Specialty Pharmacy with a Focus on Outcomes – Dr. Autumn Zuckerman

Hillary:    00:01    Welcome to the talk to your pharmacist podcast. We’re dispensing stories of success from across the continuum of care. I’m your host, Hillary Blackburn. Thanks for joining us to learn from leaders throughout the pharmacy industry. This podcast is sponsored by their works relief. Many of you get sore, achy legs from standing all day or get asked about painful foot and leg cramps. If so, you’re going to want to hear about their works. Really a clinically proven topical foam that prevents and relieves muscle cramps and soreness. Learn more at their works. relief.com. all right, so today we have a special guest on the talk to your pharmacist podcast, our guest Dr Autumn Zuckerman and she received her doctor of pharmacy degree from Stanford University, the quarter school of pharmacy and then completed two years of Ash p accredited residency training at the Tennessee valley healthcare system via specializing in ambulatory care. She then began working at Vanderbilt specialty pharmacy. We are actually here today. Uh, they’re on site in July of 2015 and soon after joining the infectious disease team where she provided clinical pharmacy services under a collaborative practice agreement. For those with Hep c infection and um, high risk for HIV acquisition. Dr Zuckerman was appointed program director of Health Outcomes and research at Vanderbilt Specialty Pharmacy in January of 2018 and since its inception, the Vanderbilt Specialty Pharmacy Outcomes Program has engaged in numerous outcomes research projects demonstrating the value of pharmacists in specialty pharmacy practice setting. And she also serves as an affiliate professor at the ut or University of Tennessee College of Health Sciences, Lipscomb University College of Pharmacy and Belmont University College of Pharmacy and was recently awarded the recipient of the crawl, Wayne Shaddox Pharmacy Practitioner of Excellence Award from Sanford. And you were the welcome speaker, right?

Autumn:    02:19    Yeah, ceremony white coat. Um, so as program director of Health Outcomes and research at Vanderbilt specialty pharmacy or VSP, um, her goals are to empower clinical pharmacist to Birdie’s meaningful research that improves the way we deliver specialty care and demonstrates the value of the pharmacist and patient care. Autumn, welcome to the talk to your pharmacist podcast. Thank you for having me. I’m excited to be here. Well, thanks for joining us. And now that our listeners have heard a little bit about your background, maybe you can fill in any gaps from that intro or share a little bit about your personal life. Sure. Yeah. So, um, like you said, I did a PGY two and ambulatory care and then just got interested in health outcomes research, uh, because it really demonstrates the value of pharmacist and how we can provide care in the clinics and, um, really help physicians and nurses and the hall clinic staff understand what a pharmacist can do, um, and our values. So that’s kind of how I got into that. Um, besides that, I am married to Scott Zuckerman, who is finishing his seven years of neurosurgery training. So we’re really excited about that. Um, we’re going to be moving to Africa for about six months to work in a hospital down there. So that’s exciting. Um, I’m an aunt of two wonderful nephews and other than that, just like to be outside and listened to music.

Hillary:    03:42    Awesome. Well, autumn, um, so much exciting things. And first, could you just give a little bit of a background on Vanderbilt Specialty Pharmacy Program? I would say you guys probably have one of the largest, if not the largest in the US. Um, in terms of specialty pharmacy. Yeah. So Vanderbilt Specialty Pharmacy started in 2012 and we were the second health system specialty pharmacy in the country. The first was fair view. Um, and the way that we started, we really thought it was important to have the pharmacist integrated into the clinic.

Autumn:    04:19    So, um, we are now in 22 different clinics. We have 36 pharmacists and each of those pharmacists physically sit in the clinic with the providers, seeing patients right after they’ve seen the provider. Um, and so we provide services all the way from deciding what treatment might be best for the patient, which specialty medication to helping them access the medication, which is really difficult and specialty because these are expensive medications. So we have technicians that are also in the clinic with us doing prior authorizations. The pharmacist do the appeals and then we help with financial assistance as well. Um, and then monitoring. So it’s not just, you know, here’s your medicine. We’ll see you in six months. We have very close followup with our patients. We have monthly refill calls where we’re seeing are they adherent? They are having side effects. Have they been to the hospital er visits? Um, so that close monitoring pieces is something that’s a little bit different with specialty. Um, but yeah, we’re across, like I said, 22 different clinics, 36 pharmacist and over 175 employees. So those pharmacists are kind of out in the clinics. And then we also have a whole hub where we are today, um, where we actually mail the prescriptions to the patients.

