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From Innovation and Integration to Impact: Advancing Health System Specialty Pharmacy at UC Davis Health | NASP Specialty Pharmacy Podcast · Pharmacy Podcast Network

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  Speaker 1: You are listening to the global network of podcasters dedicated
• 0:09
  Speaker 1: to the pharmacy profession. Welcome to the Pharmacy Podcast Network.
• 0:26
  Speaker 2: You're listening to the NASP Specialty Pharmacy Podcast, a collaboration
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  Speaker 2: between the National Association of Specialty Pharmacy and the Pharmacy
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  Speaker 2: Podcast Network. Each episode dives deep into trends, challenges, innovations,
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  Speaker 2: and patient centric practices shaping the future of this dynamic
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  Speaker 2: and rapidly evolving industry. Whether you're a pharmacist or healthcare provider,
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  Speaker 2: patient advocate, or industry leader, you'll hear expert insights, real
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  Speaker 2: world evidence, and thought provoking discussion that highlights all that
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  Speaker 2: makes specialty pharmacy.
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  Speaker 3: In support of NASP's mission to empower specialty pharmacy stakeholders
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  Speaker 3: to advance the standard of patient care, NASP supports a
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  Speaker 3: free market healthcare system in which all specialty pharmacies compete
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  Speaker 3: on the same fare and level playing field because that
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  Speaker 3: is in the best interest of the patients we collectively serve.
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  Speaker 3: NASP is committed to working with all stakeholders and policymakers
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  Speaker 3: to ensure that all patients have access to the life
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  Speaker 3: saving medications they need and the high touch patient care
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  Speaker 3: and support services they deserve from the pharmacy of their choosing.
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  Speaker 4: Hello, my name Michila Arquette, and I am the President
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  Speaker 4: and CEO of the National Association of Specialty Pharmacy. I
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  Speaker 4: am delighted to welcome my special guests, David G. Mitchell
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  Speaker 4: in Ruth Chen to this episode of the NAFP podcast.
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  Speaker 4: David Mitchell, pharm, D MBA, CSP and fc PHA is
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  Speaker 4: the Assistant Chief Pharmacy Officer Specialty Pharmacy and Home Delivery
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  Speaker 4: at UC Davis Health in Sacramento, California. A graduate of
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  Speaker 4: the US University of the Pacific School of Pharmacy, he
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  Speaker 4: also earned his MBA from California State University, Sacramento. Doctor
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  Speaker 4: Mitchell was instrumental in establishing u C. Davis Health Specialty
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  Speaker 4: Pharmacy in twenty ten and has since played a key
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  Speaker 4: role in expanding specialty pharmacy services across the u C.
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  Speaker 4: Davis enterprise. A progressive and forward thinking leader, he has
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  Speaker 4: developed and created numerous specialized pharmacy roles and positions, strengthening
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  Speaker 4: clinical infrastructure, advancing patient centered care, and enabling sustainable program growth.
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  Speaker 4: His professional interests include business development, accreditation research, and data analytics.
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  Speaker 4: He is actively involved in education as a preceptor for
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  Speaker 4: pharmacy students and residents. Doctor Mitchell has served as president
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  Speaker 4: of the Sacramento Valley Pharmacists Association and as treasurer and
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  Speaker 4: current President elect of the California Pharmacists Association. In addition,
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  Speaker 4: he has contributed to numerous committees within organizations such as CPhA, NASP,
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  Speaker 4: and ASHP. In recognition of his innovation and leadership, he
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  Speaker 4: received the California Pharmacist Association's Excellence and Innovation Award in
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  Speaker 4: twenty eighteen and the National Association of Specialty Pharmacy Distinguished
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  Speaker 4: a Service Award in twenty twenty four. Ruth Chen pharm
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  Speaker 4: DMHA is currently the Manager of the Specialty Pharmacy Hub
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  Speaker 4: at UC Davis Health and Sacramento. In this role, she
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  Speaker 4: oversees clinical services provided by Specialty Pharmacy program coordinators and
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  Speaker 4: manages centralized clinical Specialty Pharmacist Hub services in close partnership
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  Speaker 4: with clinic embedded pharmacists. Members of the Specialty Pharmacy Hub
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  Speaker 4: also serves core contributors to the newly established Rare Disease
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  Speaker 4: Clinical Pharmacy Team. More recently, Ruth has served as interim
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  Speaker 4: manager for clinic pharmacists across multiple specialty clinics. Prior to
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  Speaker 4: joining UCD Davis Health, she worked as a clinical pharmacist
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  Speaker 4: supervisor at Oschner Specialty Pharmacy and completed a pg Y
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  Speaker 4: one PGY two Health System Pharmacy Administration and Leadership residency
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  Speaker 4: with a Master of Health Administration at UW Medicine in Seattle.
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  Speaker 4: David and Ruth, thanks so much for joining me today.
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  Speaker 5: Thank you for having Mishila, Thanks.
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  Speaker 6: For having Ashila.
