Elements Magazine Vol. 12 Iss. 4 December 2023

Cash Pharmacies How they help customers save on prescriptions

COGNITIVE TESTING IN PHARMACY Computerized screening for better patient results

GOING SKIN DEEP Complement your front end with skin care

VOL. 12 ISS. 4 | DECEMBER 2023

CONTENTS ON THE COVER

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FEATURE | Cash Pharmacies How they help customers save on prescriptions

DEPARTMENTS

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NEWS | New Obesity Drug Approved Eli Lilly’s Zepbound is a powerful rival to Wegovy

08 TRENDS | Your Online Flair

Stand out from the crowd in 2024

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RETAIL | “For Refills, Press 1” Accelerate your pharmacy’s personal touch with an IVR System

SOLUTIONS | Cognitive Testing in Pharmacy Computerized screening for better patient results

SPOTLIGHT | Going Skin Deep Complement your front end with skin care

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MONEY | Helping Patients Save

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OUTLOOK | Nationwide Chain Closings

How to get the best deal on their medication

Your opportunity to care for stranded patients

ELEMENTS | The business magazine for independent pharmacy | DECEMBER 2023

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ELEMENTS

ON THE WEB

The business magazine for independent pharmacy

VOLUME 12, ISSUE 4 DECEMBER 2023 PUBLISHER & EDITORIAL DIRECTOR

Your Extraordinary Front End

Matthew Shamet

Displaying the right products in your front end will help boost foot traffic and improve your bottom line. In fact, average margins on front-end merchandise are 15 percent higher than margins on prescription sales.

EDITOR Gina Klein GRAPHIC DESIGNER Logan Whetzal CONTRIBUTING WRITER Cecilia Vigliaturo

Unsalable Products INTERESTED IN ADVERTISING? elements@pbahealth.com

Inventory doesn’t always match up with the demand of your customers. This leads to stranded products on shelves, and most are beyond your control.

Hearing Aids vs. PSAPs Over-the-counter hearing aids are now stocked on store shelves along with PSAPs. While they both utilize technology to help with hearing, they have completely different outcomes.

Elements magazine is published quarterly by PBA Health. ©2023 PBA Health. All rights reserved.

Neither this publication nor any part of it may be reproduced without written permission by PBA Health.

Follow Elements magazine for pharmacy business tips and advice, news announcements, industry information, and exclusive offers.

NEWS

NEW OBESITY DRUG APPROVED Eli Lilly’s Zepbound is a powerful rival to Wegovy

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n November 8, 2023, the Food and Drug Administration (FDA) approved a new weight-loss drug for adults from drugmaker Eli Lilly. The new drug is called Zepbound, a tirzepatide medication branded as Mounjaro for diabetes, and it’s been shown in clinical trials to help people lose up to 52 pounds in 16 months.

The FDA approved Zepbound, just as they did for Wegovy, for adults who are considered obese using body mass index (BMI), a ratio of weight to height. People with a BMI of at least 30 or higher, and those with a BMI of 27 and at least one health condition related to weight, such as diabetes or high blood pressure, are eligible. Patients who use the new drug should be on a reduced calorie diet along with an increase in physical activity.

Zepbound is a GLP-1 agonist, a class of drugs that mimic a hormone that helps reduce food intake and appetite. The difference is that Zepbound also imitates GIP, a second hormone that, along with reducing appetite, might also improve how sugar and fat break down in the body.

The new weight-loss drug will be administered with an injection pen. The company says it will also be sold at a lesser list price than Wegovy and Ozempic, its semaglutide competitors from Novo Nordisk.

Though there haven’t been results from comparing Novo Nordisk’s and Eli Lilly’s medications head-to-head, research suggests Zepbound just might outperform Ozempic. But a report by the Institute for Clinical and Economic Review comparing semaglutide and tirzepatide for diabetics earlier this year concluded that there was a greater reduction in weight loss along with other key markers with tirzepatide.

However, it also showed that tirzepatide has a greater incidence of gastrointestinal side effects, severe adverse events, and discontinuation compared with semaglutide.

WHAT IT CAN DO People taking Zepbound in clinical trials on average lost 48 pounds at the highest dose. At the lower dose, they lost 34 pounds on average. Additionally, during its trials, it helped some patients lose more than 25% of their body weight.

According to the FDA, Zepbound shouldn’t be used for patients with: • A personal or family history of medullary thyroid cancer • A rare genetic condition known as Multiple Endocrine Neoplasia Syndrome type 2, which causes tumors in the endocrine system There are also warnings that come along with the drug, including the risk of severe gastrointestinal disease including nausea, diarrhea, vomiting, constipation, stomach pain, kidney and pancreatitis-related issues, hypersensitivity reactions, and suicidal behavior and ideation. Patients should also stay away from the drug while pregnant due to the risk of fetal harm.

A more serious complication some patients have reported since weight-loss drugs became popular is the risk of stomach paralysis (gastroparesis). Unfortunately, this wasn’t specifically mentioned on the label, and lawsuits ensued.

Both Eli Lilly and Novo Nordisk have faced claims that their drugs cause stomach paralysis. However, while GI issues are very common with GLP-1 medications, most side effects won’t affect a person’s quality of life.

According to Eli Lilly, Zepbound should be available in the U.S. by the end of the year. The list price will be about $1060 for a month’s supply. However, the current cost may keep many people away due to insurance companies that are reluctant to cover weight-loss medications. Plus, Medicare doesn’t cover them.

Zepbound should not be combined with other GLP-1 receptor agonist drugs, including Mounjaro, as well as Wegovy and Ozempic. The safety and effectiveness haven’t yet been established.

ELEMENTS | The business magazine for independent pharmacy | DECEMBER 2023

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TRENDS

YOUR ONLINE FLAIR Stand out from the crowd in 2024

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f you want to be noticed in today’s world, online is where you need to be. This is where your pharmacy’s future customers reside, and it’s where they’re waiting to find you.

People today don’t always want to run to the pharmacy to pick up a prescription. With the recent pandemic, along with customer demands, healthcare services have gone virtual and ordering prescriptions online has become crucial. Consumers have become comfortable with the instant gratification offered by the web, so it’s vital that your pharmacy keeps up with social technology.

