A Conversation Between Pharmacists: Industry Trends and Lessons from COVID-19

Thai: My name is Ken Thai, and I am working with Drug Topics® to introduce you to a very special guest today, David Dingman. I think it's kind of interesting, because I'm an independent pharmacy owner myself and, obviously, there's a lot of vested interests here and how we continue to thrive and survive in this current climate, so it's awesome to have a guest with the expertise of David here, and love to spend some time to maybe get to know you a little bit better, Dave. Why don't give us a quick intro and then we will shoot off some questions and chat it out like colleagues.

Dingman: Absolutely, thanks, Ken. Actually, I'll clarify one thing. I don't have the doctorate, I'm an old dinosaur who’s sticking with a bachelor’s degree. In 1993 I graduated from Albany College of Pharmacy - I have to give a shout out to the Panthers. But I'm excited to be here today and I really appreciate it. I currently serve as the chairman of the board for American Associated Pharmacies (AAP).

Thai: Awesome. Well, I'm glad to have you here. We're at both sides of the country - you're in New York and the east coast, I'm here in California on the west coast.

Dingman: The left and right covered, absolutely.

Thai: Well, I love to hear a little bit more about AAP. Can you give me a little bit of an introduction about the organization? I know it is a co-op for independent pharmacies.

Dingman: AAP is exactly that. It's a cooperative of independent pharmacies and enables us to come together and have one voice and compete with scale. If we're out there on our own competing with the pharmacy benefit managers (PBMs) competing with the wholesalers. We're not going to get the best rates in the world, we're not going to be able to buy it at a rate that we need to buy it in order to be profitable, so it's the old strength in numbers. If we come together and have one voice, you get a commonality and our mission, we're able to scale in and benefit on so many different levels.

Thai: That's great. I know that that's very key for us nowadays, is to be able to have that voice and to be able to stick together and work honestly as a group, because when you have quite a bit of - whether it's change, or other companies out there that are competing with us, and we need to stick together to survive. So, on that particular note, I'd love to hear more. I mean, are you guys involved in other forms, besides, obviously, contracting and whatnot, on the legislative front, both at the state or federal level?

Dingman: We've actually asked our independent owners if they'd be willing to secure some funds out of their individual rebates that they get back, if they were willing to advocate some of those funds towards that so we can get significant dollars. Unfortunately, it takes significant dollars to move the needle in any direction. And even then, there's no guarantees. But the majority of our members have done that. We have board members from all over the country, and we get requests every meeting and we kind of prioritize which ones we think we're going to get the most bang for our buck, both at the local levels and at the state levels.

And, of course, at the national level - which, we had a big win last fall - but it's no time to stop. I remember going through school, and they were all excited with the Gallup polls that pharmacists were the number 1 trusted profession. I think we might have slipped a notch or 2, but we're still top 5. Unfortunately, as good as we are at being trusted, we're not very good at demanding reimbursement. And I think that needs to come full circle to actually be compensated for what we do so we can continue to do what we do.

Thai: So, on the point of reimbursements, I'm curious because sometimes we're in our own little silo and only know what's going on in our local area - for me, that's Southern California, and for you, maybe it's New York. But what do you see out there? You talked about reimbursement issues, and I'm curious, I mean, is it different in different states? Are we having similar issues? Is it better in certain regions with particular payers? What is the word on the street right now?

Dingman: What we've what we've noticed, about 4 years ago our subsidiaries started introducing these generic effective rates (GER) and brand effective rates (BER) contracts. And those are fine and dandy if you're dealing with a big national chain, CVS Walgreens, because it's all 1 check and it's going to 1 owner.

The problem with these contracts, number 1 we're signing them as a PSAO level for independent pharmacies, as you're taking money out of one area of the country, and you're putting it into another area. Well, those 2 different areas are owned by 2 different people. We've screened at the top of our lungs, “this isn't fair, we can't do this.” Unfortunately, in today's marketplace, these contracts are pretty much take it or leave it. If you don't want to do it, then you can't fill the prescriptions. You'll have a highly competitive area like New York City where they're selling insurance and they have to lower the rates because it has to be competitive to get the business. Whereas in suburban Kentucky, they might get a higher rate so they can pay that suburban Kentucky pharmacy a little higher than they can the Metropolitan New York store, but they don't seem to take into account that those 2 pharmacies are owned by 2 different individuals. We’re set up differently and that's definitely been a challenge. We're working through the solutions. Unfortunately, I don’t think we found a good one.