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  Speaker 4: So, David, let's set the stage. You see, Davis Health
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  Speaker 4: serves one of the largest geographic regions in California. Can
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  Speaker 4: you briefly describe the scale of your specialty pharmacy program
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  Speaker 4: and what differentiates it from other health systems specialty pharmacies.
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  Speaker 5: Thanks Sheila, I'll try to be brief. That's a big
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  Speaker 5: question there.
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  Speaker 6: We do.
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  Speaker 5: Cover a large geographic area which encompasses all of northern
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  Speaker 5: California from the Organ border down to the Central Valley
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  Speaker 5: the San Francisco Bay area, and we also have many
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  Speaker 5: patients in Nevada. So this coverage area is over thirty
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  Speaker 5: thousand square kilometers and the specialty pharmacy serves nearly ten
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  Speaker 5: thousand patients, So you're right, quite a large area and
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  Speaker 5: a large amount of patients as well. We support our
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  Speaker 5: patients that are in complex therapies that come to our
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  Speaker 5: academic medical center. You know, our medical center different itself
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  Speaker 5: through world class education, research and patient care. At the
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  Speaker 5: health system, we have the UC Davis Comprehensive Cancer Center,
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  Speaker 5: numerous centers of excellence, and many national key opinion leaders.
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  Speaker 5: We also have a top School of Medicine, School of Nursing,
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  Speaker 5: and we are a site for UCF School of Pharmacy
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  Speaker 5: rotations for students. We also have an award winning residency
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  Speaker 5: program with a large number of residents. In fact, this year,
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  Speaker 5: forty six residents are practicing at UC Davis Health in
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  Speaker 5: our pharmacy residency program. Wow. Yeah, so I've been told
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  Speaker 5: that is the largest in the country. I don't have
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  Speaker 5: that verified, but it is quiet amount of a large
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  Speaker 5: amount of residents and learning going on, and so they're
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  Speaker 5: quite integrated within our specialty pharmacy and all aspects of
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  Speaker 5: patient care, in our pharmacies and in our clinics and
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  Speaker 5: in impatient every aspect of the health system. We have
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  Speaker 5: a pharmacist residents involved. You know that being said, a
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  Speaker 5: lot going on, but I do think the number one
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  Speaker 5: thing that differentiates us are our people are pharmacists through
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  Speaker 5: residencies other experience, are extremely well trained. There are also
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  Speaker 5: many of them are board certified in the area of
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  Speaker 5: the specialty that they practice in, such as incology. Many
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  Speaker 5: of them also have the CSP certification and then have
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  Speaker 5: a lot of experience practicing in their specialty area. We
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  Speaker 5: also get the cream of the crop of our technicians.
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  Speaker 5: We have a lot of technicians have many years of
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  Speaker 5: experience in retail pharmacy, specialty pharmacy, and managed care, and
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  Speaker 5: many of them also have board certification, a lot of
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  Speaker 5: training and a lot of certification. But the number one
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  Speaker 5: thing that I believe that differentiates is that all these
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  Speaker 5: folks are very patient centered and very patient focused, and
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  Speaker 5: so I think that really is the top differentiator. We
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  Speaker 5: also have quite a focus on kind of our digital
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  Speaker 5: footprint and technology and research. We like others around the country,
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  Speaker 5: have full integration with the e m R, but we
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  Speaker 5: also are integrated within our dispensing system so that providers
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  Speaker 5: and patients can see all their dispenses right in the
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  Speaker 5: medical record. Our case management system, Compass RODS, is also
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  Speaker 5: embedded with EPIC as well. We also push the envelope
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  Speaker 5: with you know, being early adopters of things like Hello
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  Speaker 5: World for texting or artificial intelligence to use to improve
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  Speaker 5: our prior authorization process. Are you know, our staff are
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  Speaker 5: embedded in the clinics and we'll talk more about that,
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  Speaker 5: but you know, they have they're part of the patient
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  Speaker 5: care team, and they have access to you know, instantly
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  Speaker 5: have lab access, note access and so really all that
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  Speaker 5: comes together to help optimize safety and can see and
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  Speaker 5: that really translates to getting patients the correct safe medication
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  Speaker 5: and a very quick start time, a auto proactive work
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  Speaker 5: around safety and monitoring, and that translates also to better
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  Speaker 5: adherents and better therapy outcomes.
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  Speaker 4: So let's talk a little bit more about how being
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  Speaker 4: embedded within the health system changes writer optimizes what specialty
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  Speaker 4: pharmacy can deliver compared to standalone models right where people
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  Speaker 4: are organizations aren't embedded.
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  Speaker 5: Yeah, I think, you know, that is a big piece
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  Speaker 5: of what differentiates us and our clinical pharmacists that are
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  Speaker 5: you know, very well trained within their special area are
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  Speaker 5: embedded within the clinic, so they are part of the
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  Speaker 5: care team and you know, they are a part of
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  Speaker 5: the process of selecting therapy. Early on, when the patient
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  Speaker 5: comes to clinic appointments, they often are see the pharmacists
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  Speaker 5: separately or as a part of a shared visit with
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  Speaker 5: the physician. They're often consulted on therapy selections or a
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  Speaker 5: part of their collaborative practice agreement, are prescribing these therapies.
