I've been quiet for the past few months, and to be frank, there has been quite the amount of changes in society that I (like you most likely) have had to adjust to for the interim. I am now teaching classes remotely, and my clinical work is on hiatus due to PPE shortages, mitigation of patient exposure, and I would say adjusting to a new practice environment as everyone tries to figure out what to do. 

Nonetheless, I have been keeping up on reading what is coming out, and Digital Health has had no shortage of interesting advancements and missteps as they seek to grapple how to navigate this pandemic. I don't blame them, I would imagine funding is tight right now, and businesses have to determine if this pandemic is a blip on current practice, something that can be leveraged, or if a whole pivot may need to occur with the concept that whatever is happening now will dictate future clinical practice in the US. To be frank, I am not sure which is correct, and it's too early for us to tell, but I am sure that some guesses and gambles may pay off well for some of these companies long term compared to others.

But, one industry I'll focus on is what's going in pharmacy, and possible implications that I think need to be watched closely. So with that being the case, the following are some concepts I am wrapping my head around and analysis on what may occur in the next 12-24 months.

Current Business Plans of Large Retail Pharmacy - A Time to Pivot

I have been quite fascinated with the business models of CVS, Walmart, and Walgreens for the past few years. So much consolidation has occurred, and they have either discarded or started new initiatives based on acquisitions. CVS, for instance, I am quite interested to see what they do with their HealthHUB model. After all, it reminds me of some other businesses (e.g., Lululemon) which were trying to bring in customers for more hands-on activities to be bastions of experiences. In the case of CVS, diet, exercise, and chronic disease management seemed to fall in line with their recent Aetna acquisition, which would see them responsible for patients' chronic management and directing them to lifelong patients aside from medication services. But looking at the current focus, we are witnessing hours being cut, the front ends of the stores having difficulty, and pharmacies being encouraged to use drive-thru or mail delivery services. That is definitely putting a hamper on business, and patients have the opposite customer experience I think CVS was aiming for. 

I would say this is across the board. We are seeing issues with the chains, independents, and others. Delivery of medications will be critical, and those that did not have a robust system are likely paying the price for putting those services off. Arguably, the pharmacy startups that have been focusing on medication delivery services (e.g., on-demand, <24hrs, mail service) are probably making a big push to open their markets given that social distancing and general avoidance of public shopping has led patients/customers to now have a preference for these services. I mean, it's nice to have a pharmacist you can talk to, but when fear is a factor, then the phone/teleservice is the next best thing.

And that is the rub. All this push to bring patients back to the pharmacy may have just been set back for years, if ever able to recover. I would say that in the short term, there will be a push to get patients enrolled into quick delivery services with current mail partnerships, but if that works, why wouldn't the patient then adjust and keep registered and moved to a more formal mail-order system? Given that many boards of pharmacies have put holds on regulations and laws that have posed a barrier to medication delivery (e.g., controls), I could see some not returning even after this pandemic. Then, the patient only has to go back for possibly more urgent conditions (e.g., post-ER visits, antibiotics, OTC meds) or drugs that cannot safely be delivered to a certain point, such as refrigerated items. Still, I would say that we could see those services also supplemented by USPS as this gets off the ground and having patients just avoid the pharmacy altogether. It's going to take a lot of marketing to drive consumers back to the pharmacy if delivery can become foolproof and be high-quality service in the next 6 months. That leaves all pharmacy companies with any stake in this to get it right if that is the business model they ultimately want. Does that mean pharmacies start closing? Possibly, but not all, and not overnight. I'd expect a slow closure/sell-off to other chains. Hour cuts, to function during select times to help the quick home delivery services, and a pharmacy more geared towards working with such services. Front end and pharmacy may end up working to encourage deliveries, similar to what CVS has been trying to emulate with Amazon.

But, I do see some other opportunities that could also be leveraged by pharmacies that the delivery startups cannot keep up with at this time.

Getting People Back to Work - Mass Testing, Vaccinations, and Treatment Opportunities

I hope that in the next 12-24 months, we have a viable vaccination for the population to utilize. At that point, it would be likely that we would vaccinate HCPs and their families, individual segments of society, and related to get people back to work. Where will these vaccines occur? I could see pharmacists playing a significant role and doing mass vaccinations. Age limitations may be a barrier, but maybe those may be overturned as well in the interest of public health (it wouldn't be the first time this has occurred). Nonetheless, this relies on the idea that vaccination would have to be administered by an HCP and not something patients can administer themselves (e.g., patch). If that was possible, then the startups have a path forward, and businesses like Amazon could make a considerable push for current acquisitions and likely future partnerships.

