Looking to the Future of Independent Pharmacy

Drug Topics in partnership with American Associated Pharmacies sits down with Don Arthur, RPh, a pharmacist and owner of Black Rock Pharmacy in Buffalo and Brighton Eggert Pharmacy in Tonawanda, New York, to discuss what clinical care may look like, the biggest challenges that lay ahead for independent pharmacies, and successes that he's seen in pharmacy.

Drug Topics®: Hello, and welcome to Over the Counter, a podcast from Drug Topics. We're joined today by Don Arthur, to discuss the challenges that lay ahead for creating the next generation of independent pharmacies, how ground advocacy is shaping clinical care delivery, and what he's implementing to create the improved pharmacy of the future. As we transition into this next phase of the pandemic, what do you think clinical care delivery will look like at independent pharmacies?

Don Arthur: Well, I think it's going to take on many different appearances. But I think point-of-care testing is the big theme, you know, that I'd like to talk about today. Some of the other clinical services that independent pharmacies have been providing: medication therapy management, some of the newer programs with diabetes, I think those will continue to have opportunities. I think what's happened to community pharmacies in the last two and a half years now, is how they were able to quickly adapt and become familiar with the various point-of-care testing that's out in our community. So I would say as we transition away from the pandemic, I think antibody testing, still talking about COVID is some opportunities, and I'd like to talk a little bit about that. But I think some of the lab partners that we had not even known of prior to COVID have approached us now to do finger pricks for vitamin deficiency. So lots of clinical opportunities in the near future.

Drug Topics®: So do you think that this future will require state or federal legislative changes? Or will it be on the ground advocacy work that makes this care a reality?

Don Arthur: Well, I wish it were the latter. I wish it was simply advocating for it, and it would become a thing, but unfortunately, it doesn't work that way and our pharmacy space. We have the federal government involved, obviously, the FDA and others, but we also have states involved: State Board of Pharmacy, state health department's. In community pharmacy, we have to deal with all of those regulatory bodies. But specific to where we are today, emergency orders really created our opportunities. We began COVID testing in November of 2020, 9 months after the pandemic began. It took us that long for our state governor to recognize that independent pharmacies could play a role. And then it took us several months to go through the licensing requirements to become an LSL and receive a CLIA waiver. So I think I'm really hoping, we showed here in Western New York, that we have been able to test our community quickly, efficiently, professionally. We've tested over 92,000 people to date. We continue to test much smaller daily numbers. But our vaccinations, we have vaccinated over 15,000 people since the pandemic began. And I think that that volume, hopefully has shown the regulators or politicians that we are absolutely the best place to receive certain types of point-of-care testing, but it will take permanent legislative action, both at the state and federal levels, for us to be able to do that.

Drug Topics®: So what do you foresee as the biggest challenge in creating the next generation of independent pharmacies?

Don Arthur: Well, in terms of my family, my dad started our pharmacies back in 1958. And most independent community pharmacies at that time were single pharmacies, opened by graduates of local pharmacy schools. And the average prescription, I think back then was under $10 and there were no such thing as PBMs. We actually, if you look at this historically, when we put our typewriters, I began working in 1977 in our family's pharmacies and in the early 1980s, when pharmacy computers were introduced to independent pharmacy, we took those typewriters that I still remember and put them under the counter, and we began processing prescriptions with our computers. At that time, insurance plans had started to evolve and offer prescription benefits with co-payments for patients and once we went to computers, we needed a platform similar to MasterCard Visa, to just basically handle that transaction for a transactional fee of 25 cents, 30 cents, whatever it was at the time. And they did a phenomenal job at that. But look what they've become, you know, now they're called prescription benefit managers. And unfortunately, even though we were there in the beginning, and we helped create that industry, they're probably our biggest challenge for independent community pharmacies. They are a partner, one would think, but the relationships we have with them are very, very difficult. We all have contracts that we sign independently as community pharmacies. But as I talk to my attorney, friends who do contract law, they're always confused by the lack of negotiation in the contract. So they are contracts, but they don't really feel like contracts because we as independent community pharmacies don't really have any options. And they're unfortunately becoming more and more difficult. On a day-to-day basis, I have two community pharmacies in Western New York, one Black Rock pharmacy opened in 1958. It's a traditional pharmacy, our volume is based on dispensing of tablets and capsules and solutions and liquids. And it's been very challenging to be able to work within this PBM world that's been created. My second pharmacy, Brighton Eggert pharmacy is a little bit different. We are a compounding pharmacy. We do nonsterile compounding. And we've been very fortunate in that regard to get a large amount of support from our physician community and our patients. So we've grown that business, we have a large erectile dysfunction business that we created with neurologists and throughout our area within a 60-mile radius. So, Brighton Eggert has been able to adapt a little more quickly than our traditional Black Rock pharmacy, but we shouldn't have to, these clinical opportunities, these things that pharmacy does, they should supplement an already vibrant, successful pharmacy, if you've been in your community since 1958, you're filling a large volume of prescriptions, which we are because we've developed a relationship with the community, sometimes three generations of families, and they respect us, they trust us, and they want to be with us. But a pharmacy like that should be able to compete to thrive, to be successful in the community, on providing those services, those traditional pharmacy services, if they're able to adapt and add staff and great clinical opportunities, that's fine, but they shouldn't have to do that to keep the lights on. So our biggest challenge is PBMs. And, of course, government, working with government, most independent pharmacies tend to be somewhat moderate, because we're just trying to find somebody out there on the state level and the federal level to help us.