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  Speaker 5: And you know, a big piece is again the people.
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  Speaker 5: So we're our folks are are meeting face to face
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  Speaker 5: with patients, So we're getting to know that the patients themselves,
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  Speaker 5: involving them in the care process and decisions. You know,
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  Speaker 5: getting that face to face time, building that trust, and
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  Speaker 5: so I think that you know, translates to a a
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  Speaker 5: good working relationship with the patient and the physician down
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  Speaker 5: the road that then helped translate to safer and better
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  Speaker 5: therapy outcomes. Also, all of this work goes through really
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  Speaker 5: streamlining the process, since early on we can be doing
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  Speaker 5: things like benefit investigations, looking at formularies to help understand
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  Speaker 5: what might be the most cost effective therapy for the
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  Speaker 5: patient aslong with what is best for their condition and
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  Speaker 5: their lifestyle. And you know, all of this pre planning
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  Speaker 5: and face to face time really helps decrease the patient
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  Speaker 5: bouncing bouncing around or getting lost between different silos, and
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  Speaker 5: really streamlining the process so we're able to address things
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  Speaker 5: earlier on, make earlier in inventions to help decrease things
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  Speaker 5: like side effects. We're able to watch therapy and ty
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  Speaker 5: trate therapy, I think more closely, and then just overall
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  Speaker 5: provide a smoother patient experience for the patient through the
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  Speaker 5: whole process.
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  Speaker 4: What are the biggest payer or policy challenges facing health
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  Speaker 4: system specialty pharmacies today? In how is you see Davis
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  Speaker 4: addressing them?
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  Speaker 5: Well, we do face significant challenges around the ability to
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  Speaker 5: dispense specialty medications for patients due to what we call
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  Speaker 5: pair lockouts, which a lot of that is driven by
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  Speaker 5: vertical integration of large specialty pharmacies and PBMs. So we
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  Speaker 5: do help patients navigate this by we we actually do
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  Speaker 5: a lot of the process for the patient and for
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  Speaker 5: these specialties pharmacies, such as the prior authorization. We we
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  Speaker 5: believe that having you know, that aspect equally done for
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  Speaker 5: all of our patients helps them through the therapy process.
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  Speaker 5: We often had patients coming back to us that we
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  Speaker 5: did not do these services for, so you know, that's
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  Speaker 5: one aspect that we help at least patients navigate some
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  Speaker 5: of these issues. We also provide clinical services to all
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  Speaker 5: of our patients as well, so some of that the
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  Speaker 5: education piece, the monitoring even if we're not dispensing the medication,
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  Speaker 5: so that helps the patient and streamline therapy as well,
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  Speaker 5: and you know, to help you know, it is our
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  Speaker 5: goal to be able to dispense for all of our
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  Speaker 5: patients because we find, you know, the clinical portion goes
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  Speaker 5: very far to help with outcomes, but there's only so
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  Speaker 5: much we can do. We can't guarantee the streamlined, integrated
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  Speaker 5: experience that we give to the patients. We can do
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  Speaker 5: clinical management and dispensing for if we can't also dispense
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  Speaker 5: the medication. So we have you know, opened up discussions
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  Speaker 5: with a number of payers to open up those contracts
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  Speaker 5: to be able to dispense for all of our health
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  Speaker 5: system patients. We've also, as far as regulatory worked with
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  Speaker 5: our legislature in California to help ensure open access to
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  Speaker 5: patients and then fairness within the p b M space
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  Speaker 5: through a recent law that went into affect s P
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  Speaker 5: forty one. So you know, really you know, trying to
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  Speaker 5: smooth some of the roadbumps of pair access through our
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  Speaker 5: clinical activities, you know, as a focus, uh, interfacing with
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  Speaker 5: payers to see how we can you know, find win
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  Speaker 5: win situations and open up some of those contracts and
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  Speaker 5: then being active legislatively and you know, getting active with advocacy.
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  Speaker 5: It really has been how we've tried to address some
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  Speaker 5: of those issues and regulatory issues that we face.
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  Speaker 4: Do you only feel prescriptions for for patients who are
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  Speaker 4: seeing by your health system physicians.
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  Speaker 5: For the most part, yeah, y, but are we we
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  Speaker 5: do provide prescriptions, you know, we're are We're open to
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  Speaker 5: the public, so we have an ability to fill prescription
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  Speaker 5: and build a prescription for a patient who walks in
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  Speaker 5: off off the street. That is a possibility some cash patient,
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  Speaker 5: but overall predominantly nearly all of our patients are health
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  Speaker 5: system patients.
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  Speaker 4: Okay, yeah, that's incredible that you provide all of those services, right,
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  Speaker 4: whether or not you can dispense the drug. That's because
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  Speaker 4: that's where a lot all of the work effort in
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  Speaker 4: the cost is it is.