If you’d like to draw in new customers to your pharmacy in the new year, here are the essentials your pharmacy needs: WEBSITE Having a pharmacy website is the first step to building your digital storefront. It’ll be your own personal canvas where you can publish all the information about your products and services. If you’d like an easy-peasy way to set up your own website, check out free builder tools like Wix, Weebly, and Mailchimp. They provide templates that are simple to use for basic websites.

But first, check out your competitions’ websites. What makes them stand out? What are their unique selling points? If you already have a website, look to see if there’s anything you’d like to improve. Is it personable enough? All of this is important because your website reflects your pharmacy. It should tell visitors what sets you apart from others.

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Add a personal photo of yourself, your employees, and add some photos of your physical pharmacy store inside and out.

When you bring out the emotional connection between you and your website users, they genuinely feel it and find your pharmacy more relatable.

Once your website is designed, look at it through the eyes of a patient. Be sure it’s user friendly and includes the following: • Easy to navigate • Design that matches up with your brand

successful social media posts. You can also start posts on how to book an appointment in your pharmacy, pharmacy updates, and any promotions or offers you have right now.

Social media isn’t just about posting. As a business owner, it also means engaging with your followers. You do this by responding to comments and replying to messages. If you block out 15 minutes a day to hop onto your social pages and respond to or like comments, your followers will know you care.

Your social media pages can be a relatable way to promote wellness while influencing patient behaviors. You’ll also collect irreplaceable engagement and feedback.

• Easy to read and understand • Main points are highlighted • All pages have the same text size, font, and color scheme If your pharmacy already has a website, when was the last time it was updated? If the design or the information currently posted dates back more than a year, it’s time to make some changes. An outdated website will send viewers to your competitors’ sites instead.

Drive more patients to your site by including such things as a health blog, refill and transfer page, online shop, and a contact page. Keep these pages updated regularly, and your website will be hopping with regular patient visits.

SOCIAL MEDIA If you don’t have a business account on a social media platform, now’s the time. The first step is to determine which platform your customers are most likely to spend time on.

Facebook, Instagram, and LinkedIn are your best bets for most consumer-facing businesses.

Once you choose your platform, check out other pharmacy pages and what they post. What types of posts get the most “likes” or comments? How many followers do they have? This is key information for what to post on your own pharmacy page.

As you create your business account, don’t forget to include important information like where your pharmacy is located, hours of operation, services offered, your contact information, and links to your website.

Once you have created your social media page, you’re ready to make your first post. You might want to start by introducing your pharmacy team. Be sure to include a photo of the entire crew! Photos are an important part of

GOOGLE MY BUSINESS This is an important social media marketing tool. It’s not only free, but it’s easy to use and it helps customers find your location. Be sure to include all of your important information, such as your pharmacy hours, street address, phone number, email address, and website address.

CHATBOTS Your customers have a lot of questions, and while you have the answers, you don’t always have the time. Your technicians are busy juggling multiple tasks, such as filling medications and helping patients.

Customers are anxious. Some want to know the side effects of their medications. Others inquire whether their two medications taken together might cause bad side effects. The longer it takes you to answer their questions, the more their anxiety builds. That’s why chatbots are your saving grace.

Chatbots offer confidentiality and support, even for the most awkward questions. They allow your customers the ability to upload images to the bot. If their medication request shows it’s not available over the counter, they can upload a photo or screenshot of their prescription to be verified by the chatbot or by your staff.

Did you know that a chatbot has a broadcast feature that you can use to schedule reminders for your customers to refill or take their medications? A chatbot also has a great memory.

It remembers everything and even saves every interaction it has with your customers on the interface. This means your employees can access each interaction with your customers.

Keep in mind that medical chatbots aren’t set up to deal with every single request. In fact, they can’t verify prescriptions, nor can they handle every single question asked.

ELEMENTS | The business magazine for independent pharmacy | DECEMBER 2023

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They can, however, seamlessly transition from automated responses to live responses from a virtual agent. Plus, the agent can view the entire conversational history on the platform, so the customers don’t have to repeat their questions.

Inventory management is another procedure AI can help pharmacies with. The AI-powered algorithms can predict the demand for a drug and boost inventory management, all while managing enough stock levels and lowering waste.

Your pharmacy has a lot to gain using a chatbot. It’ll answer almost any question and offers round-the-clock support seven days a week (including live assistance and multimedia).

With this amazing technology, your customers’ journeys become so much easier.

As a pharmacist, you have concerns when it comes to medication errors and patient safety. The good news is AI technology can help detect and prevent errors such as incorrect dosages or possible drug interactions. This will minimize unfortunate events and readmissions to hospitals.

ARTIFICIAL INTELLIGENCE (AI) Artificial intelligence (AI) is changing today’s practice of pharmacy and health care. For example, the ways in which pharmacists deliver care today is more than just filling prescriptions. Pharmacies are changing patient outcomes by improving medication management and simplifying workflow. Here’s how:

AI has a lot of potential. However, the implementation of it in pharmacies faces some challenges. The initial expense required for AI integration may be seen as challenging by some pharmacies with limited finances and resources.

• Medication Management One of the key areas in which AI can make an impression is with medication management. Decision support systems driven by AI help physicians and pharmacists select the right drug, choose the right dosage, and identify possible drug interactions and adverse events. This improves clinical judgment and reduces medication errors.

To get more pharmacists on track with AI-driven operations, education and training may be necessary to build trust.

Cooperation between pharmacists, AI developers, and healthcare providers will be what eventually drives change and refines AI tools to meet the distinct needs of pharmacies.

AI algorithms analyze large data sets and correctly identify possible drug candidates. By doing this, the algorithms are changing the drug discovery process. And with new drugs being developed at a fast pace, there’s the possibility of new treatments for various illnesses emerging.

AI can also influence personalized treatment through care plans based on a patient’s genetic makeup, lifestyle, and medical history. This lessens the possibility of adverse events.

• Workflow and Performance AI simplifies many processes such as pharmacy workflow.

It also frees pharmacists from a variety of tasks so they can focus on patient care. This is all due to a method of AI known as robotic dispensing.

Today, many large pharmaceutical companies are adopting AI-automated dispensing systems. The systems are equipped with AI technology, which accurately packages and labels medications. This improves efficiency and reduces dispensing errors.

Technology is always changing. So, be sure to stay on top of what’s new and “all the rage” in pharmacy. Don’t balk when it comes to trying something new. Embrace it, and watch your business and patient base grow.

