A New age of pharmacists

The past few years may have been challenging but they’ve also brought about transformation in the pharmacy setting. Daniel speaks with Dr. Dan Knecht, the chief clinical innovation officer at CVS Caremark, about ways he’s working to provide more integrative, individualized care for patients with conditions like diabetes, heart disease, and hypertension — as well as behavioral health.

What is Healthy Conversations?

Healthy Conversations brings together leaders and innovators in health care to talk about the biggest issues facing patients and providers today. Every month, we explore new topics to help uncover the clinical insights and emerging technologies transforming health care in real time.

Dr. Dan Knecht:
We feel that the pharmacist is an unsung hero in the health care system, and in particular, during COVID. And I think the secret ingredient to all of this is that trusted relationship between a pharmacist and a patient.

Dr. Daniel Kraft:
Welcome to Healthy Conversations. I'm Dr. Daniel Kraft, and today feel fortunate to be in healthy conversation for the second time with Dr. Dan Knecht. He's the chief clinical innovation officer at CVS Caremark. Welcome, Dan.

Dr. Dan Knecht:
Thanks for having me.

Dr. Daniel Kraft:
A lot has transpired since we talked in 2020. Maybe describe a bit about what you do all day at at CVS Health.

Dr. Dan Knecht:
So it's essentially ideating, developing and deploying new programs and initiatives that improve the health of our customers, patients, and the communities we serve. Now more than ever, it is so important to be driving clinical innovation. The past few years have been just incredibly challenging for society. We've seen a decrease in life expectancy over the past three years. The resurgence of undertreated, cardiovascular and metabolic disease, a lot of it is driven by substance use disorder and behavioral health conditions, and unfortunately, the impact of the pandemic has been really crushing. I think CVS Health and Caremark really are uniquely positioned to make a real positive impact on the health of our clients, customers and America.

Dr. Daniel Kraft:
And how do you measure that. Health is a broad term. What kind of KPIs or key measures do you get to measure within CVS to help understand when you're moving the needle?

Dr. Dan Knecht:
There's many ways to measure that. Most tactically, we can look at medication adherence rates, we can look at lab values, so improving hemoglobin A1C, improving blood pressures, and then ultimately another big challenge is how do you make sure people getting high value care? Care that is certainly goal concordant, but also adherence to evidence-based guidelines. And so there are many ways to measure health, but I think, to your question, you have to measure it to improve it.

Dr. Daniel Kraft:
So there's a saying, you get what you measure and you get what you incentivize. And many of the incentives in health care are misaligned, but I think we're all aligned on the fact, speaking of, as you mentioned, medication adherence, there's that often used quote that about, "50% of prescribed medications aren't taken as prescribed." Are you able to measure adherence through refill rates or other measures and then impact that one directly?

Dr. Dan Knecht:
Absolutely. That's a really important data point, and we're working hard to increase medication adherence. I think one particularly exciting clinical innovation we've deployed is a program called Pharmacy Panels, or Pharmacist Panels, to engage patients and coach them on improving medication adherence, but also a variety of other really important health actions.

Dr. Daniel Kraft:
So you're pulling the pharmacist more into the direct care. Can you give some examples of how that's being integrated in beyond the normal pamphlet that we all never read when we open our pill bottles?

Dr. Dan Knecht:
Sure. They're data driven encounters and provide individualized coaching. But I think what's really special about this program is we're providing the pharmacist the time, the training, and the tools to coach these members. Month after month, patients will come in and have an ongoing conversation and a relationship with the pharmacist, opening the aperture to addressing total health. So medication adherence, optimization, but also comorbidity management, coaching and information around self-monitoring of blood glucose for patients with diabetes and encouraging preventive and complication screenings as well.

Dr. Daniel Kraft:
You can do many things that maybe impact hemoglobin A1C from diet to exercise to medication, and you want to create wins of that aren't just based on a blood level. Have you seen that translate into other measures?

Dr. Dan Knecht:
Yeah. Let's talk a little bit about our Transform Diabetes Care program, which relies on this Pharmacist Panel capability. So we routinely see our pharmacists have conversations and engage members around the importance of diabetic retinopathy screening, as well as foot exams for diabetic neuropathy. Many of our HealthHUBs also have the ability to screen for diabetic retinopathy at the store. So not only is the pharmacist having that conversation, but he or she is sometimes walking that patient over to the HealthHUB where they can engage with our nurse practitioners to screen for diabetic retinopathy. So that's incredibly exciting to me.