Hillary:    05:28    Wow, so 22 different clinics. That is a lot of different areas. So just for our listeners who may not be as familiar with specialty pharmacy, could you tell maybe like some of the most common or the most, I guess the biggest needs for specialty pharmacy?

Autumn:    05:49    Yeah, so by and large, our biggest clinics are rheumatoid arthritis and inflammatory bowel disease. Ibd and Ra, um, are the most common that we have. We feel the most prescriptions for, um, behind that is multiple sclerosis is a really big clinic. Um, some of those drugs are kind of moving towards infusions, but still a lot of oral medications. Um, and then oncology, I worked in the Hepatitis C and HIV clinic. Those are specialty disease states. Uh, we have a pharmacist in movement disorders and Migraines. We have Pah, IPF, um, cystic fibrosis, lipid ology with the PCSK nine inhibitors. Um, those are the big ones that I can think of. Uh, but then you’ve got really specialty disease states and endocrinology with certain bone disorders. So we have patients that come from all over the country. We actually serviced 47 different states, so patients come from all over the country to see these providers at Vanderbilt and were able to fill their specialty medications and ship to those states. Wow. And so not only are our patients coming to see the worldclass, uh, providers at Vanderbilt, they’re also getting worldclass pharmacy services through the specialty program.

Hillary:    07:09    Um, and then you guys also provide a specialty services for other health systems to, am I right on? Um, I think actually I have a, a friend who might do some of that recruiting. So if there might be a health system that is not familiar or doesn’t have the resources to um, set, stand up their own program, they could outsource some of that to you guys.

Autumn:    07:36    Yeah, we started that pretty recently because we had so many health systems coming to essay saying, how did you start your program? How do we do this? There’s a lot that goes into starting and investing in those medications. Initially building those clinics, you have to have um, patient care program. So for every medication, every clinic you have to have a plan of how you’re going to take care of the patient. So building those out, there’s a lot that goes into accreditation. So typically to get contracts with insurance companies, you have to have at least one accreditation. So those are things that we had multiple health systems coming to Vanderbilt to see how can we do this, how do we do this? And it became really a full time job kind of hosting them and giving them advice. So we created a consulting arm that will go in and help specialty pharmacies within health systems that are starting to build their programs.

New Speaker:    08:26    Awesome. Well, very good. Um, so autumn, could you tell us a little bit about what are some of the responsibilities and tasks of a specialty pharmacist?

Autumn:    08:36    Sure. So I’ll kind of just give you a day in the life of when I was in clinic. Um, so in the infectious diseases clinic I would, well when a patient first comes in, they would see the provider and the provider would kind of assess them, make sure that they had chronic hepatitis C, talk to them about risk factors and maybe how they got it. And then he’d come back into the room and debrief me and talk a little bit about the patient. And then as a specialty pharmacist, I went in and talked to them about their medications, perform medication reconciliation, um, assessed based on the information that we had, what might be the best treatment for them, and then counseled them on, um, both the medications and what to expect from the medications and the process. So I kind of alluded to the fact that it can be difficult to get these patients on treatment because they’re so expensive. So, um, I would kind of caution them, you know, keep answering my phone calls because he could take a couple of days to a week. And that specifically, and Hepatitis C was difficult, um, when we were first starting, uh, with those medications and certain insurance plans. But we talk about that process of getting them on treatment that helps keep them engaged and know what to expect. So after that initial visit that I made sure all their labs were completed in time and their imaging was completed so that we could decide which treatment was best. And once we had that workup and we have that workup, then we’ll say, here are all your possible options. Um, talk to the physician, talk to the insurance company and see which medication would be covered for them. Um, and then we’d go through the process of getting them approved. So we have great technicians that completed a lot of the prior authorization paperwork for us at the beginning, and we usually review that, submit that. Um, and then if it’s approved, that’s great. If it’s denied, then we help write letters of medical necessity. So when I first started, I was a little bit worried about that and I was like, I had retail experience where I didn’t want to fight with the insurance company and be doing pas all day, but I’m writing appeal letters. You’re really advocating for the patient and it means so much to them. Um, and it’s, it’s pretty interesting because you’re a lawyer building the case to get your patient the treatment. So you referenced the clinical trials and the primary literature and why the patient should be approved. So we’re pretty successful in that. We have about 96% access rate for most of our medications. Um, and then after the patient’s approved, we help them with financial assistance. That could be in the form of a grant through a foundation or through manufacturer Copay Card if they have commercial insurance, um, or through the Vanderbilt medication assistance program grant. So we walked through all those different possibilities. If their copays on affordable after insurance, um, and then if they don’t have insurance, we help them from the beginning get set up on a patient assistance program with the, with the medication manufacturer, and then we counsel them either in clinic or on the phone in depth. And uh, then we have monitoring after they’re on treatment. So every month we’re calling him like I was in for their refill. And then we have clinical pharmacists assessments either quarterly or every six months or annually. Um, and then in some disease states, like in Hepatitis C, I would actually see them in clinic at four weeks, at eight weeks, and that at the end of their treatment, um, so I was the one kind of performing those management, uh, appointment so the provider could see more new patients and, um, cure more patients. So that was pretty neat. So those are our main goals is kind of like making sure medications are appropriate, getting access to treatment and then optimizing them while they’re on treatment, helping them through side effects. Because a lot of specialty medications have side effects. So we don’t just say, you know, good luck that you may experience this will say you are probably going to experience this and here’s how to mitigate it or, or help get over those side effects.