Drug Topics®: Okay, and so conversely, what successes have you seen in the industry so far?

Don Arthur: If we can get away from our traditional filling of prescriptions with tablets and capsules and having to interact with PBMs, and I'm always optimistic, I'm hoping that they do recognize the value we have in our community. Certainly our patients recognize and respect that. I think the local politicians in our communities too, but we're just not getting that from the PBMs. I'm hoping we soon have some successes in that area, both at the state and federal legislative level, in our interactions with prescription benefit managers, but in our relationships with our PSAOs, our pharmacy service groups that help us represent us in interacting PBMs. I hope we can come to some kind of an understanding that independent pharmacies truly do have value. We can help outcomes. We can help reduce healthcare costs. We can help make people healthier. So I'm optimistic in that regard. We are involved with CPSEN and CPSEN has grown throughout the 50 states, which is great for independent community pharmacy. They get it. Some of their programs we are working with. In New York state, there are active programs for diabetes. You had a nice article in your last Drug Topics that talked about HbA1c point-of-care testing. I'm very interested in doing that. I think that's a big opportunity for independent community pharmacy. Again we've clearly shown everyone that there are certain health care services that are extremely convenient at independent community pharmacies. We showed that again, I do have 2 pharmacies and we decided to create a drive thru testing facility at my Brighton Eggert pharmacy, to be able to test 92,000 Western New Yorkers and counting and to vaccinate 16,000 people. Well, we didn't do it with our current staff. We were fortunate, we hired at one point 12 RNs working for us on a full time basis, and we were vaccinating 150 people a day. And I'm not any different than other independent community pharmacies throughout the country. I think in the last 24 months, we've shown that vaccinations, point-of-care testing, programs through CPSEN, medication therapy management. The spotlight has clearly been on us, the last two years. I think we've performed exceptionally, and I think that's hopefully going to create opportunities for the next several years and into our future.

Drug Topics®: Okay, so in your current pharmacy practice, what kind of programs and practices are you implementing, to help create the improved pharmacy of the future?