Dr. Daniel Kraft:
What's coming to, let's say, the standard pharmacy, the HealthHUB of today, and maybe what you see in the next few years on the possible technology track?

Dr. Dan Knecht:
We are working to increase the number of health services and health products available at CVS across our entire fleet. So for example, you can go in and there's a care concierge that will be there to greet and helping individualize their experience. Maybe it's getting your kidneys checked and then that care concierge can walk that individual to resource in the store. In the front of the store, we have a large selection of products for folks living with diabetes; glucometers, socks for individuals with diabetes. And then I think about all the clinical services we're providing as it relates to chronic condition management. Our MinuteClinic clinicians can now start insulin, start other medications and they're receiving additional training and tools.

Dr. Daniel Kraft:
Some socks are even now digitally enabled to pick up hotspots and prevent ulcers or amputations eventually. Are you seeing the eventual ability to purchase something at a CVS and connect the data into the flow that the patient sees their endocrinologist and their pharmacist?

Dr. Dan Knecht:
So our Transform Diabetes program is essentially providing all those wraparound services. We have a digital app and that connects with the glucometer that that patient is using. It's also surfacing up individual recommendations. As you know, hypertension is more prevalent in people with diabetes and, unfortunately, uncontrolled hypertension is a real accelerant for poor health outcomes. So we're really working hard to provide an omnichannel experience for folks. In particular, those with chronic conditions.

Dr. Daniel Kraft:
Expanding upon the example of hypertension, it's quite common, as we know, for patients with essential hypertension to be on a beta blocker, an ACE inhibitor, calcium channel blocker. Three plus meds and take some time to actually dial that in. How do you enhance the ability for your Pharmacist Panel, the patient, the primary care doctor to see that blood pressure data and personalize the hypertension regimen?

Dr. Dan Knecht:
I like to describe our program as twofold. The back end is all the advanced analytics serving up those individualized proactive recommendations and then the front end are our very talented, passionate clinicians, pharmacists, nurse practitioners, care managers that get those recommendations and then deliver them in a way that is personalized, empathetic, and really empowering for those individuals.

Dr. Daniel Kraft:
At the same time, how do you empower the clinician not to have to fax back and forth changing a beta blocker, for example? Are there ways that you're connecting the dots and the workflow so that the clinician and the pharmacist are working more tandem?

Dr. Dan Knecht:
What you're hitting upon is interoperability. How do we make sure the work we're doing, the coaching, the prescribing, links up with that patient's primary care doctor or endocrinologist? We use Epic for many of our clinical programs. Coram, which is our Home Infusion company, also uses Epic and our pharmacists are currently on RxConnect. We're in the process of expanding Epic to them as well. So I think it's really important to make sure any recommendations or change in therapy is documented and shared with the patient's primary care doctor.
I will say that I think it's one in four Americans don't have a primary care doctor, and those who do have PCPs, sometimes the relationship is very touch and go. And then so if you think about how frequently we oftentimes have individuals coming to us at the pharmacy up to 12 times a year, so we have substantially more touch points with patients than even PCPs oftentimes. So doubly is important why we need to ensure there's interoperability

Dr. Daniel Kraft:
And now we have to increasingly use the interoperability of telemedicine or virtual care or video visits and MinuteClinic offers those as well. How've you seen that interface evolve? Certainly in the beginning of the pandemic, a huge bump?

Dr. Dan Knecht:
We see, as we mentioned earlier, there's a tremendous spike in folks accessing care through virtual channels. So telehealth, most of that has dropped, I think the notable exception there. We still see increased utilization of behavioral health services through telehealth. So I think that speaks to the nuances here of meeting people where they are. So we need to have a strong telehealth presence, but also be there as it relates to in real life for brick and mortar as well.

Dr. Daniel Kraft:
Back to the Pharmacist Panel. Increasingly, we're not just prescribing pills. Can you give some examples of how you see that starting out and where that's heading?

Dr. Dan Knecht:
The way we think about improving health is identifying the biggest unmet needs and then bringing solutions to the marketplace. So I think two domains that I feel we have really compelling solutions that are partially digital, partially in person, but individualized is our nutrition offering and behavioral health. We have a pilot program which we're expanding around behavioral health resources within the HealthHUB in a number of markets. And so essentially we have licensed clinical social workers within HealthHUBs that can serve as navigators to provide resources in the community, they can help identify digital resources that would be helpful and they can, frankly, screen and treat folks with some common behavioral health conditions like anxiety and depression.
The other one is around nutrition. And so all those chronic conditions we were talking about earlier, we can provide pharmacotherapy, which is quite helpful for folks with hypertension and diabetes and hyperlipidemia. But an important piece, a huge driver of that, is nutrition. So we have a program in Phoenix where folks can come in and engage with a dietician, get coaching, get biometrics done at the MinuteClinic, and also use a digital tool to help coach that individual and get them the tools and resources to better manage their diet.

