In this episode we finish our conversation with Rebecca Grandy, Director of Pharmacy at CHESS, and learn how pharmacists can overcome barriers to issues in patient care through tools such as prior authorizations. We also talk about how CMS doesn’t consider pharmacists care providers and how resolving that will lead to greater efficiency and better outcomes.

So Rebecca Grandy, welcome back to the Move to Value podcast. Glad you could stick around and continue this conversation about pharmacy services with us.

Thank you.

Rebecca, last time we were talking about all kinds of great things and how a pharmacist is such an integral part of the care team and we talked about collaboration with clinical providers and other healthcare professionals. One of the things I wanted to talk about is prior authorization because that's prior authorization for medication is crucial in value-based care. Can you explain to us a little bit about the process and any, I don't know, administrative burdens that might be there and how do we address these to make sure that our patients are getting timely care?

Sure. You know, I think if you were to ask some of our physician or provider colleagues, they would probably say prior authorization is a four-letter word, right? However, I do believe that as we think about value based care and we think about cost effectiveness, we have to have some sort of process or I'm blanking out here Thomas, we have to have, we have to have some sort of process or way to guarantee that the medicines we're using are going to be cost effective. So, when you think about prior authorization, that's really the intent, right? Usually they're for expensive medicines or they're for medicines that can potentially have lots of side effects or that have very specific clinical niches, if you will. And so I do think they're necessary. However, more and more medicines are needing prior authorizations now, and that's really created an administrative burden for our providers and provider offices That has gotten to the point actually where Congress is sort of intervening at this point. And there's lots of legislation over the next few years, you should see that process get better. So for example, if I'm a physician and I want my patient to have a very specific diabetes medicine, so there's some diabetes medicines that need prior authorizations, I send the prescription. And for most of our providers, they're not even going to know it needs a prior authorization until the pharmacy sends either a fax or an electronic prior authorization back to that office. So I may not even know. So my patient has already left the office. I tried to send in their prescription. Now I get kicked back from the pharmacy saying, OK, this needs a prior authorization. So you can already see in this example, you sort of set yourself up for some dissatisfied patients and some for dissatisfied providers. And so once I get that prior authorization paperwork, someone has to complete it. And in my experience, I've actually had experience doing prior authorizations. If you don't dot every I and cross every T, you're not going to get it approved and you're going to get a denial. You may not know about it, you know, for several days or even several weeks, depending on the insurance and depending on the priority. And so now you have a patient that's sort of left in the dark because they don't know why they can't get their medicine from the pharmacy. The pharmacy's saying why I sent the paperwork to your provider. They need a prior authorization. The physician offices has no idea where it is in the insurance queue. And so you take that and you compound it with the fact that every insurance has a slightly different process, every medicine is a slightly different process. You have to log into external portals which are not part of the day-to-day workflow. And so the administrative burden, again, it's just a nightmare. However, I again, I do think that prior authorizations or something similar are necessary to make sure we're being good stewards of our healthcare dollars.

Interesting that does, you know, when you, when you talked about patient dissatisfaction that really resonated with the core tenets of value based care, right? And, and provider satisfaction as we talk about the quadruple or even the quintuple aim. So I do think that that is certainly something that could be alleviated and that probably we should do a better job and work on that a little. So how do pharmacists support chronic disease management and what impact does this support have on overall healthcare costs and patient health? And are there, this is a multi-part question and and what specific interventions can you as a pharmacist provide to improve outcomes in those programs? And I'll be glad to feed that question to you one bit at a time if it will make it easier.

Thanks. Yeah. I mean, when you think about chronic conditions, almost all chronic conditions have some sort of medication therapy. And the role of pharmacist is to really help figure out what medication therapy is best for that patient, right? So again, can they access it? Are they going to be adherent to it? And we've talked about the nuances to adherence in our last podcast. And then, you know, are there ways to optimize it? So, when you think about medication and administration, interactions with other medicines, interactions with other disease states, I mean, you can get really complicated. And so, you know, part of CHESS and our pharmacy team's motto is, you know, making the best use of medications for every patient. So how is it that we make sure that medication is best for the patient? And so chronic diseases, you know, are going to come with chronic medications. And so I think pharmacy and pharmacy technicians can play a role in helping get those medicines and making sure they're best for the patient. And then, you know, there have been studies like if you have, if you're able to get access to medicines that are guideline directed, have evidence to support them, patients take them, then you're going to decrease your healthcare costs because you're going to have less emergency room visits, less inpatient admissions. Hopefully you're preventing things too, right? Like also preventative medicines. So, preventing progression of those chronic conditions, preventing heart attacks, preventing strokes, you know, and when I think about, you know, diabetes, that's a common chronic condition that we work with. You're also, again, preventing sort of those cardiovascular outcomes, but you're also protecting people's kidneys and preventing progression to end stage renal disease and dialysis. You're preventing, you know, retinopathy and blindness. Like there's lots of things that we can do if we're able to help optimize those medicines that we can just keep people healthy for longer and help them, you know, just live a good full life.