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  Speaker 5: And you know, we are are working through you know
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  Speaker 5: what what is the provide the patient the maximum benefit
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  Speaker 5: clinically to help with those therapy outcomes and we concentrate
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  Speaker 5: on those and but you know, we we also find
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  Speaker 5: we can only do so much, and so we do
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  Speaker 5: have to let other special pharmacies do a piece of
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  Speaker 5: of the work. And then obviously we can't dispense the medication,
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  Speaker 5: and so we unfortunately, with all the work we do,
• 17:11
  Speaker 5: we do, you know, end up the other thing we
• 17:14
  Speaker 5: end up doing is a lot of you know, I
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  Speaker 5: guess h helping and triaging issues and you end up
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  Speaker 5: playing intermediary with external specialty pharmacies because of the issues
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  Speaker 5: our patients face. And unfortunately, a lot of times if
• 17:34
  Speaker 5: we were able just to fill the medication, those would
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  Speaker 5: not be problems in the first place. But you know,
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  Speaker 5: those are some of the daily issues, especially our pharmacy
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  Speaker 5: technicians and pharmacy pharmacists have to deal with. But but
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  Speaker 5: we really we try to do the best we can
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  Speaker 5: to help all of our patients.
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  Speaker 4: Yeah, I'm sure that your you know, your physicians and
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  Speaker 4: your providers appreciate that, right because you're you're still contributing
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  Speaker 4: to the successful outcome of this patient on which they
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  Speaker 4: are graded right or their mind.
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  Speaker 5: And you know, from a physician standpoint, it's really hard
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  Speaker 5: them for them to differentiate between a patient that fills
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  Speaker 5: at our specialty pharmacy and one that doesn't, and they're
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  Speaker 5: really concerned with all their patients. And you know, going
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  Speaker 5: back to that relationship of the clinical pharmacist and the clinic,
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  Speaker 5: you know that they're also there as part of the
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  Speaker 5: team for the clinic and so you know they want
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  Speaker 5: the best for all their patients. But going back to
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  Speaker 5: the you know, the providers and physicians, they really highly
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  Speaker 5: love our services. You know, I always remember one of
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  Speaker 5: our first clinics where we had a very very nice
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  Speaker 5: physician but just honestly say, I have no idea what
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  Speaker 5: a pharmacist is going to do my clinic are they're
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  Speaker 5: going to be dispensing medication? And then within a year
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  Speaker 5: that that uh physician was like, I don't know what
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  Speaker 5: I would do without my clinical pharmacists because they've become
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  Speaker 5: such an integral part of the of managing their patients,
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  Speaker 5: especially in all the biologics that that are out there.
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  Speaker 5: And you know, we are finding, you know, comments on
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  Speaker 5: our provider survey that we used through an ASP annually
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  Speaker 5: of just amazing feedback from these physicians. It decreases physician burnout.
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  Speaker 5: They're able to you know, see more patients. They're able
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  Speaker 5: to you know, provide therapy, uh, you know, safe therapy
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  Speaker 5: that's more effective because they have the pharmacists a part
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  Speaker 5: of the care team. And just the feedback of our
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  Speaker 5: overall services are are just amazing from these providers, So
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  Speaker 5: they really do appreciate our services. And then you know,
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  Speaker 5: we do the quarterly an ESP patient survey and you know,
• 20:09
  Speaker 5: get an amazing feedback from our patients. So we really
• 20:12
  Speaker 5: feel that, you know, from the feedback we get from patients,
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  Speaker 5: the feedback we get from providers really speaks to this
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  Speaker 5: integrated model and just the benefits that are patients providers
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  Speaker 5: received from the model and the care that we provide.
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  Speaker 6: Yeah.
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  Speaker 7: I have a son who is a surgeon, and we
• 20:32
  Speaker 7: were talking discussing some of this, and he was and
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  Speaker 7: this kind of hit me because he said, we're held
• 20:36
  Speaker 7: accountable for these outcomes, but we can't pick anybody that
• 20:39
  Speaker 7: we want to work with, right We're told what pharmacy,
• 20:42
  Speaker 7: what imaging, what lab even sometimes no, not.
• 20:44
  Speaker 4: That drug, this drug. Yeah, And I thought, wow, that's
• 20:47
  Speaker 4: pretty pretty interesting. And he tells me the same thing
• 20:49
  Speaker 4: because he's at you know, a health system or hospital
• 20:52
  Speaker 4: health system and that's what he thought would be lost
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  Speaker 4: without my pharmacists. He's like, they're amazing.
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  Speaker 5: Yeah. Yeah, I mean, you know, we and a lot
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  Speaker 5: of our clinical areas don't work with surgeons, but one
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  Speaker 5: area we do that comes to mind when you mentioned
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  Speaker 5: your son is transplants. So you know, oftentimes they do
• 21:12
  Speaker 5: get a chance to work with us, and you know,
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  Speaker 5: we've shown that we are able to keep our patients
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  Speaker 5: more adherent and have better outcomes that utilize our pharmacies,
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  Speaker 5: and I you know, the surgeons and the clinic physicians,
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  Speaker 5: you know, really appreciate the services that we provide. And
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  Speaker 5: that was one of our earlier programs actually was our
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  Speaker 5: first program that started in twenty ten and just has
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  Speaker 5: been become just a you know, a real key component
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  Speaker 5: the success of our transplant program here at UC Davis
• 21:51
  Speaker 5: Health is having that integrated pharmacy within that program.