Dr. Daniel Kraft:
Yeah, we're really entering this interesting age of precision nutrition. There's that phrase from Hippocrates, "Let medicine be thy food and food be thy medicine." What are some other benefits to the broader health care system you're seeing now from what's evolving within CVS in your work on efficiencies, safety, patient and clinician satisfaction?

Dr. Dan Knecht:
I still practice medicine in the hospital and I see substantial amount of burnout and fatigue among health care providers. We feel that the pharmacist is an unsung hero in the health care system, and in particular, during COVID. And I think the secret ingredient to all of this is that trusted relationship between a pharmacist and a patient. Year over year the pharmacist is ranked one or two as the most trusted health care professional by patients. And I think the reason for that, that high level of trust, is the pharmacists we employ are members of the communities they serve. They bring an authenticity and passion for health care. That's why they went into the space. And then finally, just the frequency of touchpoints and the positive experiences each time a patient comes to a pharmacist and has a conversation that compounds and that's real positive feedback loop.

Dr. Daniel Kraft:
Yeah, hundred percent. I still remember growing up with the corner pharmacy, one man shop almost, and we had a relationship with that pharmacist. Even do home-based deliveries and gets to know the family and can make recommendations that really impact health. And health is social and the human touchpoint is super critical. Where do you see technology today in terms of what you're doing at CVS and where do you see it heading?

Dr. Dan Knecht:
What I've been really impressed about is our ability to use data in an actionable way. I think about our Transform Diabetes program; the team has built very powerful model that essentially is so powerful what we are able to determine a patient's A1C, so hemoglobin A1C, pretty much on par to that of actually getting your blood tested. And the model was built on roughly 250,000 folks with diabetes, and they've applied machine learning to really drill down and be able to serve up the most important clinical recommendations for patients.
And so I like to describe it as almost like having your own digital endocrinologist. That's incredibly powerful, but I think it only works when you have the right empathetic, passionate clinicians to deliver those messages. And we have 25,000 pharmacists, care managers, nurses, nurse practitioners, PAs to deliver those messages. So I think in the next few years we'll continue to build these models and allow for really precision health care to come alive and also by partnering with providers in the communities and hospitals as well.

Dr. Daniel Kraft:
And the key part of that interface with the data that might power insights often still depends on where you obtain the data. And there's interest now in health equity and data equity, meaning that a population of Hispanics in New Mexico might have a different set of genomics and social determinants that impact their health.

Dr. Dan Knecht:
Yeah. A little over a year ago, we've rolled out community testing for COVID-19, and we used the data and worked with the CDC Social Vulnerability Index to ensure that where we were providing testing was in underserved, vulnerable communities. I think it was about 50% of communities we were in were defined by the CDC as socially vulnerable. So we had the data, it's readily available and we're acting upon it

Dr. Daniel Kraft:
In terms of acting upon the data, some are digital natives and want to only interact with their pharmacist and their pharmacy via the app, and others want the eye-to-eye contact and the hand on their shoulder.

Dr. Dan Knecht:
Yeah. One example that we're particularly proud of is our pre-eclampsia prevention initiative. We recognize that we needed to tackle the health care disparity related to maternal mortality in this country, in particular with African American women. So we launched a program where we sent resources around the importance of screening and engaging an OBGYN around preventing pre-eclampsia. And we went a step further than just sending a pamphlet, we actually sent a kit with low-dose aspirin, which as you know, is effective in reducing the risk of developing pre-eclampsia.
And pre-eclampsia disproportionately impacts African American women, so we work with our employee resource groups to ensure that the messaging really resonated with that population. And we've sent out several thousand of these kits and we've gotten really positive feedback in particular from our African American expecting mothers. I'd say start with the clinical insights, the unmet need, then using the data as well as working with those populations you're trying to serve and help.

Dr. Daniel Kraft:
Maybe it's 2025 or 2031. What are some of the innovations you're hoping to see for the Pharmacist Panel or the clinician tool set?