Hillary:    12:22    Yeah. Very interesting. And so it’s, it’s a little different than a regular community or maybe even just a an ambulatory care position where, um, you guys are dealing with, with some of the insurance difficulties and, and cost and, and a lot of times these diseases are um, uh, really challenging. So having a diagnosis of Hepatitis C. Um, so yeah, it’s, it’s very interesting to hear more. Yeah. And it’s very, we tell people who interview, it’s a perfect marriage of retail. We have pharmacists that have come from retail that have done great pharmacists that have come from PGY one PGY, two trained that have done really well. Cause it’s that clinical involvement, clinical piece expertise, writing soap notes, working with the clinical team and then also the retail side of helping patients access treatment. So, and you’re right, you really are there for them at the time where they’re diagnosed with something that’s really difficult and challenging.

Autumn:    13:26    So it’s a great opportunity to build relationships with patients.

Hillary:    13:29    Awesome. Uh, and so autumn, just a little bit more kind of about the landscape of specialty pharmacy. So we keep hearing how specialty pharmacy, uh, the drug prices with specialty is, is definitely something of concern. Um, but it’s only about 2% of the population is affected. So, um, what, what are some kind of like higher level things that you could share I guess, about the industry in general? Sure. So that’s definitely what you hear in the news is how expensive these medications are. And our patients are very blessed because we do help them through this process and make sure that they get treatment. Um, and so I kind of have a little bit of a biased view, but I think that there’s a lot of hype about how expensive the medications are and that’s, you know, who’s to say whether they are, that’s how much it cost to make them and all that.

Autumn:    14:24    I’m not going to comment on that. But I will say that there are lots of programs out there to help patients afford medication. And it breaks my heart when patients hear, like I had patients come to the Hep c clinic or even call them and say, Oh, I’m not going to come to my appointment because I can’t afford the medicine. And they’re so many foundations and patient assistance programs that are set up to help patients cover those costs. Um, that I hate that it deters them. Oh wait, that’s the conversation started. That deters them away from seeking treatment. Um, so I would, you know, about 30% of retail spending is on specialty for about 2% of the population’s. Those numbers were right on. But what I don’t think we talk enough about is non-optimized medications. So even after you’re paying for the medication, how is that medication being delivered to the patient? Who’s monitoring them, who’s taking care of them? Um, and that’s what specialty pharmacist can really do, is make sure it’s the best medication for them, that they’re benefiting from it. And as soon as we know they’re not benefiting from it, we’re stopping treatment because we don’t want to waste costs and costs more money. Um, but making sure it’s safe, it’s appropriate, they’re benefiting from it. Um, I think that’s a really important piece of the conversation that we haven’t really talked about. And as you know, pharmacists are not reimbursed for their services and so we’re doing all of these extra services to make sure they’re being used appropriately without getting reimbursed for it. So, um, there’s a, there’s a lot that goes into this specialty landscape a lot around drug pricing. That’ll be interesting to see how exactly it plays out. Um, but I don’t think that without legislation much is going to change. I mean they were talking about a $3 million drug at the last conference that I went to. That was, again, a cure. But when the science is advancing, you know, beyond how the healthcare system is paying for it, you’ve got a problem. So we’re curing people, how do you pay for a cure for the rest of their life? So, right, right. And Are you all able to use any of the new biosimilars or, yeah, we’re definitely able to use them. I would say we haven’t had a huge uptake of them at Vanderbilt. Um, we have a lot of providers that, um, we’re in the controlled clinical trials and where investigators on those trials. But I think we’re very open to it and it’s something that we would love to see more of. Um, but haven’t seen a lot of uptake yet on the provider’s side. Yeah, definitely hearing that.