Thai: Yeah. And I think it's going to take us some time before we get to that point where we can get, I don't even want to go as far as to say great reimbursement, just fair, right?

Dingman: Absolutely. We're just begging for legislation now to make it so we don't lose money.

Thai: On that note, from the patient's perspective, what are your thoughts right now? How easy is it, do you think, for patients now to get access to us? Do you still think there's this push towards potentially patients being steered elsewhere? What are your thoughts on that, and what do you see the future in terms of how we can rectify that?

Dingman: Dealing with the payers directly. Just an example, last year I had to deal with one PBM cutting me out. I had the contract in hand, and they said, “No, you belong to the wrong PSAO, and you're no longer be able to fill these prescriptions.” And it just so happened to be for the local school district, my particular store has filled 2 generations of people coming out of the school district, so simply being left out was not an option.

I contacted the local union representative for the school district, who had a meeting with the teachers and staff and they said, “Look, we have to have this pharmacy in our network, this is what we use.” So, they got me in touch with the broker, that actually brokers with the PBM for the contract. And the broker informed me that they were told by the PBM that I was not willing to take the contract. I informed them it wasn't true. And at that same time, they said that they actually weren't signed with the PBM. They were in negotiations. They called the PBM and said, “Look, we need this pharmacy added to the network,” and it was added to the network.

So today, continually, I'm able to fill those prescriptions. But if I sat on the sidelines sitting on my hands, I would not be able to fill those prescriptions today. I think going to the payer is a huge thing. And I called up the PBM directly. And they said, “Well, the client doesn't want you to as a pharmacy.” They're talking out of both sides of their mouth, and it's not going to last. It's going to catch up with them. It's just bad business, and they continue to do it.

Thai: And this is a great story, by the way, because it just goes to show you when there's a will, there's a way and I think that's some of the independent entrepreneur spirit that we as independent owners, we encompass and quite honestly, it's a great story, because I think that it just hopefully tells the audience out there how important it is to not never give up. As long as you stick with it, the truth will come out. We've all heard that there's quite a bit of different truths, depending on which mouth it is coming out of and at least we know that we're ready and willing to serve our patients.

Dingman: Are you willing to fight for them? You have to be willing to fight for them, because everybody, everyday is trying to take them away from you. And nobody's going to take care of them as well as you will, because you're there and you're present. But you got Amazon, there's all different types of angles that are trying to take your take your prescriptions away.

Thai: I think on a different front, in California, we're actually passing a patient steering bill, which would not allow some of these bigger, large-scale box-office chains to essentially force patients to go by differentiating on co pays or forcing them to go mail order and whatnot. And so, I think both on the legislative front as well as on a personal willingness to fight for your contracts, I think we can make it happen, That's something that hopefully we can all, again, continue to keep the spirit up for.

Dingman: The old saying is the truth will set you free and I believe we're on the truth and the right. Unfortunately, the legislative process is slow and cumbersome, and by the time they get enacted, there's usually a workaround. But you can't give up. You just got to keep fighting for your business, you got to keep fighting for your patients, because, frankly, the independent pharmacy tends to cater to the more needy of patients, the ones that need more help that need more attention. And by going to these far-off places, and just having things mailed to them, it just doesn't work for them.

Yeah, and I think you and I know, we worked with our patients long enough where they're not your typical onesies, twosies, right? They're coming in with 15-20 medications, sometimes 6 or 7 comorbid conditions. And it's not like you could just mail someone or just throw them the meds once a month and call it a day. It's not that simple.

Dingman: And not only dealing with multiple medications and polypharmacy. You also got to find out which cousin is setting up the prescriptions this week - you know the family. You know the whole backstory as opposed to just the medicine.

Thai: I think it'd be hard for us to not talk about all that's happening around us, mainly with COVID-19. I’d love to pick your brain a little bit about some of the things that are happening, including vaccinations, and obviously with the third booster shot, I think coming soon for immunocompromised as well as for everybody. There's a lot going on there. What do you see out there with your store and with the pharmacies that you represent? Are the numbers really plateauing or are folks out there still looking for vaccinations? And how much of that are you seeing coming through the independent pharmacies?