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  Speaker 4: That's awesome. So as we look through the future, what
• 22:00
  Speaker 4: innovations or strategic initiatives are you most excited about that
• 22:05
  Speaker 4: are going to impact the future of specialty pharmacy at
• 22:08
  Speaker 4: U see Davis Health.
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  Speaker 5: Yeah, so I'm really excited about the future at UC
• 22:14
  Speaker 5: Davis Health. Specialty pharmacy are really excited for you know,
• 22:19
  Speaker 5: all the amazing therapies that are coming to market, and
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  Speaker 5: you know, we've really not shifted, but we've opened up
• 22:28
  Speaker 5: an approach to caring for disease states rare diseases where patients, uh,
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  Speaker 5: there's a smaller patient population. So we've established our Rare
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  Speaker 5: Disease Center within our Specially Hub, which Ruth will tell
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  Speaker 5: you more about. We are seeking Rare Disease URRAQ Center
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  Speaker 5: of Excellence certification here coming up but next week. So
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  Speaker 5: we're really excited about that and really trying to meet
• 23:01
  Speaker 5: the needs of rare disease patients. And I really do
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  Speaker 5: think we've talked a lot about that integrated care model
• 23:08
  Speaker 5: and what makes you see Davis special, and I really
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  Speaker 5: think all the things come together to you know, really
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  Speaker 5: provide an excellent situation to provide the best care for
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  Speaker 5: these patients with rare diseases. We're looking at, you know,
• 23:27
  Speaker 5: through technology and data analytics, really improve our research that
• 23:33
  Speaker 5: we do. I'm really excited about that. We have our
• 23:38
  Speaker 5: director director especially Value and Trade Relations, Tiffany Fun that's
• 23:42
  Speaker 5: heading an effort to really improve our relationship with pharma
• 23:48
  Speaker 5: and really be a partner to you know, research these
• 23:52
  Speaker 5: agents and in practice and really help and improve the
• 24:00
  Speaker 5: outcomes that our patients are receiving with these medications. I'm
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  Speaker 5: really excited about those partnerships and what that research will
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  Speaker 5: highlight and and really help to drive to improve care.
• 24:13
  Speaker 5: We really focus on technology and uh improving digital communication
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  Speaker 5: with our patients. So we've invested a lot in our
• 24:25
  Speaker 5: app our patient portal through my UC Davis Health are
• 24:31
  Speaker 5: also known as my Chart through EPIC and so providing
• 24:35
  Speaker 5: a lot of self help tools and education that patients
• 24:38
  Speaker 5: can receive at the time that they want to receive
• 24:41
  Speaker 5: it or you know, interact through that portal. We've also
• 24:47
  Speaker 5: you know, invested in texting so that patients can receive
• 24:51
  Speaker 5: text and we can you know a lot of patients
• 24:57
  Speaker 5: you know, like that ability to communicate fashion. We're also
• 25:02
  Speaker 5: looking at how we can become improve the quality of
• 25:06
  Speaker 5: our operations and efficiency as the specialty pharmacy gets larger
• 25:13
  Speaker 5: and serves more patients. So we're looking at how we
• 25:16
  Speaker 5: can employ technology such as arterficial intelligence with the prior
• 25:21
  Speaker 5: authorization other processes to be able to you know, further
• 25:27
  Speaker 5: improve things like speed to therapy. We're we're already amazing,
• 25:30
  Speaker 5: but we're always trying to push how we can do better,
• 25:34
  Speaker 5: and so technologies we're hoping technologies like artificial intelligence, and
• 25:38
  Speaker 5: we're the early signs that we're seeing of some of
• 25:42
  Speaker 5: the implementations of that technology. We have seen uh, you know,
• 25:47
  Speaker 5: reductions and turnaround time and improvements. So we're really hopeful
• 25:52
  Speaker 5: that that will continue to help us improve the patient
• 25:56
  Speaker 5: journey and through the prescription process. So really looking forward to,
• 26:02
  Speaker 5: you know, further leveraging technology to improve the process and
• 26:07
  Speaker 5: patient care.
• 26:08
  Speaker 4: Well, now, Ruth, let's chat with you, and let's talk
• 26:10
  Speaker 4: rare disease and why strategy matters. So why is it
• 26:15
  Speaker 4: important for our health system, especially pharmacy to have a
• 26:18
  Speaker 4: focused strategy for rare and complex diseases.