Hillary:    16:55    Uh, so let’s talk about outcomes. So that is something that, uh, you’re really passionate about and, um, I think it’s, it’s so important. So we’re, we’re hearing more and more about like, how do you, um, you know, demonstrate value based care or even like value based medicine. Um, and what a great, uh, like niche of pharmacy to look at that was with these specialty medications. So what kind of things are you guys doing at Vanderbilt for, uh, to demonstrate outcomes?

Autumn:    17:27    Yeah, so you hit the nail on the head. It’s a perfect area to demonstrate what a pharmacist can do. And that’s kind of what I was alluding to earlier is we’re doing all these additional things to make sure patients are getting the outcome of the medication you’re paying for. But we’re still relying on drug margin for pharmacists salary. And that’s, you know, across the board in retail pharmacy, um, where you go, it’s all about the quantity. So how can we move to that value based. Um, so my goal with outcomes research in our goal really is to show if that drug margin goes away tomorrow, how can you justify a pharmacist in that clinic? How can we justify 36 pharmacists across 22 clinics taking care of patients? Um, so we do projects, um, that really run the full patient journey. So from the time they enter into care into monitoring them, some of the ones that we’ve done have been around access. So helping patients get on treatment. Um, like I said, we found a 96% access rate for PCSK nine inhibitors. The national average is around 35%. So our pharmacist, you’re a really good job at helping patients who are appropriate for therapy get on the therapy that they need. Um, and then another interesting study that kind of really shows the value of the pharmacist is our pharmacist that is in the IBD clinic, the inflammatory bowel disease clinic. He spends a lot of his time writing appeal letters so patients can be on a higher dose of Humira or Enbrel. Um, and if they get on that higher dose you can avoid a hospitalization. Is Surgery an infusion more expensive things. And so we’re trying to show at what rate he does that and it for patients who don’t get approved for the higher dose, what happens to them. So then we can say we’re cost savings this much money by him being able to write this appeal letter and putting some dollar signs behind the work that he is doing. So that’s, that’s a little bit, we deal a lot around adherence and persistence. We’re actually doing a prospective randomized study, um, where patients who are at risk for being non adherent to their medication are randomized to receive an additional adherence clinic intervention a versus not. And seeing what those outcomes are. Um, we recently did a study and oncology where we tailored our call schedule, so how frequently we’re monitoring patients based on when we knew the medication side effects were going to happen. So instead of saying, we’ll call you in a month for your refill, we know that they’re going to have diary on day three, so let’s call them and talk to them about their diarrhea on day three. And then on day seven and then on day 12, what’s gonna happen. Um, and we showed a 50% reduction in discontinuation rates and a medication changes. So we’re really trying to optimize the way that we provide care, helping patients get on treatment, um, and succeed while they’re on medication. So we have about 36 different projects right now. I said that’s just kind of the tip of the iceberg.

Hillary:    20:24    Yes. And where are you showing a lot of the, the results. Are you sharing it with mainly within the pharmacy profession or are you, um, kind of trying to demonstrate back to Vanderbilt, like, Hey, this is why we have so many pharmacists on staff.

Autumn:    20:43    Yeah, exactly. So we, we go everywhere. So we really try to hit the medical community because we think that’s really important. Um, we actually got a podium presentation at the American transplant Congress coming up on our, um, collaborative practice agreement in that clinic and how we’re able to reduce provider burden, increase the speed to patients getting their medication when you have a pharmacist prescribing the therapy. Um, so that was accepted as a podium presentation, at ATC. So we really tried to go to the medical community and show the value of the pharmacist there. And then we typically do encore presentations at pharmacy conferences. So AMCP, APhA, after we’ve presented or tried to present to the medical community will take there. Um, but we do a lot of our kind of access adherence, um, managed care things will take to AMCP. Um, we have 20 students that we work with on research projects, so they always like to present a asap. Um, and again they can kind of do an encore presentation. Um, we just had two pharmacists go to CPMP, which is the psychiatric and neurologic pharmacist. So we want the pharmacist to go somewhere where they’re going to benefit and learn more and kind of see their peers. So it’s all over the board. And we just got back last week from Baltimore presenting at the Pharmacy Quality Alliance, um, where we were talking about developing quality measures and how do we assess, um, how well we’re providing care. And we actually had a technician that presented at that conference, so that is really exciting.