After all, a vaccination is still some time away. We also need to figure out who is infected or possibly has antibodies allowing them to go back into the public. So that leaves testing, which I think can range from seeing who is acutely infected to those with antibodies that may resist future infections. Testing will likely be a mixed battleground, where those who are wealthy can probably afford mail-order testing (unless payors get involved to a large extent), or we may see pharmacies as testing beds, similar to what is now being rolled out across the US, and available to the broader population. These tests, I could also see a move beyond the diagnosis of infection towards seeing who may be immune.  This I think will be pushed heavily in the coming months, based on April 8, 2020, HHS announcements:

“Giving pharmacists the authorization to order and administer COVID-19 tests to their patients means easier access to testing for Americans who need it. Pharmacists play a vital role in delivering convenient access to important public health services and information. The Trump Administration is pleased to give pharmacists the chance to play a bigger role in the COVID-19 response, alongside all of America’s heroic healthcare workers.” - HHS Secretary Alex Azar

“In an effort to expand testing capabilities, we are authorizing licensed pharmacists to order and administer COVID-19 tests to their patients.  The accessibility and distribution of retail and independent community-based pharmacies make pharmacists the first point of contact with a healthcare professional for many Americans.  This will further expand testing for Americans, particularly our healthcare workers and first responders who are working around the clock to provide care, compassion and safety to others.” — HHS Assistant Secretary for Health Brett P. Giroir, MD.

Along the same vein could be acute treatment. Now, I am going to stay away from what treatments are worth tackling at this time, but I would agree there will be options likely in the next few months. So who gets them? A combination of on-site testing and then treatment via protocols for pharmacists to dispense seems a high probability to me. This would be an easier task likely, compared to some other startups that would likely have a more serious logistical problem with turnaround times, I suspect. This may build-up goodwill and get some good PR for pharmacy in the short-term, but I am unsure if it would be enough to overcome the issues stated previously for chronic disease management.

Leverage the Pharmacist and Their Clinical Services or Perish

That brings me to my final point. I think pharmacy businesses will face a cross-road that has been coming for years, but this pandemic just sped things up quicker than all stakeholders wanted to consider. Namely, a product-based model with brick-and-mortar will lose more ground to online services. That face-to-face business will have to move beyond the exchange of drugs for cash. And that pharmacists providing services may be that opening. Face it, we are seeing many patients with chronic conditions turning to teleservices, but even those have significant waiting times, and patients may be tied to health systems that aren't enabled to deal with this level of telehealth that is needed. We have been talking for years for pharmacists to be the intermediaries for mid-stake disease management, and this is that opportunity I would say. But, just hoping that patients come into a pharmacy for clinical services won’t be enough as well. Pharmacies will need to leverage online services and be able to compete on the digital landscape like the rest of healthcare is migrating towards.

Pharmacy could embrace digital health and engage in a business to sell services and products that could enable telehealth services with their pharmacists as providers. Based on recent telehealth changes by CMS and others, I think this is something that should be considered by profession. Because I think with a population that gets used to the concept of telehealth and delivery care, there will be little purpose for patients to come back to the pharmacy as they did. There are other factors to consider aside from disease management. New starts on specialty medications, patient education, adherence concerns, and more are likely to be hit at this time since they may not be seeing their providers as much anymore. Pharmacists, again, could serve as the intermediaries for these services to help the population. Ultimately, my argument would be that pharmacists won't be the health professionals in the limelight that are managing acutely sick patients in this pandemic. However, they could help with the vast majority of other patients that still require care and demonstrate our ability for future precedence and acceptance. It will demand some creativity, and I feel some start-ups and companies that can pivot or adapt to this reality (and previously mentioned factors) have much to gain to guide where pharmacy goes in the future. This window, I would argue, is only open for the next 3-6 months and will need much market-shaping to make a difference for the future.

I welcome your thoughts or predictions of what the profession should consider for these unusual times.