ELEMENTS | The business magazine for independent pharmacy | DECEMBER 2023

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RETAIL

“FOR REFILLS, PRESS 1” Accelerate your pharmacy’s personal touch with an IVR System

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our pharmacy’s daily operations depend on a menagerie of tools that help make your workflow more efficient.

For instance, your pharmacy management software (PMS) is integrated with automation tools that help tremendously with your daily workflow efficiency. One such tool is an interactive voice response (IVR) system.

• Calls automatically triaged: After you’ve set your general message, set your system up to instruct patients to select a button that matches the reason for their call. From there, the IVR will either give them the requested information or they’ll be directed to an appropriate staff member for more help.

In the beginning, IVR was a way to automate prescription refills by organizing patient voicemails. Today, however, it’s a customer-service phone system that is computer operated and manages incoming calls. It also routes incoming calls through a pre-set service menu that enables patients to obtain the information they’re looking for without having to speak to a staff member. Your pharmacy can automate answers to common questions, such as refill requests and store hours.

• Reduced interruptions: Shifting your focus from patient care to phone calls is distracting and can lead to errors. An IVR system will help you and your staff stay focused and more productive.

IVR systems are designed with community pharmacies in mind. The benefits they offer will help you compete more effectively with larger pharmacy chains. Here’s how:

• Pharmacy mobile app: With some IVR companies, you’ll get a custom mobile app created just for your pharmacy.

Your patients will be able to download it from an app store, and they can request refills, set medication reminders, and more.

• Customized messages: Record a customized message that will play whenever someone calls your pharmacy. You’re in charge of what your message says, and you can change it whenever you need to.

You can make your message simple with a welcome greeting, or you can advertise your services or seasonal promotions.

• Outbound patient messaging: Send out a message through IVR to inform patients through text that their prescription is ready.

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• Fewer errors: An IVR system integrates directly with your PMS for a simplified workflow that directs patient needs.

As a result, pharmacy staff can focus on providing quality care.

• Extended access: An automated phone system allows you to accept calls at any hour. Plus, patients can obtain general pharmacy information or request a refill at their convenience. Your staff will be alerted to all requests that pop in overnight.

• Outbound calls: With an IVR system, your pharmacy can also place automated ready-for-pickup alerts and appointment reminder calls.

• The good: With bundled services, you usually get a discount with the IVR service.

• The bad: IVR and VoIP are tied together. So, if the IVR service is having an issue, the phone service will most likely be affected as well.

Now that you know all the great perks IVR offers, you may wonder how easy it is to use. The following tips can help you make your IVR system as user-friendly as possible and improve your patients’ experience.

KEEP IT SHORT AND SWEET When your IVR system answers the phone, be sure your messaging is straight to the point. Skip the introduction and information about your pharmacy. Patients don’t want to sit through that when they’re calling to refill their medication.

Start with, “Thank you for calling our pharmacy,” and transition immediately to the menu. If you need to put patients on hold, include that extra information as a part of your hold message.

DITCH THE ROBOT VOICE Steer clear of using the standard robot voice to read your IVR messaging. That gives off a cold and corporate feel.

Your patients come to your pharmacy because they like its personal feel. So, add warmth to the phone call by having one of your employees record all the messages.

BE CLEAR AND CONCISE Before recording your phone system messages, be sure that the script is easy to understand. Don’t use jargon and technical terms that may confuse your patients. It’s also wise to avoid modern slang.

When recording, enunciate your words clearly and pause between each menu item. That way, patients will have time to process what you said and decide if that’s what they need.

Be aware that people may not retain all the information they need on the first listen. So, offer the option to repeat at the end of all your menu items.

MAKE NAVIGATION EASY-PEASY Don’t confuse your patients with multiple menu options along with extra sub-menu options. The more options you give them, the more likely you’ll confuse them, and they’ll give up.

By creating menu items using the top reasons patients call your pharmacy, you’ll cover the bulk of your calls. The rest can be sent to pharmacy staff.

SEND CONFIRMATION Patients are sometimes wary of IVR phone systems because they don’t trust that a real human is handling their request. You can appease their fear by following up with a confirmation via text message or email. This will reassure them that their request is getting taken care of.

ALLOW PATIENTS TO “CUT IN LINE” For those savvy patients who call the pharmacy regularly, know what they want, and know how to use the IVR system, make it easy for them to “cut in line.” (Make sure your phone system allows this.) If they know they need to press “3” to get to the department they need, they don’t have to listen to the first two menu options.

UPDATE FREQUENTLY Review your messaging every six months to ensure all the information is accurate and up to date. Outdated recordings will frustrate patients.

ELEMENTS | The business magazine for independent pharmacy | DECEMBER 2023

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PAY ATTENTION TO EXTENSION NUMBERS Make your patients’ IVR experience more user-friendly by paying attention to how you are introducing extension numbers.

Always put the department before the number. Instead of saying, “Press one to refill a prescription,” say “To refill a prescription, press one.” Saying the department first signals to patients that they need to pay attention to what comes next. Putting the number first may result in patients having to run through the menu twice to make sure they have the right extension.

IVR and VoIP

Traditional phone systems are nothing new.

They’ve been around for a long time. However, along with IVR, they’re changing fast due to cloud technologies and voice over IP (VoIP).

IVR and VoIP have slowly become a must for

RECORD AN AFTER-HOURS MESSAGE An IVR system can be on 24 hours a day, seven days a week, even if your pharmacy is closed. However, that doesn’t mean every service is available.

Create an “after-hours” message to let patients know that no one is currently on duty, and they will not be able to reach a member of your staff. If you check voicemail messages regularly, recommend they leave a message that includes a callback number. But if you don’t check messages or call patients back daily, it’s best to just have the IVR system recommend they call back during business hours.

Oh, and don’t forget to turn on your after-hours message every evening when you close. That way, patients don’t have to worry about being put on a long, agonizing hold when there’s no one available. Plus, you’ll sleep better at night.

those looking to open a pharmacy today. Only now, many IVR companies are aiming towards a bundled service that includes VoIP phone service with the IVR. In other words, they’re trying to increase their revenue by also acting as your phone company. With a system like this, you’ll get the good with the bad.

The good With bundled services, you usually get a discount with the IVR service.

The bad IVR and VoIP are tied together.

So, if the IVR service is having an issue, the phone service will most likely be affected as well.