• 26:23
  Speaker 6: Yeah, Shela, I think this is a great question because,
• 26:26
  Speaker 6: as Dave kind of highlighted, our specialty pharmacy program here
• 26:30
  Speaker 6: at UC Davis services patients you know that are geographically
• 26:36
  Speaker 6: diverse and expansive. But also with the way our program
• 26:41
  Speaker 6: has grown and established clinical areas, we are starting to
• 26:46
  Speaker 6: see those patients who have rare and complex diseases that
• 26:48
  Speaker 6: are within those kind of your bread and butter specialty
• 26:52
  Speaker 6: pharmacy spaces. You know, rheumatology always has some of those
• 26:57
  Speaker 6: classifications of rare diseases. You know, cardiology clinic definitely does
• 27:02
  Speaker 6: as well. And so while those clinic pharmacists are able
• 27:07
  Speaker 6: to support these patients under our specialty pharmacy model, there
• 27:10
  Speaker 6: have been instances where it's been identified that there are
• 27:14
  Speaker 6: patients who because of there were diagnosis or like the
• 27:20
  Speaker 6: limited distribution of a drug, we've needed to explore having
• 27:26
  Speaker 6: a team that can support these patients because they've come
• 27:29
  Speaker 6: to UC Davis for their care because we have a
• 27:32
  Speaker 6: provider who is a leading expert for that disease state.
• 27:38
  Speaker 6: And since our specialty pharmacy program has grown and we've
• 27:41
  Speaker 6: had the footprint that we've had in our specialty clinics,
• 27:45
  Speaker 6: it's also meant that we have these smaller clinics that
• 27:48
  Speaker 6: maybe we don't have an embedded pharmacist, and but that
• 27:52
  Speaker 6: is the clinic that a patient is seen at who
• 27:55
  Speaker 6: has a rare disease, who in the last few years
• 27:58
  Speaker 6: finally has a drug tree option available to them because
• 28:03
  Speaker 6: we've gotten to that point and ultimately that patient in
• 28:08
  Speaker 6: order to get a therapy that treats their condition and
• 28:12
  Speaker 6: manages their condition so that they can go about their
• 28:16
  Speaker 6: life and kind of feel like there is a solution
• 28:23
  Speaker 6: and a medication that is beneficial to them. They do
• 28:28
  Speaker 6: need our pharmacy team's support. But the reality is a
• 28:33
  Speaker 6: lot of these disease states, we have very few patients
• 28:36
  Speaker 6: within the system who have the diagnosis and neat criteria
• 28:40
  Speaker 6: to be on these therapies, and as a result, the
• 28:43
  Speaker 6: way that our specialty pharmacy program is set up, we
• 28:47
  Speaker 6: don't have We can't justify allocating one pharmacist to that
• 28:53
  Speaker 6: clinic to serve five patients. But if we centralize that
• 28:57
  Speaker 6: model and we look at the opportunity ahead of us,
• 29:00
  Speaker 6: as we get access to these therapies or established relationships
• 29:05
  Speaker 6: with these providers and clinic, we'll be able to support
• 29:08
  Speaker 6: those patients and provide that quality patient care that we
• 29:12
  Speaker 6: pride ourselves in.
• 29:14
  Speaker 4: Yeah, I was a pharmacy dijector for a health plan
• 29:17
  Speaker 4: for many years, and so for some of these you know,
• 29:19
  Speaker 4: rare and orphaned disease patients, we never knew that they
• 29:23
  Speaker 4: were part of the plan until a treatment became available,
• 29:26
  Speaker 4: right because there was nothing anybody did for them, and
• 29:29
  Speaker 4: so they didn't you know, rise to the level that
• 29:31
  Speaker 4: would would get somebody's attention. So that's how I remember
• 29:35
  Speaker 4: when the drug for Douche muscular diystrophy became available, We're
• 29:38
  Speaker 4: scrambling trying to figure out, Okay, how many of these
• 29:40
  Speaker 4: patients do we have, right, because we didn't even know
• 29:43
  Speaker 4: there was nothing to treat them to your point.
• 29:46
  Speaker 6: Right, And interestingly enough, that is actually one of our
• 29:49
  Speaker 6: clinics here that you know, the team supports those patients
• 29:54
  Speaker 6: and while we don't have access to the therapies, we're
• 29:57
  Speaker 6: seeing the success story of those patients on the therapy
• 30:01
  Speaker 6: and so we you know, we continue to support them
• 30:03
  Speaker 6: on that on that journey, and you know, our hope
• 30:06
  Speaker 6: is if we demonstrate our value, we can kind of
• 30:09
  Speaker 6: break down some of those barriers that will make it
• 30:13
  Speaker 6: easier for those patients, whether uh, you know, they will
• 30:18
  Speaker 6: ever be able to use our pharmacy or not, but
• 30:20
  Speaker 6: at least they have access to the therapy and they
• 30:25
  Speaker 6: have a pharmacy team member who could support them. But
• 30:30
  Speaker 6: you know, definitely, our Rare Disease team has been centered
• 30:33
  Speaker 6: around the medications that we do have access to and
• 30:37
  Speaker 6: the and the patient populations. However, we are hoping that
• 30:41
  Speaker 6: one day that model expands to uh you know, continue
• 30:45
  Speaker 6: to support patients who do have some of those road
• 30:48
  Speaker 6: diseases that right now our pharmacy will not be able
• 30:52
  Speaker 6: to dispense for, but we have a service that can
• 30:55
  Speaker 6: at least ensure that they don't have gaps and care.