Dr. Dan Knecht:
Focusing more on prevention and coaching is incredibly exciting to me. So can a pharmacist also provide coaching and education around various wellness topics? For example, nutrition, sleep, stress management? Ultimately, to really impact population health, you need to go upstream. You need to address issues before they occur.

Dr. Daniel Kraft:
And with the power of CVS Caremark Aetna, you have a tremendous amount of data and insights where you can hopefully find folks early on and be proactive in terms of preventing something, whether they're at risk for it or starting to show early signs and pick up disease at stage zero rather than stage two or stage three. Would you see in the next few years the ability now to connect the consumer wearable to integrate into the role the pharmacist and what CVS sees as a way of tracking whether medication's working or not?

Dr. Dan Knecht:
We're actively looking at using a wearable with somebody who has a rare or serious illness, for example, rheumatoid arthritis, and then piping that information to our specialty pharmacist as well to provide additional coaching or intervention sooner. Definitely we see a number of great applications for wearables, and we're starting to make inroads in that space already.

Dr. Daniel Kraft:
Yeah, we're both trained as internists. Are you starting to see this model evolve from siloed problem list to more holistic, even integrative care that the pharmacist and the clinicians in your platform can engage with?

Dr. Dan Knecht:
Absolutely. We work with Unite Us, which is a company that curates solutions for folks struggling with particular social determinants of health. So I can easily envision our care concierge or pharmacist connecting an Aetna member or a Caremark member with resources in the community to address food insecurity or transportation to and from doctor's office or even connect with local resources around employment.

Dr. Daniel Kraft:
We're 20 years almost since the first genome was sequenced, folks are going out and getting consumer genomics done, which often include pharmacogenomics. Is that something you're seeing yet integrated into clinical and pharmacologic care? Picking the right statin or even whether aspirin might work in some patients?

Dr. Dan Knecht:
I think one area where there's a lot of compelling evidence is in oncology. We have a program, Transform Oncology, where one piece of that is using a broad panel genetic testing on tumors, and that helps the community oncologist tailor the right medication for the right cancer patient. So early innings, but it's definitely paying off in spades in the oncology space.

Dr. Daniel Kraft:
Maybe we might mention, what are some learnings and feedback you've had, let's say, from your staff?

Dr. Dan Knecht:
So what we're hearing from our pharmacists in the field that are actively enrolled in this program is that they really enjoy the work. It allows them to practice at the top of their license. In particular, as it relates to building deeper longitudinal relationship with patients. Frankly, that's why they went into medicine. Patients really enjoy the program too, and I think the statistics speak for themselves. Reach rates are about 70%, which are quite high in any sort of care management program. And engagement rates are about 75% too. So really, we have that trust and permission to engage members and patients on health conversations. And then also just the role of omnichannel care, I think, is critical, right? People have embraced telehealth. We have to really protect and cherish that trust we have.

Dr. Daniel Kraft:
And you mentioned omnichannel a few times. How would you encapsulate omnichannel and where it might be heading next?

Dr. Dan Knecht:
I just think about the people we're trying to serve. And so let's talk about an individual with Medicare. So somebody over 65. Recent study by JAMA Internal Medicine, I believe, demonstrated that one in four Medicare beneficiaries did not have a smartphone, did not have broadband. And frankly, I think many of those folks are really vulnerable. They're socially vulnerable, and so expecting them to sort of navigate the health care system or use digital apps to get the right level of care is just not going to work. So omnichannel is essentially acknowledging that people want or need different ways of engaging with the health care system and meeting them there

Dr. Daniel Kraft:
As we bring our composition to a close, any things you'd like to share with our audience? Many of them are practicing clinicians, pharmacists, primary care doc specialists.

Dr. Dan Knecht:
The COVID-19 pandemic was a, and still is, an unprecedented health and social crisis. And there were so many lessons we've learned the hard way. And so I think learning from, "How do we best engage with people? How do we share data and science and really support fellow caregivers," is critical. And I hope we learn from that and carry it forward to improve the health care system.

Dr. Daniel Kraft:
I'm an optimist and like to think of COVID as a catalyst to bring us into a new health age and move us from some of the incremental elements to much more connected, data-driven, intelligent and overall holistic level of care. And it seems like you and your team at CVS and Caremark and beyond have really been leading the charge to help accelerate that future faster. So thanks for all you're doing. Thanks for joining us today on Healthy Conversations.

Dr. Dan Knecht:
Thank you, Daniel. Enjoyed the conversation.