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SOLUTIONS

COGNITIVE TESTING IN PHARMACY Computerized screening for better patient results

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ognitive decline is on the rise. The World Health Organization estimates that about 50 million people have dementia worldwide, with Alzheimer’s disease the most common form. In fact, according to the Alzheimer’s Association, an estimated 6.7 million Americans 65 years and older are living with the disease in 2023, with 73 percent of them 75 or older.

Individuals who are at increased risk of dementia include those who are overweight, have diabetes, hypertension, or lead a sedentary lifestyle. While screenings that can show signs of these chronic diseases exist, there currently isn’t a standard of care for being screened or tested for cognitive decline. However, according to Rannon Ching, PharmD and President/Chief Pharmacy Officer of Tarrytown Pharmacy in Austin, Texas, cognitive testing has the potential to reinforce community pharmacy as a driving force for preventative health services.

“The more pharmacists can educate their patients and local providers about the benefits of early detection of cognitive decline will only lead to better patient outcomes and higher quality of life,” Ching said. “I would recommend thinking about what positive impact you can have on your community by offering such a ground-breaking and needed service.”

You can get a head start in testing for early cognitive decline so your patients will be able to take action to modify underlying risk factors. The risk factors include diabetes,

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heart health, hearing or vision loss, obesity, and sleep disorders. The screenings rely on paper-and-pencil tests and measure attention, executive function, and memory.

However, this can be limiting, so a new cognitive assessment device called Cognivue was born.

Cognivue is a computerized, cognitive screening based on FDA-cleared technology. It’s available as two different products: Cognivue Clarity is a 10-minute, self-administered test that can be done in a medical facility. It weighs less than eight pounds, folds up like a laptop, and it evaluates six cognitive domains: abstraction, delayed recall, executive function/ attention, language/naming, memory, and visuospatial ability.

The clinical scoring is: • 75 or greater: normal cognitive function • 51-74: low cognitive impairment • 50 or less: moderate to severe cognitive impairment Cognivue Thrive is a 5-minute, self-administered test and can be done in a pharmacy setting. The device can be folded easily and transported to different areas of an ambulatory care setting or community pharmacy. It evaluates executive function, memory, and visuospatial ability. It also includes a report with scores for three cognitive domains, and a letter that can be shared with the patient’s healthcare provider.

Cognitive screenings will contribute to the “We have had success and a lot of positive feedback with providing cognitive screenings,” Ching said. “The next step of our process is to expand the access of the test by working on finding medical insurance reimbursements for providing the screening and the interpretation. Right now, that looks like partnering with a physician who can bill Medicare and commercial insurances, but in the future, we’d like to see the ability to bill directly as the pharmacy.”

According to the Alzheimer’s Association, adding cognitive screenings to your community pharmacy can provide numerous benefits for you and for your patients.

Benefits for patients: • Receive the most benefit at the earliest point possible from treatment options • More time to plan for the future • Lessened anxieties about unknown problems • Increased chances of participating in clinical drug trials, helping advance research • Opportunity to participate in decisions about care, transportation, living options, financial, or legal matters

services you currently offer in your pharmacy:

Accessibility Your patients can be screened without having to make an appointment at a doctor’s office or a separate testing facility.

Early detection Early assessment is important because dementia can take years to present itself. Cognitive impairment can be an early sign of dementia or other neurological disorders. By offering screenings, you can assess brain health and promote earlier interventions, which can slow down or even reverse the impairment.

Impartial results Tests like Cognivue Thrive eliminate healthcare provider bias and offer reliable and consistent results.

Proactive patients When you engage patients in the testing process, you can educate them on controllable risk factors that affect cognitive function. When your patients are engaged in their health care, they’re more likely to stick to their treatment plans.

• Time to develop a relationship with doctors and care partners • Benefit from care and support services, making it easier for them and their family to manage the disease As the demand for cognitive screenings continues to rise, implementing Cognivue in your independent pharmacy will enable you to differentiate your business and attract new customers.

With this service in your pharmacy, you will also strengthen referrals with local physicians by making it available to their patients while also complementing in-store sales of supplements for brain health.

Doctor referrals Your patient’s cognitive screening report is routinely provided to the patient’s primary care physician. This may lead to more doctor referrals.

Profits With cognitive screenings at the point of care, you will be provided a new, non-dispensing revenue stream. Plus, with a baseline report, you’ll be able to schedule follow-up screenings and recommend protocols that may include treatment.

Improved workflow Once you offer more clinical services in your pharmacy, you’ll attract more patients. With more patients, you’ll bring in more revenue and reduce the burden on primary care physicians. You’ll also free up resources for other healthcare services.

ELEMENTS | The business magazine for independent pharmacy | DECEMBER 2023

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FEATURE

CASH PHARMACIES How they help customers save on prescriptions

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rescription drug costs have been rising for more than a decade. At the same time, your pharmacy profit margins have dwindled. This has strained both patients’ wallets and your bottom line. And as prices continue going up, more cash pharmacies are opening around the country offering generic medications outside of insurance. What’s more, they’re saving some customers hundreds of dollars on their prescriptions.

Today, nine out of 10 prescriptions filled are generic medications. And while it’s been quite puzzling for patients, generics are paving a trail with increasing frequency.

• According to KFF, only 5% of prescriptions in 2019 were purchased at a pharmacy’s “cash” (non-insurance) price.

• A study by Prescryptive Health in 2022 reported that 61% of consumers surveyed had paid cash prices for prescriptions even though the drugs were covered by their health insurance.

• In that same 2022 study, 50% of those surveyed living in urban markets said that paying out of pocket is less expensive than using insurance.

Cash pharmacies can be a life saver for people who lack prescription coverage. They provide critical access to affordable medication.

Other barriers keeping patients from attaining their medication include distance from the pharmacy and a lack of transportation. However, a cash pharmacy offering direct-todoor delivery could be their saving grace.

Mitchell’s Drug Store in Neosho, Missouri is exactly that. Not only does it offer free delivery to their patients’ doors, but it has also added a cash pharmacy.

“We’ve been in business for over 20 years, and we’ve come to realize that there aren’t a lot of options for people who

do not have prescription insurance,” said Tanner Mitchell, PharmD, Mitchell’s Drug Store. “We also started to realize that the insurance model is broken, and a lot of people are being overcharged for their medications and don’t even realize it. That’s when we came up with the idea to start a generic pharmacy. We wanted to better serve this population and improve access to care.”

