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340B Insight provides members and supporters of 340B Health with timely updates and discussions about the 340B drug pricing program. The podcast helps listeners stay current with and learn more about 340B to help them serve their patients and communities and remain compliant. We publish new episodes twice a month, with news reports and in-depth interviews with leading health care practitioners, policy and legal experts, public policymakers, and our expert staff.
Narration [00:00:04]:
Welcome to 340B Insight from 340B Health.
David Glendinning [00:00:12]:
Hello from Washington, D.C. and welcome back to 340B Insight, the premier podcast about the 340B drug pricing program. I'm your host, David Glendinning with 340B Health. Our guest for this episode is Mark Riggle, the Assistant Chief pharmacy officer at UC Davis Health, based in Sacramento, California. Mark spoke at this year's 340B Coalition winter conference about how 340B can support clinical pharmacy services at hospitals, and we caught up with him while he was there to learn more about the subject. But before we get to that interview, let's do a quick recap of some of the Latest news about 340B. A federal judge in Washington, D.C. has announced she will allow 340B health and two of our member hospitals to intervene as defendants in lawsuits from four drugmakers over the 340B rebate issue.
David Glendinning [00:01:13]:
This is a crucial development in our efforts to persuade the court to block the drug company's efforts to implement their rebate schemes on all 340B hospitals. As an intervener, we will participate as party in the case, allowing us to submit significantly more briefing than is permitted for friend of the court briefs, participate in oral argument, and appeal any unfavorable decisions, even if the government declines to appeal or settles with the drug companies on the rebate issue. In her order, Judge Dabney Friedrich with the U.S. district Court for the District of Columbia said 340B Health has legal standing to intervene on behalf of our more than 1,500 members and that Genesis Healthcare System and UMass Memorial Medical center had standing to intervene as individual 340B hospitals. If you missed our previous interview with the Genesis Director of 340B about this intervention, be sure to check it out to learn more about what the court will be hearing from us. And now for our feature interview with Mark Riggle with UC Davis Health. Clinical pharmacy services are a key element of how many 340B hospitals and health systems apply their savings toward expanding care for patients in need. We spoke with Mark about how his system has used savings to give more of his patients and his fellow providers access to the pharmacy team's resources.
David Glendinning [00:02:44]:
Here's that conversation.
David Glendinning [00:02:48]:
I'm here with Mark Riggle, the Assistant Chief pharmacy officer at UC Davis Health. Mark, we're here at the 340B Coalition Winter Conference in a much different part of the state. Thank you for coming down to Southern California to be with us and welcome to 340B Insight.
Mark Riggle [00:03:06]:
Thanks happy to be here.
David Glendinning [00:03:07]:
Tell us a little bit, if you could, about UC Davis Health and, and the patients you serve there.
Mark Riggle [00:03:13]:
UC Davis Health is one of five academic medical centers under the University of California umbrella. So we're located in Sacramento, which of course is the state capital, as you mentioned, in a different part of the state from San Diego, where we're at today, 500 miles to the north. And we serve a pretty large geographical area of Northern California, basically from Sacramento all the way north to the Oregon border. So we serve about 600, or, excuse me, 6 million patients in that area in about 33 counties in northern California. And most of that area is rural, outside of the Sacramento metro area, a lot of rural areas in the Sierra Nevadas and the coastal range and the northern Sacramento Valley. So a lot of our patients don't have access to the quality of care and the level of care that we offer at UC Davis Health. And some of the services that we offer that are funded by our 340B savings. I mean, like many academic medical centers, we have a trauma center that serves pediatrics and adults, burn center, NCI designated comprehensive cancer center.
Mark Riggle [00:04:22]:
So our 340B savings goes to fund a lot of the cancer services that we provide for our oncology patients and then just lots of financial assistance programs because we have a lot of patients that are funded through Medicare, for example, so they have a large coinsurance and out of pocket expense. So we really help to ensure that they're able to afford their medications.
David Glendinning [00:04:44]:
Wonderful.
