Speaker 1 (00:04):
Welcome to 340B Insight from 340B Health.

David Glendinning (00:11):
Hello from Washington, DC and welcome back to 340B Insight, the podcast about the 340B drug pricing program. I'm David Glendinning with 340B Health. We are back from our late summer break and we hope the rest of your August was enjoyable. This episode is sponsored by 340B Link. Leveraging the highest claims qualification standard in the industry, the 340B Link team helps covered entities capture eligible mixed-use, specialty, mail-order, and contract pharmacy savings. Their dedicated client teams focus on delivering an exceptional service experience while advocating for their clients in support of the 340B program.

David Glendinning (00:55):
Our guest today is Nicole Shoquist, the chief pharmacy officer at JPS Health Network in Fort Worth, Texas. We spoke with Nicole about some of the innovative ways JPS uses 340B program savings to bring needed healthcare beyond the hospital walls, including to patients experiencing homelessness, but before we go to that interview, let's take a minute for a roundup of 340B news. August is typically a slow month in Washington, but this year, it was anything but slow for the 340B community

David Glendinning (01:27):
Recent drug manufacturer attacks on 340B have intensified. As you will recall, Eli Lilly was the first drug company to say it would stop offering discounted prices on one of its medications when a covered entity purchases it for dispensing through a contract pharmacy. Since that watershed moment, several additional manufacturers have followed that example by either cutting off 340B access for contract pharmacies or threatening to do so unless covered entities share claims data that companies are demanding and Lilly significantly escalated the conflict recently when it expanded its restrictive policy to nearly all the drugs it manufacturers, including many of the nation's top-selling diabetes medications.

David Glendinning (02:20):
The developments have created an uproar. Hundreds of individual hospitals have signed onto a letter circulated by 340B health calling on HHS Secretary Alex Azar to use his authority to block what they consider a violation of 340B statute. Numerous hospital pharmacy and provider associations, including 340B Health, have sent separate letters to Secretary Azar with the same message, and Congress has gotten in on the act, too, with the leaders of the influential House Energy and Commerce Committee and a bipartisan group of House lawmakers pending their own letters to ASR. A swell of opposition to the drug actions has not gone to noticed within the administration. As of the recording of this episode, the Health Resources and Services Administration said it was reviewing the latest Lily move. HRSA notes that if the policy is in violation of 340B statute, the company could be subject to civil monetary penalties for knowingly and intentionally overcharging for its 340B drugs. You can find out more about all these developments in the show notes for this episode.

David Glendinning (03:35):
Now, for today's feature interview with Nicole Shoquist, the chief pharmacy officer at JPS Health Network in Fort Worth, Texas. Dr. Shoquist has been with JPS, a public health system, since 2008. She is responsible for the system's inpatient pharmacy, outpatient pharmacy, clinical pharmacy services, and correctional health medication management. She also was co-chair of the JPS Pain Stewardship Committee. After Nicole spoke on the Beyond the Four Walls of the Hospital panel at this year's 340B Coalition Virtual Summer Conference, our own Miles Goldman sat down with her to discuss how JPS extended its care mission during the peak of the community's COVID-19 outbreak. Let's hear that conversation.

Miles Goldman (04:22):
Thank you, David. I'm Miles Goldman with 340B Health and I'm joined today by Nicole Shoquist, the chief pharmacy officer at JPS Health Network. Nicole, thank you for joining us.

Nicole  Shoquist (04:35):
Thank you for having me.

Miles Goldman (04:37):
I'm looking forward to our conversation on how JPS has been using 340B to support patients experiencing homelessness during the pandemic, but before we get into all that, can you first share with us a little bit about JPS Health Network and the community you serve?

Nicole  Shoquist (04:54):
Yeah. JPS Health Network is in downtown Fort Worth, Texas. We are a one-hospital system with 589 beds. We provide primary care and specialty care services in 34 clinics throughout the Tarrant County community. We have 19 school-based clinics and we are a teaching hospital with the largest family medicine residency in the United States.

Miles Goldman (05:20):
That's great. Now, patients experiencing homelessness, they are certainly an underserved population. Now, before the pandemic, how did JPS serve people who are homeless?

Nicole  Shoquist (05:32):
We had numerous access points for patients prior to the pandemic. We have a primary care clinic that was set up specifically for our homeless patients where we also provide acute or sick care, anticoagulation management, and some limited specialty care. We are able to offer some Hep-C and HIV clinics in that area and something super cool at JPS is we have an outreach mobile van, so we're able to provide primary care and acute and sick care visits out in the streets. Our provider is able to locate patients he's looking for and provide the services that they need. Additionally, we had some medical services in the homeless shelters in Fort Worth that included having a nurse practitioner onsite to handle any acute care or try to connect patients into the JPS health network system for care.