• 30:59
  Speaker 4: So are implementing the rare disease hub model. What were
• 31:02
  Speaker 4: the biggest challenges you see Davis faced in managing rare
• 31:05
  Speaker 4: disease patients and how did those challenges shape the development
• 31:09
  Speaker 4: of this hub model and its core functions for both
• 31:12
  Speaker 4: patients and the providers.
• 31:15
  Speaker 6: Yeah, so, you know, definitely a two part question here.
• 31:18
  Speaker 6: So I think the first part, you know, some of
• 31:20
  Speaker 6: the biggest challenges I kind of addressed earlier is where
• 31:24
  Speaker 6: are these patients being seen, which providers are seeing them,
• 31:29
  Speaker 6: what is their therapy selection strategy? And do they even
• 31:33
  Speaker 6: know that they could ask pharmacy to help them out?
• 31:38
  Speaker 6: And I think, anecdotally in my time here at you
• 31:41
  Speaker 6: See Davis, one thing I have learned is that when
• 31:45
  Speaker 6: providers for complex therapies don't have support and they and
• 31:50
  Speaker 6: their clinic staff are kind of on their own navigating
• 31:54
  Speaker 6: the first patient that they're trying to get on a therapy,
• 32:00
  Speaker 6: the pharmacy speak of navigating insurance and identifying what pharmacy
• 32:04
  Speaker 6: needs to fill with therapy is kind of something that
• 32:07
  Speaker 6: pharmacy is the expert on, and so that was something
• 32:11
  Speaker 6: that we really took to mind when we were exploring
• 32:17
  Speaker 6: and justifying why we wanted to bring around a centralized
• 32:23
  Speaker 6: hub model that would be able to support these rare
• 32:25
  Speaker 6: disease patients. And so in terms of challenges in developing
• 32:32
  Speaker 6: this hub model, you know, Dave talked about, we have
• 32:37
  Speaker 6: really good clinic based footprint with our pharmacists, so developing
• 32:44
  Speaker 6: a central lized hub model meant that we had to
• 32:47
  Speaker 6: identify what patient population this pharmacy and pharmacists team was
• 32:52
  Speaker 6: going to number one focus on, and then number two,
• 32:56
  Speaker 6: without really talking about division of work, how do they
• 32:59
  Speaker 6: work together If a patient is seen in a clinic
• 33:03
  Speaker 6: that does have a clinic based pharmacist, but really that
• 33:07
  Speaker 6: clinic based pharmacist is not going to be the best
• 33:11
  Speaker 6: individual to support the rare disease patient. And so you know,
• 33:15
  Speaker 6: that takes a lot of collaboration and teamwork, dialogue between
• 33:19
  Speaker 6: different groups and just kind of realizing who is ultimately
• 33:24
  Speaker 6: going to make the best sense to get the work done.
• 33:29
  Speaker 6: You know, I've been at a couple of different health systems,
• 33:33
  Speaker 6: and I went to pharmacy school in the Midwest, So
• 33:36
  Speaker 6: I feel like I've seen pharmacy practice and healthcare practice
• 33:39
  Speaker 6: across the country. And let me tell you, we don't
• 33:43
  Speaker 6: practice pharmacy and providers don't have the same healthcare practices everywhere.
• 33:51
  Speaker 6: It's not the same and kind of learning and understanding
• 33:55
  Speaker 6: and adapting to how care is delivered, what the mission
• 34:00
  Speaker 6: and values are here at UC Davis, and how our
• 34:04
  Speaker 6: pharmacy team prides itself in a very progressive practice under
• 34:10
  Speaker 6: our CPAs, while also recognizing that there's therapy state, therapies
• 34:15
  Speaker 6: and disease states that don't live under those CPAs, and
• 34:19
  Speaker 6: therefore we do need the providers to really work with
• 34:25
  Speaker 6: us to ensure correct documentation and that labs are ordered
• 34:30
  Speaker 6: and that they send a medication order to the correct
• 34:35
  Speaker 6: pharmacy so the patient can actually fill the medication. And
• 34:41
  Speaker 6: so those are just some of the challenges and conversations
• 34:44
  Speaker 6: that kind of came about when it comes to developing
• 34:48
  Speaker 6: this hub team, and then in terms of like core
• 34:52
  Speaker 6: functions for patients, the pharmacy team and providers, I think
• 34:58
  Speaker 6: it was easy for us and I say that loosely,
• 35:05
  Speaker 6: it's not it wasn't truly easy, but we had a
• 35:10
  Speaker 6: really good framework to work off of, coming off our
• 35:14
  Speaker 6: specialty pharmacy model that it was really about what needed
• 35:18
  Speaker 6: to be adjusted to meet the needs of you know,
• 35:23
  Speaker 6: the rare disease patient population. Dave mentioned we're going up
• 35:27
  Speaker 6: for RAQ rare disease COE and you know, there's a
• 35:31
  Speaker 6: couple extra things that we need to do. So instead
• 35:34
  Speaker 6: of reinventing the wheel, it was looking kind of what
• 35:37
  Speaker 6: is extra on top of the way we already provide
• 35:41
  Speaker 6: care as a team to ensure that those needs are
• 35:45
  Speaker 6: being met and that doesn't happen overnight. You know, that's
• 35:52
  Speaker 6: a reflection of how our specialty pharmacy team has been
• 35:56
  Speaker 6: built over the last decade and how it's grown and
• 35:59
  Speaker 6: how we've opted demise and use those technologies, tools, the
• 36:05
  Speaker 6: workflows that we have to have allowed our program to
• 36:09
  Speaker 6: grow to the point that it is at that we
• 36:12
  Speaker 6: can really look at this patient population and say, we
• 36:18
  Speaker 6: know that we can do this, and that's why we
• 36:21
  Speaker 6: took the time to develop it.