David Glendinning [00:04:45]:
We are here to speak about a very particular type of service you provide for patients, which is clinical pharmacy services. We have spoken with guests on the podcast in the past about some individual elements of those services, but we're going to be taking a little bit of a deeper dive into the concept behind it and what UC Davis Health does in that area. So if we could start. Walk us through, what are some of the benefits of having clinical pharmacy services at hospitals, whether they are 340B supported or not?
Mark Riggle [00:05:16]:
Pharmacists are drug experts, so they really understand medications and how they're used. They're really there to help educate the patients on how to take their medications, how to address side effects, and then they're also there to help the providers, the physicians and other clinicians that are treating those patients to manage those most difficult patients so they can spend more time on direct patient, you know, caring for other patients. So it's really important to ensure that we're partnering with our physicians to ensure their patients have better outcomes and can manage their medications. More effectively. We kind of see ourselves, our clinical pharmacists as physician extenders. So we're doing additional work beyond just the, the normal office visit when you go in and see your physician. So if a physician has identified a patient that needs additional help with their medications, they will refer those patients to the clinical pharmacist. And then we have direct encounters with those with patients to understand what difficulties they may be having with their medications.
Mark Riggle [00:06:22]:
And then with all of those services, we kind of lump those into a couple different buckets. One of them is direct patient care. Again, that's where the pharmacist is actually having a direct impact interaction with the patient. And then we have ancillary services. And those ancillary services are helping the non patient facing work to be done. So refill authorizations, prior authorizations, financial assistance, those types of things. And then with all of those service, or with both of those groups of services, if you have an in house pharmacy, there's an undeniable opportunity to then refer your patients to your own pharmacy. And that helps to improve the 340B savings that you get from those prescriptions to further grow these clinical programs.
David Glendinning [00:07:10]:
Okay, I'm hearing sort of a triad there. The direct care, the ancillary care, and I guess we call it increased capture. Let's cover each of those categories a bit in more detail. What types of direct patient care do clinical pharmacists provide in the hospital setting?
Mark Riggle [00:07:30]:
Most of this is referred by physicians. So in physicians I've identified patients that need additional care, they'll refer them to our clinical pharmacists and they're often helping the physicians to treat their patients with diabetes, hypertension, weight loss management and a whole myriad of different disease states. So a lot of these patients are on different medications and they may have multiple conditions that they're trying to manage. So the pharmacists are really able to identify those patients needs, whether it be financial or otherwise. And really to help identify and educate those patients why it is important for them to take those medications and ensure that they are well versed in understanding. There's sometimes very complex medication regimens and.
David Glendinning [00:08:24]:
We speak about medication adherence a lot on the program and you know, keeping patients healthy at home and keeping them out of the hospital.
Mark Riggle [00:08:32]:
Right.
David Glendinning [00:08:33]:
You mentioned also ancillary support. This would be support for other providers. So what form does that support take?
Mark Riggle [00:08:40]:
A couple different things we do. One is refill services. So you know, obviously patients need to have their refills approved when they run out of medication. So rather than having the physician manage those refill requests coming in from outside pharmacies. We have a team of pharmacists and pharmacy technicians that really kind of help manage those cues coming in. And our pharmacists are working under collaborative practice agreements with our physicians. So they actually have the authority to approve those refills on behalf of the physician as long as certain conditions are met. So that really takes a lot of that work off of the physicians to be reviewing those refills and managing that.
Mark Riggle [00:09:19]:
And then even through that work, we'll identify issues that potential issues that patients might be having. So we may need to reach out to that patient to ask them questions. So they may appear non adherent because maybe they haven't had their last refill for three months on their cholesterol medication, for example. So that may spur an outreach to that patient to figure out what's going on. Is it a, an issue with affordability? Is there something else going on that we need to identify? And then sometimes we might even see refill requests coming in for medications that the patient should not be taking anymore. So again, that would spark an outreach to that patient to figure out what's going on. Maybe there's something else that's changed in their condition that may warrant a visit, a follow up visit with their physician. One of the other services that we, ancillary services that we provide are prior authorizations.