Miles Goldman (06:30):
What was 340B's role in the services that were, that were being provided?

Nicole  Shoquist (06:35):
The 340B savings are absolutely necessary to reduce burden for prescription costs so that the hospital can stretch the scarce resources to provide these services. If we didn't have our 340B savings, I'm not sure we would be able to provide all of the services we do, especially in our clinic for our homeless patients.

Miles Goldman (06:58):
Now, of course, COVID-19, we've all been dealing with the pandemic. What has the impact been like in the Fort Worth area, especially for patients who are homeless? I can imagine there are big challenges for people without homes.

Nicole  Shoquist (07:13):
Yes. When you're in an environment where you have stay-at-home orders and you are not currently housed, it's a significant struggle. Additionally, our homeless shelters were not able to maintain safe distancing, and so they did close, so our homeless patients then are no longer able to access medical services at the homeless shelters, or receive mail, which was a mechanism for them to receive prescriptions, and the housing situation became a significant concern for our patients in ensuring that they had access to care when they needed it during a medical pandemic.

Miles Goldman (07:53):
When the clinic closed, how did JPS respond?

Nicole  Shoquist (08:00):
We had to really sit back and think about how we were going to continue to provide access for our homeless patients and we were real fortunate the city of Fort Worth stepped up and opened the civic center for the homeless patients in Tarrant County. The civic center was able to maintain a safe distancing of patients and able to house a couple of hundred people there so they could meet the requirements of the governor's stay-at-home orders and have the ability to access care. We were able to provide both onsite and telehealth medical services at the civic center, which is fantastic. It was important that our patients had access to care in whichever modality that they needed.

Nicole  Shoquist (08:49):
Our onsite staff included people from the closed clinic and our mobile van, so we had nursing available 24/7, and primary and acute care visits were handled by our providers during the day. Additionally, the JPS IT team got everything set up for telehealth. Specifically, we had iPads and phones in private areas so that patients who are already established with a JPS provider could continue their care with that provider. From a prescription standpoint, we were able to work with the nurses that were down at the civic center, get a list of patients that needed refills or had new prescriptions written, and have them delivered each day so patients wouldn't have to leave to go pick up their prescriptions at the hospital.

Miles Goldman (09:43):
You had staff that were dedicated to delivering those prescriptions to the civic center, right?

Nicole  Shoquist (09:49):
We did. JPS has a courier service and they really, really stepped up to the plate. They were able to run not only prescriptions down to the civic center, but they were running linens, lab specimens, and floor stock medications for administration right onsite.

Miles Goldman (10:10):
How did 340B help you provide those services?

Nicole  Shoquist (10:14):
Again, we could not offer the breadth of services without our 340B savings. The community would really suffer with reduced services, including the care we provided for our homeless patients during the pandemic.

Miles Goldman (10:28):
One aspect of your conference presentation I found interesting is how these innovations also address non-pandemic specific challenges, such as patient access to prescriptions. Can you tell us more about that?

Nicole  Shoquist (10:42):
Yes. Prior to the pandemic, we were operating under the assumption that the patient needed to come to the pharmacy to access their prescriptions. One thing that is a silver lining to changing operations is the understanding that we need to provide the care where the patient is, not assume the patient can come to us, so continuing to deliver prescriptions to areas where patients can access easily has been a silver lining to the pandemic changes in our operations.

Miles Goldman (11:15):
We have been hearing more about hospitals going beyond their four walls to care for the community they serve. Is it more difficult to create that model from the perspective of 340B compliance? What were some of the challenges you and your colleagues faced?

Nicole  Shoquist (11:31):
It is an incredible privilege to be able to serve the community, and with that privilege comes responsibility for compliance. One of the things that we needed to keep in mind is the rules of eligibility still carried even though we were outside of our normal four walls. One of the cleanest areas where patients were already established with the hospital utilized telehealth services and just continued with their already established providers. Where it got a little more sticky and we were actually unable to qualify some prescriptions were when it was the first access for the patient and they were seeing only at the civic center. We still served those patients, made sure they had their prescriptions, but some of the complexities of the compliance really did limit our ability to successfully use 340B for all patients down there.

Miles Goldman (12:32):
That, of course, leads, I would imagine, to even a greater gap in terms of the amount of uncompensated care you're providing, right?

Nicole  Shoquist (12:40):
That's correct, yes. The patients are still homeless. They were being serviced at the shelters, but not at JPS so it did create an additional area for uncompensated care, but again, it is our absolute privilege to take care of our community, so it was important to make sure they had what they needed when they needed it.

Miles Goldman (13:03):
Are there best practices JPS developed that you think will carry over into the post-COVID care?