Hillary:    22:13    Speaking of education, are you aware of the 2014 drug disposal of controlled substances ruling that regards safe disposal of unused medications? Well, we’re lucky to have rx destroyer sponsoring the talk to your pharmacist podcast rx destroyer ready to use chemical drug disposal systems are safe, easy and affordable products which protect the environment and can save thousands and fines to get more information on products, training and medication waste compliance. Check out www.rxdestroyer.com/talk to your pharmacist. Um, yeah, I, I love that. I think, I think, um, I have been following more and more of the medical community or looking at the broader healthcare space because, um, if we’re only telling the pharmacy profession what we do right, um, that’s important. But we need to be, you know, seeing what’s out there, uh, and the rest of the healthcare space. So great work with that.

Autumn:    23:14    And then, sorry, just one other thing. We take everything that we presented for the year and present that at Vanderbilt and invite the csuite and everybody to see kind of what we’re doing. And then we just got a website, VSP outcomes, research.com where we post all of our manuscripts in posters and podium presentations.

Hillary:    23:31    Wonderful. Very good. And so you work very closely with, with all the schools too. Yeah, I love it. I’m sure they love that. Um, so if someone was wanting to go into specialty pharmacy, maybe there, um, a or maybe they’ve been out practicing for awhile, um, what are some things that maybe they need to be doing or how would they be able to get involved in specialty pharmacy?

Autumn:    23:55    Yes. So I, I, I didn’t even know about specialty pharmacy until after my PGY two you, uh, when I was looking for jobs. So, uh, we really tried to go into schools of pharmacy and I have a lecture that I do with Lipscomb about here’s specialty pharmacy. I just talk to Sanford’s is poor chapter about specialty pharmacy. And I’m hearing from everyone that they really don’t know much about it. So I think we need to first do a better job at getting it into our schools is an option, especially because 50% of the drugs approved by the FDA or specialty medication. So it’s a big area and it’s a growing industry. But I would say to students, I tell them, I try to get them on research projects with us. Um, I have them at least shadow, if not take a rotation with us. Um, if they can’t get a whole month with us, then we have them shadow a couple of days. Um, just to kind of understand what it is, what a specialty pharmacist does. Um, I think that things that you can be doing are learning how to work within a health care team. Um, you know, so on those rotations a, even if it’s not specialty writing notes, talking to providers, um, because some of the interview questions or, you know, do you feel comfortable working with a team? Um, and then within retail really pay attention. I don’t think too, we get enough in pharmacy school about how do you get patients on medications? What is, what are Dir fees? What is a rems program? What are these kind of managed care aspects that we need to know about, um, to, to better understand the whole managed care piece of it, because that is, these are costly medication. So, um, like I was saying before, it’s a perfect mix of retail and clinical. So both of those rotations help, um, but try to shadow specialty pharmacists understand what they do.

Hillary:    25:39    Yeah, definitely. Um, well, wonderful. Well, autumn, um, this has been so interesting and I’m excited to be able to share this information with our listeners. But for our final question, what is some advice that you would tell your younger self or for other pharmacists who are just getting started in their career?

Autumn:    26:01    um, definitely that it works out the way it’s supposed to. So I think that we just stress so much as type a pharmacist that most of us are, you know, what am I gonna do? Where am I gonna work? Um, and like I said, I didn’t know anything about specialty. I wasn’t going to do a residency until my fourth year and things just keep falling into place and, um, and don’t close any doors, you know, meet new people, keep up with those relationships. Um, and really try to be open to doing different, different things, leadership positions that make you more comfortable with presentations, taking on research. Um, when I was interviewed for my pharmacist here, they said, well, you starting outcomes research program. I said, no way. I love patients. Like I just want to take care of patients. But my, that’s just kind of where I went towards advocating pharmacist and research. So, um, just take advantage of every opportunity that you have and know that you’re going to land where you’re supposed to be. Awesome. Well, thank you so much for being a guest on the talk to your pharmacist podcast. Thank you for having me. It’s been great.

Hillary:    27:06    And if you enjoy this episode, be sure to check out the show notes www.pharmacyadvisory.com. Thanks for listening to this episode of talk to your pharmacist produced by the pharmacy advisory group. If you liked this episode, let us know by subscribing to the podcast rating and reviewing it, share it with friends. And if you want to be a guest or know a pharmacist, a leader who has a great story to tell, connect with me Hillary Blackburn on linkedin and check out our Facebook page pharmacy advisory group for updates on new podcasts. Thanks for listening.

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Hillary Blackburn

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