Mitchell admitted that it wasn’t easy to do. In fact, it took a lot of thinking about how to do it correctly. “We wanted to prove a model of a cost-plus pharmacy on its own. This meant coming up with a different entity. So, we created Mitchell’s Cost Plus Pharmacy.”

In creating Cost Plus, the Mitchell family decided to keep everything separate and created new wholesaler accounts with PBA Health that allowed them to purchase medications at a good price. With that, they were able to accept new patient accounts and stock the generic medications in another area of their store. Their biggest struggle, Mitchell said, was educating the public on Cost Plus, who it may be best for, and how it can save them money.

“There are a lot of other pharmacies in this town, but we don’t have other pharmacies with this model,” Mitchell said.

“We started by looking at the demographics of our area to see if it was right for us. Just because it’s right for us, though, doesn’t mean it may be right for other people. However, we did see that we have a higher percentage of the uninsured population in our area. So, we’ve been trying to find ways to help those people as well.”

Prescription insurance is expensive, especially if patients aren’t using it. Then they’re paying a premium for something they’re not using. At Mitchell’s Cost Plus Pharmacy, there is a one-time fee for one-year access, and patients have coverage throughout the year if they become sick, have prescriptions called in, or need any other maintenance medications. They also receive 10 percent off any over-the-counter products, so it’s a low-risk, high-reward concept.

“We’ve seen a lot of people have a much simpler pharmacy experience when they transfer to Mitchell’s Cost Plus Pharmacy,” Mitchell said. “Word has started to spread throughout the town of new ways of doing pharmacy and new ways of receiving care.”

ELEMENTS | The business magazine for independent pharmacy | DECEMBER 2023

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How a Cash Pharmacy Can Benefit YOU

Financial Independence

Innovation Opportunities

By operating on a cash basis, you reduce dependence on insurance reimbursements, providing more financial stability and control.

If your pharmacy is operating on a cash basis, it may have more flexibility to explore innovative services or integrate technology solutions that enhance the overall customer experience.

Streamlined Processes Receiving cash transactions simplifies your billing and paperwork processes. This allows you time to focus more on patient care and less on administrative tasks.

Faster Service When you don’t have the need to navigate insurance-related procedures, cash transactions can speed up the dispensing process. This leads to faster service for patients.

Transparent Pricing Cash transactions typically involve transparent pricing, helping patients understand the cost of medications without the complexities of insurance coverage.

Larger Profit Margins With a direct cash model, you could retain a larger portion of the revenue generated, which could potentially lead to increased profit margins compared to relying on insurance reimbursements.

Flexible Pricing You can set your own pricing for medications and services, which could attract a broader customer base with competitive rates.

Customer Relationships Having a cash-based model may encourage stronger pharmacist-patient relationships. This is because it allows for more personalized interactions and discussions about medications without the constraints of insurance protocols.

Less Administrative Burden Dealing with insurance claims and paperwork can be time consuming. Cash pharmacies may experience less administrative burden, allowing pharmacists to spend more time caring for patients.

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Adaptability With a cash-based pharmacy, you can adapt more readily to changes in the healthcare world, regulatory environment, or shifts in market dynamics without being overly constrained by insurance-related considerations.

The advantages of cash pharmacy may sound great, however, don’t immediately dive in. You need to carefully evaluate the needs of your community and consider the potential challenges associated with transitioning to a cash-based model.

MITIGATING DIR FEES Direct and Indirect Remuneration (DIR) fees have been one of independent pharmacies’ biggest concerns for years.

With Pharmacy Benefit Managers (PBMs) under pressure from regulators and with policymakers on their backs, these insurers are in overdrive trying to make people believe they don’t need supervision or reforms, while carrying on with tactics that make it hard for patients to access care and independent pharmacies to keep their doors open.

Tim Mitchell, RPh and owner of Mitchell’s Drug Store, stresses the enormity of the DIR hangover (the higher up-front DIR fees coupled with lower patient copays leading to cash-flow issues and financial difficulties). “It’s a serious issue and people need to take it seriously and be ready for it. We need to invest in

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forward thinking and doing things differently. For us, Cost Plus was one of those things,” said Mitchell. “But we’re also looking at opening a clinic, doing point-of-care testing, and other innovations that will create more revenue streams for us.”

Mitchell’s stores have worked on mitigating their DIR fees by moving them to patients who qualify for long-term care at home. The long-term care at home doesn’t get charged DIR fees because the patients have more complicated situations.

“The dollar investment here is low compared to your normal pharmacy. The clinic is going to have fairly low overhead as well. It’s not a high-margin return on investment. But it is a return. What we’re doing right now in traditional pharmacy

STRATEGIES TO LOWER DIR FEES Mitigating DIR fees in your pharmacy can be a challenge.

Here are some strategies you might consider:

• Documentation and Transparency Maintain accurate and detailed records of transactions, prescriptions, and patient interactions.

Clarity in your pharmacy’s operations can help dispute unjustified DIR fees.

• Adherence Programs Starting medication adherence programs can improve patient compliance. Demonstrating efforts to enhance patient outcomes may lead to better negotiations with PBMs. • Technology Use Utilize technology to enhance efficiency in prescription processing and documentation. Automated systems can help streamline operations and reduce errors, which can potentially affect DIR fees.

• Evaluate Networks Regularly assess your pharmacy’s participation in PBM networks. Analyze the impact of network contracts and explore alternative network options if possible.

is typically negative margin. So, we’ve got to be able to change that process,” Mitchell said. “You can’t get rid of everything, but you can mitigate it. By mitigating, it might enable you to have some cash in the bank when the double DIR happens.”

According to a survey by the National Community Pharmacists Association (NCPA): • 98% of respondents are concerned about the upcoming DIR hangover and the effect it will have on their pharmacy.

• 70% of independent pharmacy owners are concerned about upcoming cash flow challenges resulting from changes to federal policy effective January 1, 2024.

• Follow Legislative Advocacy Stay up to date on legislative efforts that are aimed at addressing DIR fee issues. Engage in industry advocacy to influence policies that impact independent pharmacies.

• Educate and Train Keep your staff informed about legislative efforts that are aimed at addressing issues with DIR fees. With proper training, you can help ensure compliance and minimize activities that could contribute to higher DIR fees.

• Explore Specialty Pharmacy Opportunities Incorporate specialty pharmacy offerings to diversify your services. This can open up new revenue streams and potentially reduce the impact of DIR fees.