Don Arthur: I had mentioned our compounding business, and we focus on opportunities in that particular space. We're frustrated. We're fairly new compounders. We aligned ourselves with PCCA, Prescription Compounding Centers of America. And they've been fantastic. My father, we had eight pharmacies, and my father was a former president of NCPA. And my brother Brad, my dad was president in the early 80s and my brother Brad went through the system, and he was president a few years ago. So I've been going NCPA conventions since 1980, when I was in pharmacy school down University of Florida. And compounding was there back in the beginning, and my father and I, we had eight pharmacies. We were big front-end pharmacies at the time. We had gift departments and grocery departments. We sold beer, and we were part of True Value Hardware. And we said, ‘you know what, that's not us. We're pharmacies, we care for our community back in the pharmacy department. But we're also retailers and compounding’s just not something that we have an expertise in, or we're interested in.’ Well, I kept walking by their booth, and five years ago, we decided to start a compounding, a nonsterile compounding business. So we are somewhat new to the industry. But it's really changed our relationship with physicians, we now are problem solvers for our physicians whether it's in pain management, orthopedics, podiatry, or dermatology, but physicians now call us and ask us to help them solve problems. That's pretty neat. I didn't really experience that prior to getting into compounding. So we'll continue to grow that business. But it's this point-of-care testing, which is really exciting to me. We learned so much over the past two and a half years. It's amazing how technology changed from in the beginning of the pandemic. You would have to go to a large lab like Quest labs in our area and you would have to pay $225, wait upwards of seven to 14 days to get results on a COVID test. And now we do rapid antigen testing with results in 15 minutes. We do rapid PCR testing with results within an hour. We have a lab partner where we do lab-based PCR with results the following morning. So it's amazing how technology has been so rapidly evolving in that particular space. With that we met in creative relationships with businesses that I never even knew existed in our community. And we've been partnering with a local lab that has a national and an international presence. And they just received FDA EUA approval for a COVID antibody test that’s simply a fingerprint that gives you an analytical, numerical value. You know, we've been antibody testing in our pharmacies for the last year and a half with we've been using the first step. And it's a great antibody test, but it's just yes or no. So it doesn't really help the person know what level of antibody protection they have at a given time. This test will give you a number and that number equates to what they call the COVID-19 immune index and the number that goes from one to 20. It will define if you're at low risk or at high risk. So we're pretty excited. We think we're within weeks of launching that, again the company received an FDA EUA for this, where our role will be point-of-care testing. We will take the finger prick, we will put the sample into a card, and a courier will pick up those sample later that day. The patient will have very, very specific numeric report of their antibody levels with a very user-friendly explanation. Why is this of value? Probably, we're vaccinating about 25 people a day. Most of those people are age 51 and older, receiving their second boost, their fourth shot. And I think the number one question they have those under age 50, who are not yet eligible unless they have an underlying condition. Their question is, ‘do I need it?’ As I talked to the lab specialists that we work with and really understand and know this much better than I do, they think it's an excellent question, because it's not beneficial to overvaccinate someone. So if we know that people have different levels of antibody, well, we don't know, is it a genetic component? Is it a health component? There are several factors, I'm sure. But they all go back to the point of, if we have an antibody level, that's accurate, we can answer that question. And if your levels are low, it would be appropriate to receive another booster, if your antibody levels are high, you have significant protections still, and it's not necessary at the time. So we think we're going to be doing that, within the next two weeks. We feel it's going to be a covered service under insurance due to the Cares Act back in 2020. We're pretty excited about that. Because unfortunately, fall is right around the corner and we don't know what that's going to bring in the world of COVID. But to have a tool like that, for people to be able to know their antibody levels, and then make a decision based on that as to whether or not to receive another vaccine, I think is exciting.

Drug Topics®: Okay, so do you have any final thoughts or takeaways that you'd like to share? Before we wrap up?

Don Arthur: The final thoughts are that March of 2020, COVID, it's changed my pharmacy. I don't talk very much about the hand sanitizer, but if you remember in the beginning Purell just wasn't available. And, again, the country came to independent community pharmacies, especially those that had some compounding and lab experience, provided us with a federal formula, and asked if we could compound basically hand sanitizer. We made 10s of 1000s of bottles of hand sanitizer. We were providing in five gallon bottles for companies. We did that. We were able to adapt to do that over several weeks. We were able to gear up and provide a drive thru point-of-care testing for COVID. And the nasal swab as other independents have throughout the country and in very large numbers, up to 1500 in one day, during one of the holiday outbreaks. We were able to adapt to do that. Vaccines we've talked about, we've been vaccinating in New York State for 10 plus years. Unfortunately, the rate of flu vaccines is not as high as we would like it to be. So we would do 10,15, 20 a day during the season. We vaccinate for shingles. We vaccinate for pneumonia. But we had never thought that our staff expanded with some registered nurses could vaccinate up to 150 people a day. We've clearly showed our government that we can do these things. If you remember independent pharmacies throughout the country, it took some of us three months to receive our first vaccine, the government felt it was best to handle in clinic settings, which I think they may or may not have been right. I think those clinics, there was such a demand in the beginning when the vaccination became available, but they could have done better, they could have absolutely opened up those vaccine clinics and communities. I was actually a big part of some of those in our area. At the same time, they should have gotten those vaccines out to independent pharmacies day one. Ee should have been the focal point and chain pharmacies, because we've been vaccinating the community for the past 12 years. The rollout was difficult, but we're still vaccinating 20, 25 people a day. And I don't think there are any vaccine clinics. They've been gone in western New York for over 10 months. So I think government quietly, I wish it was publicly said, ‘wow, independent community pharmacies, look what you've done’, but I think they absolutely know. Tvery time we order vaccines, which we do weekly, New York State calls us and says ‘where are you finding these people? We've got pharmacies that haven't ordered vaccines and months.’ Where are these people coming from? I would say 90% of them are not our current patients. They're people that have heard about what we've done in the community in relationship to COVID and they're driving to us and we're vaccinating them. I'm excited about our future. I've got two boys, third generation working in our two community pharmacies, so I'm excited for them. I don't ignore the challenges we have with prescription benefit managers, but look what's happening around the country, all 50 states seem to be taking a much closer look, the FTC decided to take a look. I bounced around quite a bit today, as I do, but I do think there's lots of opportunities in the future.

Drug Topics®: Thank you for listening, and we hope to see you next time at the counter.