marable and immediate past president Dr. Lakesha Butler, who share insights on health disparities and the social determinants of health. 

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