Dingman: Well, I really want to give a shout out to the states that had the foresight to bring independent pharmacists in right from the beginning, Unfortunately, New York was not one of them. And it was a challenge for both the chain that they used and the populace in general. And I think we can learn something from the states that put the independent pharmacy right there in the front line and starting up the program. They got the vaccine rolled out in a smoother manner. But that's in the past, you know, as long as we can learn from it.

But I'd like to champion the independent pharmacies that that were there from the beginning. And I have colleagues that did it. And I'm very thankful that I had them as colleagues, because when we started getting to our supply, I was able to use them as a resource, which is another benefit of the cooperative because you end up networking and have those contacts with people in Arkansas and Missouri and those other states that were able to do it from the get-go. But this has been a game changer for the profession in general. People are looking at us differently than they did a year ago. We're able to solve some of the problems from an individual level, from a state level, from a federal level, from a health care level that we didn't know that there was even going to be a problem, but we stepped up and got it done. And I'm proud of my colleagues for doing so.

Awesome. Speaking of that, we're hearing the latest developments every minute here. And of course, we just heard that the Pfizer vaccine was officially approved by the FDA finally. And so, what are your thoughts on that? It took a long time, because essentially, we've been given vaccines for over 8, 9 months now. And also, see in California, at least a lot of vaccine hesitancy so I'm not sure if that's something that you're also experiencing, and what are your thoughts on that?

We there is hesitancy out there, whether it's politically driven, whether it's really religiously driven, there's going to be a certain population that's not going to want the vaccine. There's a certain - anti vaxxers is not a not a new term. There are people that do not trust them, don't believe in them. And, we live in a free country where you have individual rights and when it starts infringing on other rights, that develops into a political debate, and it's not really appropriate, or I don't have the bandwidth to even comprehend everything that that entails.

We've seen a significant drop off in vaccines that were given. We had a big push, everybody wanted to get to the front of the line and get it and we rolled it out. And now we’ve gone from about 150 in each store - I have 2 stores - so about 300 a week, probably down to less than 50 a week now. Now, the ones that I'm doing are pretty much due to mandates, whether they work in the health care industry, their employment is requiring it. A lot of kids are heading to school this month and their school is requiring it. So that's pretty much what we're seeing now.

We'll obviously get ramping up here again, when the third dose in the series starts coming into effect 8 months after their second dose. We've had a few that are immunocompromised, that they only have the 28 day, but most of those folks were kind of frontline in New York and they got theirs in January and February, so they're doing now, but I, we've seen a big drop off. But some people, you just have to keep talking to them, and keep walking them through the process. They are afraid. Maybe they have a very boisterous, politically motivated member of the family that's telling them all not to get it, but they want it and you kind of get them walking through those landmines. And as long as you're there for them and keep the dialogue open and keep it going, they realize they can get it if they want it, and we'll go from there. But you can't I'm not of the opinion, you should force anybody to do anything. But that's it's an individual's choice.

Thai: And I think that's the key what you just said. We live in a great country where anyone who wants it can get it. And for free. As health care providers, the best we can do is provide facts and prove and educate, and then ultimately, the decision or the risk is up to the patients. I really salute all our colleagues and fellow pharmacists and staff out there.

Dingman: Two years ago, if you said we’re going to give everybody in the country a vaccine, it's going to be free, and you get about 3 months to do it, that's, that's quite an undertaking. And I'll tell you what, we've stepped up and done it, it's been great.

Thai: Yeah. And I'm going to be frank and say, Hey, if it weren't for some of us, and some of our colleagues out there, and of course, other health care providers, this would not have happened.

Dingman: We all had more hair back then. I think, personally and the business, it was very challenging to not sacrifice the core business for the sake of doing the vaccines and doing so many times, you're called to do a transfer to another pharmacy or from another pharmacy, and you're on hold for 40-45 minutes, because they're just so busy and we've had a huge influx in business coming into our pharmacy, because we were able to maintain our level of service, as well as do the vaccines. And we didn't abandon our day-to-day business in order to do it. And I would encourage others to do it the same way.

Thai: And I totally agree. As matter of fact, we talk about this quite often, more people are probably dying of diabetes, hypertension, and heart attacks and strokes, than they are of COVID-19. And that's the reality, and then that's where pharmacists come in. Because while the pandemic is still going on, and we have to do our part with vaccinations and whatnot, we still need to make sure we keep these patients healthy, so that they can be strong enough to fight the infection, even with the vaccine.