While these strategies may not eliminate DIR fees entirely, they could help mitigate their impact. For personalized advice on your specific circumstances, consult with industry experts or legal professionals.

• 85% of respondents are taking steps now to prepare for DIR hangover. 64% are setting aside cash.

• 42% are looking into loan opportunities to help get through the hangover period.

As an independent pharmacist, you are an inventor of your craft. Be sure to stay informed on the latest news and developments with DIR changes. Have a solid financial plan in place, and look for ways to offset fees and set up additional revenue streams. Preparing now will help you and your pharmacy thrive in 2024.

ELEMENTS | The business magazine for independent pharmacy | DECEMBER 2023

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OPENING A CASH-ONLY CLINIC Mitchell’s Drug Store is set to open a cash-only clinic from the ground up to help people by driving down drug costs.

The clinic will have a registered nurse who will be able to care for patients with regular chronic and acute conditions.

“It’s the same concept as what we’re doing with Cost Plus Pharmacy, but it complements it because the idea is you’re taking out any of the middlemen that could drive up fees,” said Lacy Epperson, PharmD, Mitchell’s Drug Store. “I call it the insurance you can’t live with or live without.”

Starting the cash-only clinic as a virtual-only option is the best way to introduce it to the community, Epperson said.

“For one, we have to think about our location and who we’re going to service. Then, we need to think about the associated risk with opening a clinic. We don’t want to staff a nurse just to sit there without patients. So, while we grow that population and grow our memberships, then we can look into transitioning to a more in-person clinic. So, it’s a low-risk option for us,” she said. “The most unique thing about what we’re doing is that we have a perfect setup for a healthcare hub to take care of our patients.”

and it’s a new, computerized cognitive assessment device that’s based on FDA-cleared technology.

“We get a lot of questions about brain health and supplements surrounding brain health, so we decided to include cognitive testing with the rest of our services as part of the healthcare hub,” she said. “With the test, we can define where the patient is, and it helps support our recommendation as well as potentially finding an early intervention for cognitive issues.”

The test is not a diagnostic tool, per se, but it is an advanced point-of-care test. The patient gets results and can take it back to their physician’s office.

“Right now, we’ve been focusing on cash-only services. We’re finding it to be way more convenient for the patient as well,” said Epperson. “For us, the cash model has been working.

Maybe it’s not a sustainable idea, but for right now it is, and that’s the easiest way for us to implement something quickly.

We don’t have to put a lot of effort into training staff on medical billing or things like that. It doesn’t take any extra steps, so it’s been very exciting.”

In addition to a cash-only clinic, Epperson said they’re also adding cognitive testing to their services. It’s called Cognivue,

ELEMENTS | The business magazine for independent pharmacy | DECEMBER 2023

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SPOTLIGHT

GOING SKIN DEEP Complement your front end with skin care

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ave you ever thought about making skin care a niche in your pharmacy?

Believe it or not, skin care doesn’t always revolve around beauty.

Having a skincare section in your front end can complement your care services while acting as a source for preventative healthcare tools. In fact, if you make it your store’s specialty, your pharmacy could become a destination for skincare help.

LINK YOUR PHARMACY’S SERVICES TO SKINCARE PRODUCT RECOMMENDATIONS When you stock the right skincare products in your pharmacy, it’ll be easy to guide your patients to what type is best for their personal skin needs. Here’s how: DIABETES COUNSELING Your diabetic patients need skincare solutions. As the disease shrinks their peripheral glands, they have difficulty sweating properly. This leads to dry and cracked skin that can get infected. Educate these patients about examining their skin daily for wounds, and recommend a daily moisturizer from your skincare section to help combat dry skin as a part of their daily regimen.

WELLNESS PROGRAMS During dietary or exercise counseling sessions, include some information about the importance of selecting the right sunscreen. For patients who are avid runners, recommend a long-lasting, sweat-proof sunscreen that won’t have to be reapplied halfway through their run. Or feature waterproof sunscreen for patients who swim for exercise.

Make sure you stock and recommend spray or roll-on sunscreen for patients with children. The easier application methods will help make protecting their skin less of a struggle.

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FLU SHOT IMMUNIZATIONS For patients who want to stay healthy during cold and flu season, stock hand sanitizers and cleansers in your skincare section to give them added protection.

Also recommend these products to patients who just got their flu shot, who are at high risk for the flu, or are especially concerned about getting sick due to their exposure to germs at their workplace.

Moisturizers are also important to stock in your skincare section. Remind patients that while washing their hands will help them stay healthy during cold and flu season, it can also dry out their skin. Recommend a good moisturizer or lotion to keep skin hydrated and supple during the winter months.

SMOKING CESSATION For those who have quit smoking with your pharmacy’s smoking cessation program, help them combat some of the damage that smoking has done to their skin. Recommend age-defying and restorative creams in your skincare aisle.

POST-OPERATIVE PRESCRIPTIONS When patients come in to fill painkillers or other post-operative prescriptions, consult with them and their doctor about postoperative wound or scar care. Help them find the right product to transition from the dressings to the bandages and advise them on how to prevent infections and minimize scarring.

Guiding your patient to the right product for their wound will provide additional sales for your pharmacy. Plus, it will help them heal their skin when it’s most vulnerable.

PREGNANCY CONSULTATIONS If your pharmacy provides services for new parents or medication consultations for pregnant mothers, don’t forget to include baby products in your skincare section as well.

Boost your sales by recommending products that will protect, cleanse, and care for the skin of newborns, toddlers, and children.

For moms, you can offer creams that can help prevent or reduce stretch marks or skin butters that help irritated skin from breastfeeding. All of this can enhance the value of your pharmacy for new moms.

definition. Products that are considered natural often depend on the positioning of the product and the perception of the shopper. If a product aligns with a person’s alternative diet or lifestyle, they may consider it natural.

For most shoppers, it basically comes down to the ingredient list. Natural products are typically determined by what they’re free from. In other words, what they don’t contain versus what they do. Natural products are typically free from certain ingredients, such as artificial colors and preservatives, and often void of one or more of the top allergens.

NO NOS FOR NATURAL PRODUCTS Ingredients that natural shoppers want to avoid:

• Artificial fragrance • Fragrance • Parabens • PEG • Phthalates • Sulfates

PROVIDING NATURAL SKINCARE PRODUCTS How many natural skincare products are stocked in your front end?