Wow, I didn't realize that that was so intricate. Then what are some of the biggest challenges that your team faces in implementing value based care practices?

You know, when I think about pharmacy, pharmacy as a profession, and so this would go for all my pharmacy colleagues, regardless of practice site. When I say practice site, you know, that could mean the local retail pharmacy, whether it's an independent or a chain, that could mean hospital, you know, you name it. The biggest challenge for pharmacy has been there's been so much progression in what pharmacists can do, what they know, how they can contribute, but there has not been the same advancement in our recognition of being providers specifically by CMS. So Medicare does not recommend, does not recognize pharmacist as providers. If you're not recognized as a provider, you cannot get reimbursement. So when you think about sort of our fee for service world, you know, that we're straddling in the moment, it's really hard for pharmacists to be part of the healthcare team because you're not recognized as a provider as you can't get reimbursement. You know, that's not true for our physical therapist colleagues, for our nutrition colleagues, for, you know, really everyone else, that's not true, but it is true for pharmacists. And so, there is a challenge there just in the finance, the finances of having, you know, pharmacy, pharmacy tech on your team. Luckily, I think, you know, as we're moving to value based care, you know, you can pull, there are lots of papers, lots of evidence and scientific journals that really can demonstrate what a pharmacist can do for healthcare costs and also for patient outcomes. So we know that pharmacists do improve healthcare outcomes for patients. We know that they can decrease cost. And so as we move to value based care, I think it'll get easier for pharmacists to be part of the healthcare team. But now that we're sort of straddling this fee for service world, it is challenging financially to be able to have a pharmacist on, you know, a healthcare team, let's say it, you know, an independent physician practice or for our retail colleagues to do more than dispense. You know, it's hard for them to get reimbursed for their cognitive services beyond the dispensing of a product. But I do think, you know, the evidence is there that pharmacists can improve outcomes and they can decrease cost and they are important members of the healthcare team. And so my goal, you know, especially as we think about, you know, our practices that we support as CHESS or will support in the future, I want all of our providers and offices to have access to a pharmacist. And so that's one of the things that, you know, we're actively working on in our department and at CHESS.

Outstanding. So, Rebecca, looking ahead, what trends do you see in the role of pharmacy within value based care and, and maybe what your vision is of this evolving over the next 5, 10, fifteen years?

Sure. And this is going to be a boring answer, but I think there's so much room for improvement around medication access and medication adherence, right? Like I think those are going to continue to be issues that need to be improved upon in the world of value based care. And how do we do it in a way that supports the patient, supports the provider, provider offices and decreases that administrative burden, right? For example, medication access. I can probably get your patient the medicine for free or relatively free, but the resources that I have to know about and the hoops that I have to jump through make it where most people just throw up their hands and they're just ready to move on, right? So we really need to think through how do we decrease the administrative burden around access and then medication adherence. There's always going to be opportunities for adherence like we talked about in the last episode, because there's just so much psychology and feelings, you know, wrapped around adherence. I do think that value based care access to pharmacy, whether that's a pharmacist or pharmacy technician is going to continue to be a trend. You know, just in my career, I've seen the use of pharmacy technicians and primary care offices sort of takeoff, you know, and you never would have imagined when I was in pharmacy school that our physicians’ offices would have pharmacy technicians, you know, supporting refills, supporting the, again, the Med access, supporting triaging medication questions. I do think they'll continue to be a trend where our pharmacy folks are embedded in the care models. I would love to see pharmacists recognized as providers because I think that can make that trend speed up. And then, you know, again, my job is just to make sure or to help think through at least how, you know, every patient in North Carolina or every patient beyond North Carolina that CHESS supports has access to a pharmacy expert. And so if anyone listening to this podcast is interested in that, how to get pharmacists embedded in your practice, how to have centralized support, I would be happy to have conversations with anyone who's interested in those things.

Outstanding. Is there anything that I haven't asked about that you feel is important to this conversation today?

You know, for those listening that haven't had much interaction with a pharmacist, you know, I think it's worth finding a pharmacist in your life, whether that's the retail pharmacy space, hospital, you can certainly reach out to me. You can do your own research online and just really learning about what it is that we do. Again, I think I've done a pretty good job educating my mother on what I do. It's taken a lot of conversations though, since I'm like, you know, I don't work in a pharmacy. She's like, wait, so what, you're a pharmacist, but you don't work in a pharmacy. I'm like, no, I don't, I don't do anything with actual physical meds. And so, you know, I think just educating yourself about what pharmacists can do sort of beyond the stereotypical roles. And then if that's something I'm assuming if you're listening to this podcast, you're probably in healthcare and you can always reach out to me to find more information about how we can support your patients or your practices, whether that's, you know, CHESS or whether that's a pharmacist that you have local to you.

Rebecca Grandy, thank you for joining us today on the Move to Value podcast.

Thanks, Thomas. It was a pleasure.