Dingman: One of the drawbacks is our colleagues were put into a place where they had to either administer 6 COVID-19 shots this hour or be able to counsel these 2 people on how to use their glucose meter. They all need to be taken care of, but the people with the glucose meter end up saying, “Well, I'll go home and read it, figure it out.” And it's unfortunate. We tried to mitigate that and minimize it.

Thai: One other thing that came to mind is the testing. Are you are you doing testing, is testing something promoted within the AAP co-op group, and how is that coming along? Because I'm assuming with all these mandates, if you go to any venue, if you go to work, sometimes they mandate testing. Is that something that is actively being performed at your pharmacies, as well as within the AAP network?

Dingman: I personally do not do any testing at either one of my stores. I had one store where a young lady was pregnant, and inviting more symptomatically sick people into the store did not seem prudent to expose the staff to that, because being a small independent pharmacy - this is this is purely personal, not AAP - I did not want to put my staff at risk to get them all sick at once, because I don't have the resources to just march more people in behind them. API is our warehouse and he they have secured us testing and they the avenues open. I have colleagues that have told me it's been fantastic. They're doing many, many, many tests. But personally, I didn't have the resources to - being in New York when this first hit, it was the unknown that was the scariest thing. And it just came so fast and furious that I wanted to be able to stay open to be able to take care of the people I could. So that was a challenge. We do have supply in contacts through API if somebody chose that they did want to do it. Fortunately, in my 2 towns, we have enough other testing sites to manage that.

Thai: I totally agree. Sometimes it just comes down to personal decision that you need to make for the operation, for the staff and for the patients. You do the best you can, you can't do everything.

Dingman: we have a federally qualified health center (FQHC) that is more than prepared and capable of handling the need. So, for me, it would have been strictly hopping in just for the profiteering point of it, and the risk wasn't worth the reward for us personally.

Thai: I want to leave some time for you to express any other thoughts or any other messages you want to share with the rest of the independent pharmacy owners or pharmacists out there, students, technicians. I know that we're definitely living in very cloudy and unknown times now. So, at the end of the day, a lot of folks are looking for our lead to sort of a serve a little bit of a guide, mostly to see that to see the end of this. So, any thoughts that you'd like to share with us?

Dingman: I think dialogue is the best. And that's what has gotten me through this. I've been practicing almost 30 years now. I could never, never have imagined going through anything like this. It's about working hard, being an advocate for the people, your staff and your patients, and bringing worlds together and trying to solve the problems that we’re presented with. But what tomorrow brings is going to be all new. We, as pharmacists, kind of laugh every January 1, “So what is this year going to bring?” And I'm telling you what, when that ball hit, we had no idea what that year was going to bring, but it came and, I like I said, I'm proud to be a pharmacist, proud to be part of the profession.

I think we need to stick together and talk to our local, state and federal legislators to get your voice out there, be heard, be present. It's time to stop being the nice guy all the time. And we need to be compensated, we need to be able to stay open. And I would encourage everybody to do that in dialogue with other pharmacists, have a chat with them when you’re doing a transfer. It's okay to be friendly. Do the networking, it's helped me, professionally and personally, and as far as the business, it's helped immensely.

Thai: Yeah, and I think that's a great message because at the end of the day, we're all in this together. I've always said with my fellow colleagues and staff and whatnot, that there’s plenty of business out there, we don't need to be fighting ourselves. Much bigger enemies are out there and bigger competitors that we need to look at, and at the end of the day, we just make sure that we do our job, work as a team, and with other colleagues, independent owners, folks in the community, and band together. And I think, kind of going back a little bit with AAP’s concept, I think that's where these co-op affiliations provide a network for us to work together.

Dingman: We’ve got to stay open so we can keep writing those checks for those little league teams, that's important.

Thai: And then there's swim teams, and bowling teams, you name it.

Dingman: Our communities need us to be leaders in the community as well as to serve our patients.

Thai: Thank you so much, David, it was a pleasure meeting you for the first time and talking to you and just kind of sharing thoughts. I look forward to more opportunities like this. Again, thank you very much for spending time with us today. And hopefully, we fight through this.

Dingman: Thanks for having me. Well, we'll keep plugging. Absolutely.

Editor’s note: This interview has been lightly edited for style and clarity.