Be aware that natural is not only today’s new normal; it’s also a great niche to bring to the front end of your store.

People pay attention to what’s in products. Consumers worry about chemicals in their personal care products, which is why your pharmacy should take advantage of the opportunity to offer natural products and make a profit.

However, before you start adding products to your front-end shelves, know the difference between natural and organic.

Organic: The United States Department of Agriculture (USDA) regulates what can be labeled organic and provides seals for approved products. The “USDA organic” or “100 percent organic” seal means the contents are at least 95 percent organic. Organic products must be produced using natural processes and materials and using practices that promote ecological balance and biological diversity.

Products that say, “made with organic ingredients,” can have up to 30 percent of non-organic ingredients.

Natural: The term “natural” is much less clear and isn’t regulated. Therefore, it doesn’t come with an official

WHERE TO SOURCE NATURAL AND ORGANIC PRODUCTS While many traditional drug distributors carry natural products, they may have a limited selection compared to wholesalers that specialize in natural and organic products.

As you decide where to source your products, approach it like you would any other product.

To capitalize on your independent advantage, source locally first. You may find natural or organic manufacturers in your own city, town, state, or region.

As an independent pharmacy, you can develop great ties with a lot of the natural brands that are also independent.

HOW TO SELL NATURAL PRODUCTS Fully stocked and ready to go? Now make the investment pay off.

You’ll first need to train your staff on how to talk to patients about the products, how to answer questions, and how to direct them to the right place.

Promote your natural products by providing product demonstrations. Hang signage up around your pharmacy.

Give away samples and coupons to patients picking up their prescriptions. People love freebies!

ELEMENTS | The business magazine for independent pharmacy | DECEMBER 2023

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MONEY

HELPING PATIENTS SAVE How to get the best deal on their medication

T

he prices of prescription drugs have skyrocketed over the years, leaving many of your patients in a pickle wondering how they’ll afford their prescription medications.

Especially those patients who need them the most.

KFF polling from July 2023 found that more than one in four adults taking prescription drugs report difficulty affording their medication, including 40% of those with household incomes of less than $40,000 per year. Additionally, 88% of Americans favored limiting how much drug companies can increase the price for prescription drugs each year to no more than the rate of inflation.

The number of older adults who say they can’t afford their prescription medications has grown, according to a study published in JAMA Network Open. Approximately one in five adults aged 65 and up skipped, delayed, took less medication than prescribed, or took someone else’s medication last year due to the cost.

Show your patients how to navigate the prices of their prescription drugs. By saving them money, they’re less likely to have to choose between their medications and other necessities. As a result, their medication adherence can increase when medications are affordable. In turn, this leads to better health outcomes and may also help reduce patients’ stress levels.

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Don’t worry. You don’t have to lose money to help patients save money. In fact, by helping patients save money, you’re helping your pharmacy business. Here’s how: •

Increasing customer loyalty A variety of factors influence purchasing decisions. However, price is still the most important factor for consumers.

Helping your patients get the lowest price on their prescriptions will keep them coming back.

• Building patients’ trust Your patients notice when you go out of your way or sacrifice profit for them. The personal attention you give them sets you apart from national chain and big-box stores. In fact, going out of your way to make their lives easier shows patients you prioritize their well-being.

• Boosting prescription count When you make medications more affordable, the likelihood of patients picking up their prescriptions increases. Plus, you won’t have to waste time and effort to return the abandoned prescriptions to stock and avoid the headaches of inventory control.

• Helping your patients save money on medication According to the Office of the Assistant Secretary for Planning and Evaluation, during the 12-month period from July 2021 to July 2022, 1,216 products increased in price and exceeded the inflation rate of 8.5% for that time period. The average price increase for these drugs was 31.6%. In 2022, there were drugs that increased by more than $20,000 or 500%.

The good news is that in October 2022, the Inflation Reduction Act introduced a new requirement for manufacturers to pay rebates to Medicare for Part D drugs whose price increases exceeded inflation. This was designed to reduce the frequency and size of drug price increases.

As an independent pharmacist, you’re in a perfect position to save your patients money. You’re already in tune with their needs, and perfectly positioned to bridge the gap between healthcare consumers and the complicated world of pharmaceuticals. Here are some ways you can help your patients save: SWITCHING TO GENERICS Your best bet for reducing patient spending on pricey medication is to swap a brand name for a generic. Let your patients know when generic options are available and be sure to keep an appropriate stock of them. If you run out of generic and only have a higher-priced, brandname medication to offer, most patients will opt to fill their prescription somewhere else. That means they may not come back to your pharmacy with their next prescription.

HELPING THEM FIND MANUFACTURER DISCOUNTS Most patients don’t know that drug manufacturers provide discounts on certain drugs. This is why it’s important that you inform your patients about manufacturer discounts and rebates, especially for medications that don’t have a generic.

Visiting the manufacturer websites is also vital. That’s where you’ll find discounts and assistance forms. You can make the process easy for your patients simply by finding and applying the discount or printing the rebate for them.

They’ll appreciate both your effort and the additional savings.

DIRECTING THEM TO ASSISTANCE PROGRAMS Look into federal or state assistance programs that might help low-income or disabled people cover costs. For example, the Patient Access Network Foundation (PAN) helps insured people at specific income levels who can’t afford their prescriptions. Your patients can apply online for a PAN monetary grant.

Your patients can also investigate other resources, such as Rx Assist; Partnership for Prescription Assistance; Together Rx Access; and NeedyMeds. Run by nonprofits, all their services are free. You may need to assist some patients with filling out the paperwork. However, this will only highlight your excellent customer service.

Manufacturer assistance programs, like Shire Cares or Astra Zeneca’s AZ&Me, can also help patients who qualify fill their prescriptions at no out-of-pocket cost.

However, these programs are typically

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restricted to certain drugs. Plus, eligibility is tied to income and household size. These programs can be either in place of or in addition to the promotional discount programs that are open to everyone.

Online discount programs also exist, such as Blink Health, Arrive Health, and Zipdrug, to name a few. These programs make it simpler for patients to secure discounts for a wide variety of generics.

INFORMING THEM OF PAYMENT PLANS Pretty much every adult knows what a payment plan is. They’re commonly used in health care when a patient struggles to pay.

But not everyone knows this solution exists in pharmacy.

Some of your patients might assume prescription costs are all or nothing. That’s not good news for time-sensitive treatments needed on Monday when payday isn’t until Friday. That’s where a payment plan comes into play.