Mark Riggle [00:10:14]:
So prior authorizations can take, you know, several days or weeks sometimes for the physician staff to really get to, and then they have trouble sometimes navigating the complex systems. And so we figure that pharmacy is a good area for supporting that because we kind of know how to navigate through the PBMs and insurance payers to really know what they're asking for when, when we need to submit a prior authorization. So we've been able to have a team of technicians again, and pharmacists that will initiate that prior authorization request, submit that to the insurance company and then deal with any appeals that come back, because oftentimes there are appeals. And so we have to dig deeper into the chart notes and provide even additional information. So we've been fairly successful in having about an 80% approval rating in our prior authorization. And the physicians have really expressed their appreciation for having us to support those services.
David Glendinning [00:11:17]:
Yeah, I imagine this is the type of support that providers would really appreciate. So maybe we could get to a little bit more of that in a second. But I did want to get to your last point about the increased prescription capture from having the patients stay sort of in house when it comes to where their pharmacy is. Why do you see that as an important part of the equation here?
Mark Riggle [00:11:40]:
Well, a couple reasons. I mean, one is financial. Okay, you can't deny that. So, you know, we're creating revenue and putting that back into the system, and that additional revenue can help fund those additional services to support our patients in improving their outcomes and then improving the provider satisfaction by providing these, offering these ancillary services. But also, when we keep our prescriptions in house, we have a better track. We can better track our patients and identify if there's any issues. Like our own pharmacies really have a, I don't know, a better connection to our provider. So if there's an issue with a medication or a question on a prescription, we have a direct connection to our providers to really get those questions resolved.
Mark Riggle [00:12:27]:
Or we can even look in our medical record to answer the questions for ourselves without even contacting the provider. If patients go outside. I used to work at an outside retail pharmacy, so I kind of know what this is like. It can be hard to connect with physicians and get questions answered in a timely manner, so it doesn't lead to delays in the patient getting their medication. So by using our own internal pharmacies, we're able to really help the patients and get their medications quicker and. And resolve any problems.
David Glendinning [00:12:57]:
Sounds like something, as with other elements of 340B, you know, you're having patients benefit and that's great. What have all of these clinical pharmacy services and all of these three buckets that you've described, what have they meant for patient health outcomes at UC Davis Health?
Mark Riggle [00:13:16]:
Yeah, a couple of great examples of how they've improved outcomes. So in the area of diabetes and hypertension. So we looked at our patients in primary care with diabetes, and we looked at their A1C levels as a population, and we were able to see an improvement in our A1C scores. These patients A1C scores. And with hypertension, we were able to see a significant improvement in the number of patients who were able to achieve their blood pressure goal and achieve and maintain those improvements over time.
David Glendinning [00:13:55]:
Excellent. And what's the verdict from the other providers within the system? How have they responded to your efforts to support them in the work that they do?
Mark Riggle [00:14:04]:
The providers love it. The primary care support has been our number one physician satisfier. They all love having pharmacists to really help them manage their patients, you know, especially, like I said, their most difficult patients to manage. Having the pharmacist as a part of the team is really Important. And they've, you know, really embraced having. Having that support. As far as the prior authorizations go, we had one physician comment that that's one of the reasons that he remains as a UC Davis practitioner is having that support from pharmacy to really help. Help with those ancillary tasks.
David Glendinning [00:14:40]:
Pretty good review right there. It sounds like this is a really significant clinical pharmacy initiative you have at this system. And with any such large rollouts, they rarely go without some growing pains. Were there any barriers to success in ramping up these clinical pharmacy initiatives?
Mark Riggle [00:15:00]:
Oh, yeah, we've had a few with our refill program. We couldn't roll out the program fast enough for providers, and so they've had to wait patiently, you know, some of them, for a couple years for us to get to them. But, you know, once we. Once we got there, it was great. The refill program has been very successful with very few hiccups. However, our prior authorization program grew at a pretty fast rate. And, you know, with insurance restrictions, a lot of drugs were requiring prior authorizations, it seemed like more and more. So we really had to ramp up that program quickly.