Nicole  Shoquist (13:10):
Absolutely. When you're faced with a situation where you have to think outside of the box, I think you really dig into your creativity and you discover that there are new best practices available. The utilization of virtual and telehealth visits is something that JPS intends to maintain. It provides access to care without patients struggling to get to the facility. A lot of our patients at JPS have difficulties with transportation, and so the telehealth services really did provide the continuity of care that our patients needed and deserved.

Nicole  Shoquist (13:50):
One of the other things that we discovered when it comes to pharmacy services is that delivery of the finished prescriptions was not only good for our patients, but it actually helped the pharmacy focus on maybe patients that had been seen in the ED and we need to fill their prescription so they can go home and then we could complete the prescriptions that were going to be delivered in a batch and get them down to the patients at the civic center. Since the pandemic, response has shifted into some recovery in the Fort Worth area, the civic center has shut down its operations, but we do continue to deliver prescriptions for patients to make sure that they're receiving them.

Miles Goldman (14:34):
That's really good continuity of care, right?

Nicole  Shoquist (14:36):
It absolutely is and it is obviously a patient satisfier, so if we can keep prescriptions readily available and increased compliance and the patients are happy, it's a win, win, win.

Miles Goldman (14:49):
Absolutely. You mentioned telehealth just a couple moments ago and I was wondering if you could tell us a little bit more about some of the telehealth aspects that were incorporated into the civic center?

Nicole  Shoquist (15:02):
Our telehealth services at the convention center were made possible with our IT teams in making sure that everything was conducted and the technology was available for our patients. We set up private little areas where they could connect with their providers and make sure that everything that they needed could be taken care of. If they were having any type of symptoms, specifically COVID-related symptoms, they were asked to see the providers that were onsite, but is it was primary care and it was prescription discussion or the regular scheduled visit, they were able to work with their primary care provider with the iPads and telephones that were provided at the civic center.

Miles Goldman (15:45):
That must have helped you care for patients who JPS was already in contact with prior to the pandemic because you already had all their medical records in the system, right?

Nicole  Shoquist (15:56):
Yes. It really did provide a great opportunity for continuity of care. Specifically, we had 24/7 coverage with nursing staff there, so patients actually had more opportunity to work with JPS medical providers as they were housed at the civic center and we were able to stay in close contact with our patients during a real scary medical time in our country.

Miles Goldman (16:24):
Is there any final advice you would have for other 340B professionals who want to establish the type of program JPS did, either for patients experiencing homelessness or for other members of their communities?

Nicole  Shoquist (16:39):
I think the advice I would give is to really just have an open mind. Look at creative ways to deliver the services that you've always done in new ways. The pandemic actually provided an opportunity to accelerate our telehealth service offerings, gave us an opportunity to accelerate virtual environments, it gave us a mechanism to really focus on the core quality and safety measures and deliver our care in new and unique ways. I absolutely loved the process we set up for delivery of prescriptions for our homeless patients. They're extremely vulnerable with a lack of transportation normally, so for us to get the meds and the care where they are versus having the patient come to where we were, it was really a great opportunity to improve the health of the community in Tarrant County.

Miles Goldman (17:42):
Because patients were gaining more access to prescriptions and you were overcoming those transportation barriers, did you find that medication adherence improved?

Nicole  Shoquist (17:52):
Yes, we actually are seeing our compliance metrics improving. Our patients are having better outcomes. We have had better A1C numbers, we've had better blood pressure control, so it is really a great outcome from a really scary situation.

Miles Goldman (18:13):
Well, Nicole, it's been great to learn more about all the wonderful work you and your colleagues have been doing for this important underserved community. We wish you and JPS all the best as you continue to navigate the pandemic.

Nicole  Shoquist (18:29):
Thank you, Miles, and as always, thank you, 340B Health, for being our strongest supporters and our advocates in this area.

David Glendinning (18:38):
Our thanks again to Nicole Shoquist for her steadfast dedication to getting her health system's patients the care they need, no matter where they are. As always, if you have any questions or comments about any of the items we cover here at 340B Insight, please email us at podcast@340bhealth.org. Please plan to join 340B Health on Tuesday, September 22nd for a webinar about proposed Medicare Part B payment cuts to many 340B hospitals that are scheduled to take effect in January 2021. The Centers for Medicare & Medicaid Services will be accepting comments on the proposal through October 5th, so this is the time to get up to speed on what it says. You can find the link to the webinar registration page in the show notes.

David Glendinning (19:25):
We are back on our regular schedule of releasing a new episode about once every two weeks. Our next episode will focus on some of the exciting new research that demonstrates the positive effects 340B savings have on improving patient health outcomes, so don't miss it. Until then, thanks for listening and be well.

Speaker 1 (19:50):
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 at @340bhealth and submit a question or idea to the show by emailing at podcast@340bhealth.org.