A payment plan provides a way for patients to take their medication on time. It also gives your pharmacy a chance to make money that would otherwise be left on the table if you let your patient walk out without their prescription.

The one downfall of a payment plan is it poses a risk to your business.

To avoid this happening, consider some of these important tips:

• Get everything in writing.

• Make it clear how much the patient will pay, how often, and how soon the full amount must be paid.

• Set up automatic debits from your patient’s bank account to save them the trouble of making additional trips to the pharmacy and ensure payments are made on time.

If patients are unable to meet their payments, there is a chance you could lose money. So, be sure the potential loss is an amount your pharmacy can withstand. When in doubt, talk with a financial professional and ask how much risk is appropriate for your pharmacy.

EDUCATING THEM For many patients, your independent pharmacy is the most accessible link to the world of medical insurance. They don’t realize they can find a more affordable drug plan. So, offer to help them navigate health insurance plans, including Medicare Part D. Tools like iMedicare and the CMS Plan Finder can help you compare plans quickly.

Some patients with a Health Savings Account (HSA) may also be confused about how to use their account to save money. They may also have questions about which products are HSA eligible.

With your knowledge of HSAs, you’re able to help educate patients on how to maximize savings through the HSA benefits.

So, be sure to have some educational brochures on hand to give to your patients who need help understanding how HSAs work.

ACCEPTING CASH PAYMENTS If paying out of pocket will cost less than using insurance, let patients know. This is a win for you and your patients since cash goes straight into your account and bypasses thirdparty reimbursements.

PERFORMING MEDICATION REVIEWS A medication review provides an opportunity for you to eliminate unnecessary medications, combine medications, or lower dosage, all of which will save your patient money.

What’s more, when a patient receives multiple medications from several different prescribers, the odds are greater that at least one of those medications isn’t appropriate. For older patients and those with multiple comorbid conditions, this can lead to polypharmacy.

Highlight how discontinuing an unnecessary medication can help your patient reduce their overall prescription drug costs. Obtain an accurate medication and medical history and identify all the medications your patient is taking. Link each prescribed medication to a disease state and speak with your patient’s prescriber to discontinue medications that you feel are inappropriate.

ENCOURAGING 90-DAY PRESCRIPTIONS Patients who suffer chronic conditions that need long-term use of a medication might be able to save money by filling a 90-day prescription instead of the standard 30-day. Patients who fill a 90-day prescription will only have one copay rather than three copays for the same amount of medication. Plus, they’ll only have to make one trip to the pharmacy every three months.

ELEMENTS | The business magazine for independent pharmacy | DECEMBER 2023

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OUTLOOK

NATIONWIDE CHAIN CLOSINGS

O

Your opportunity to care for stranded patients

While anyone can be affected by pharmacy deserts, some are impacted more than others. Research has found that pharmacies with the greatest risk of closing are those with larger customer bases on public insurance, which doesn’t reimburse pharmacies as much as private health plans. Instead, it tends to have a significant impact on the communities that are underserved, underrepresented, and rural.

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nce upon a time, drugstore chains could be found all over U.S. cities, suburbs, and small towns. When patients needed their medications, they had no trouble getting them.

Fast-forward to today and the nation’s largest drugstore chains are reorienting their operations due to growing rivalry, a multitude of opioid lawsuits, and the need for more staff and resources. They’ve already begun vanishing from many communities that are already vulnerable to becoming pharmacy deserts.

Meanwhile, as chain pharmacies continue to close their doors one by one, community pharmacies like yours remain hopeful and ready to step up and take on more patients.

And while challenges like low reimbursements and other contracting issues may present a problem, this can truly be a golden opportunity.

“I do think this a tremendous opportunity for independent community pharmacies to serve this patient population that’s going to be left out in the cold,” Dave Wendland, Vice President, Strategic Relations at HRG (Hamacher Resource Group), said. “The opportunity is to serve a community. It’s not for the faint of heart, however, because prescription business alone is a very commoditized business.

Independent pharmacies can step up, not just to stake claim to the prescription business, but to truly serve the full health needs of that patient population.”

Access to a pharmacy directly affects how closely people stick to medication regimens set by their doctors. Seniors who struggle with difficult health problems are more likely to become dependent on their pharmacist. But without a pharmacy nearby to count on, many may fall away from adhering to their medications, which is dangerous to their health.

In a National Community Pharmacists Association survey that was conducted from September 18 to September 26, 2023, 43% of participants reported that they live near a major pharmacy chain store that’s closing its doors. Nearly 90% of participants said they can absorb and provide care for patients who were going to that store. More than 60% of them are actively working to draw in patients by increasing their advertising budgets and targeting their marketing efforts.

Don’t wait until your competition has locked their doors or their staff has engaged in a walkout before you step up. You have a lot to offer with your wide range of services.

Not only do you fill prescriptions, but you offer much more, such as immunizations, counseling, and medication therapy management (MTM).

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“Speak up. Put yourself out there,” Wendland said. “Message your neighborhood. Start today. Don’t start when you see Walgreens or CVS pharmacists marching down the street.

Begin today and let everyone know how long you’ve been in the business and that you’re not going anywhere.”

Wendland recommends reinforcing what’s different about an independent pharmacy. For example, transferring a prescription or starting with a chain pharmacy sometimes requires a lot of hoops to jump through. It can be a waiting game and it can include frustrating phone tag before a prescription can be picked up. Unlike chain environments, independents typically streamline this process.

“An independent pharmacy should say, ‘If you want to transfer your prescriptions to us, here are the steps you need to go through, and we’re here to serve you,’” Wendland said.

The people who walk through your doorway have one opportunity to form an impression, so make it simple. Start by sprucing up the store. Make sure it’s shoppable and presentable.

“It needs to look like the store is ready to serve those patients and customers walking in, so make it inviting. Send invitations to your community that say, ‘I’d like to invite you into my store. I’m your neighbor!’” Wendland said. “Ask yourself why a patient would want to come to your store.

Maybe it’s because you have unique service offerings or special programs available that are exclusive.”

Changes in the healthcare system are crucial right now. Not just for the struggling pharmacies, but for patients who are simply trying to receive quality care. While community pharmacies like yours may feel ready and willing to step in and take on new patients, patient access to your pharmacy is in trouble without improvement to Pharmacy Benefit Managers (PBMs) and the pharmacy payment model.

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