Mark Riggle [00:15:36]:
And at one point we realized that, hey, we're really not saving much time in this whole process. So we have to kind of step back a little bit and review our entire workflow to kind of see what's going on and what's causing some of these bottlenecks. So we brought in people from the outside that aren't really invested in this to kind of help us map out our prior authorization workflow. And we identified some things, such as there were duplicate requests in there, and so how is that happening? So trying to identify how these things are really impacting us, we were able to identify some of those problems and then streamline our workflow to really make it more efficient. And we were able to improve our turnaround time from about two weeks down to three to five days on prior authorizations.
David Glendinning [00:16:27]:
Now, you've mentioned financial assistance issues a few times through this interview, so I want to make sure we cover off on some of those. How does UC Davis Health help patients afford their drugs?
Mark Riggle [00:16:40]:
Yeah, so, I mean, affordability is just one of the keys to access, right? So if you know you can be prescribed the best medication for your particular condition, but if you can't afford it, it doesn't do any good. So we really feel it's important to identify affordability with all of our patients and ensuring they're able to afford whatever medication is being prescribed for them. So that's just something that we do with all of our patients and some programs that we, we have actually have a team of technicians and pharmacists that will work specifically on financial assistance. So once a patient has identified that they have financial need, depending on what insurance they have, we will look for what options might be best for them. They may be copay cards from a manufacturer. They may be manufacturer supported free drug programs. We have a waiver program that we have initiated at UC Davis Health to help our patients afford their out of pocket expense. So we have to collect data from them on their financial situation and such.
Mark Riggle [00:17:48]:
And so we really think it's important again to ensure that patients are able to afford their medications so they can continue to take that to treat their condition and overall have better outcomes.
David Glendinning [00:18:02]:
Mark, this has been a great look into what UC Davis is doing in this clinical pharmacy area. I'm wondering how you could perhaps apply that experience elsewhere. So what, what parting advice would you have for other hospitals that are considering launching some clinical pharmacy initiatives of their own?
Mark Riggle [00:18:23]:
Yeah, that's a great question. And you know, we had some challenges in expanding some of these services because none of them in and of themselves generate revenue. It's largely an expense because you have to pay the salaries of the pharmacists and technicians that are supporting this, but really have to kind of look at the big picture and identify what the benefits of this program are beyond the finances. So we've been able to show that we've improved quality, which is extremely important. So we were so interested in growing this program and knew that we were able to prove our worth by having good outcomes. We had an ambitious goal to ensure that every ambulatory care patient had access to a clinical pharmacist. So that was a lofty goal that we set, and I'm happy to report that we've achieved that. So we have pharmacists that are able to serve all of our patients from all of our ambulatory care clinics.
Mark Riggle [00:19:23]:
And then we've been able to improve physician and provider satisfaction, which is extremely important. So those are really key things that you can, you know, try to convey to your, the leadership at your organization to really, really support these programs.
David Glendinning [00:19:42]:
Well, hopefully other hospitals that are listening can sell that value proposition to their own leaders because it strikes me as a win, win, win scenario. Potentially.
Mark Riggle [00:19:51]:
Sure is.
David Glendinning [00:19:52]:
Mark, we really appreciate the clinical pharmacy deep dive you've taken us through. So thank you again for being here.
Mark Riggle [00:19:59]:
Thanks for the opportunity. Appreciate it.
David Glendinning [00:20:02]:
Our thanks again to Mark Riggle for giving us a glimpse into how the combination of 340B and clinical pharmacy can be that win, win, win for patients, providers, and the entire health system. This is the first of several conversations you will be hearing on the show from the 340B Coalition winter conference. We thank all of you who came by our podcast lounge while you were in San Diego, whether that was to sit for an interview or just to say hi. We will be back in a few weeks with that next episode. As always, thanks for listening and be well.
Narration [00:20:38]:
Thanks for listening to 340B Insight. Subscribe and rate us on Apple Podcasts, Google Play, Spotify, or wherever you listen to podcasts. For more information, visit our website at 340bpodcast.org. You can also follow us on Twitter @340bhealth and submit a question or idea to the show by emailing us at podcast@340bhealth.org.