• 36:25
  Speaker 4: So once a patient qualifies for therapy, and this is
• 36:28
  Speaker 4: another two part question, Yeah, what does the journey look
• 36:31
  Speaker 4: like from education through initiation and monitoring in what payer, operational,
• 36:36
  Speaker 4: or manufacturer related barriers are most common in rare disease programs.
• 36:42
  Speaker 6: Yeah, so when a patient qualifies for therapy, and I'll
• 36:47
  Speaker 6: go ahead and use our hypertrific cardiomyopathy patient population here,
• 36:53
  Speaker 6: when a provider has determined that the patient is a
• 36:56
  Speaker 6: candidate for therapy and has written that prescription and it
• 37:01
  Speaker 6: is transmitted through our electronic medical record which is EPIC,
• 37:06
  Speaker 6: and it's captured in our ms Q, and a cardiology
• 37:09
  Speaker 6: technician grabs that order and essentially starts it, benefits investigation
• 37:16
  Speaker 6: and works on a prior authorization. My experience has been
• 37:21
  Speaker 6: that the Advanced Cardiac Therapy Provider group really has their
• 37:26
  Speaker 6: documentation down, is really good at making sure that a
• 37:30
  Speaker 6: patient is not going to start therapy if they don't
• 37:32
  Speaker 6: meet all the criteria. But in the event that there's
• 37:35
  Speaker 6: ever information for a prior authorization that a technician needs
• 37:38
  Speaker 6: that they can't find in the chart, they work with
• 37:42
  Speaker 6: one of the clinical pharmacists to verify or seek that
• 37:46
  Speaker 6: information and then ensure that it's documented in the chart
• 37:50
  Speaker 6: so that we can kind of navigate the insurance coverage process.
• 37:54
  Speaker 6: As smoothly as possible. Our goal is to always get
• 38:01
  Speaker 6: coverage for a medication for a patient, and so that
• 38:04
  Speaker 6: includes navigating an appeals process if you know, the request
• 38:09
  Speaker 6: is denied, working with the provider if needed, if additional
• 38:14
  Speaker 6: information is needed based on plan specific criteria, and then ultimately,
• 38:18
  Speaker 6: once that PA is approved, we work through the cost
• 38:23
  Speaker 6: of the therapy for the patient. We you know, inform
• 38:30
  Speaker 6: the patient what the cost of therapy is. Most of
• 38:34
  Speaker 6: these patients understand that this is a therapy that you're
• 38:36
  Speaker 6: taking long term and not like an antibiotic where you
• 38:41
  Speaker 6: take it for you know, a few weeks and you're done.
• 38:45
  Speaker 6: And so while some patients might hear a copain be like, oh,
• 38:49
  Speaker 6: that sounds okay, you know, we do have to remind
• 38:51
  Speaker 6: them like, this could be a copay you're paying every month,
• 38:54
  Speaker 6: or if you have a change your insurance, it could
• 38:56
  Speaker 6: look different. And so we we navigate that conversation based
• 38:59
  Speaker 6: on what needs the patient has to ensure that if
• 39:03
  Speaker 6: they are starting therapy, they will be able to stay
• 39:05
  Speaker 6: on therapy in terms of you know, parent operational considerations.
• 39:16
  Speaker 5: Uh.
• 39:17
  Speaker 6: The drug that we have access to for this patient
• 39:20
  Speaker 6: population has a REMS program, so that means that our
• 39:23
  Speaker 6: pharmacy had to get REMS certified, all the all the
• 39:26
  Speaker 6: staff needed to be trained so that they could have
• 39:30
  Speaker 6: access to the portal to ensure that we were logging
• 39:34
  Speaker 6: and screening patients at every fill appro appropriately according to
• 39:38
  Speaker 6: the criteria. And then there are some patients who can't
• 39:42
  Speaker 6: fill out our pharmacy and they have to fill externally,
• 39:45
  Speaker 6: and so going back to the fact that we use
• 39:47
  Speaker 6: U saw it, the technician is able to then release
• 39:51
  Speaker 6: the order to the filling pharmacy, whether that's ours or
• 39:54
  Speaker 6: an external pharmacy, and then from there that's kind of
• 39:59
  Speaker 6: where things dev eight. If a patient has to fill externally,
• 40:05
  Speaker 6: this clinical provider group has a great nursing team in
• 40:12
  Speaker 6: their clinic and they kind of coordinate and work with
• 40:15
  Speaker 6: patients who have to fill externally. But for patients who
• 40:19
  Speaker 6: fill internally, at that point, our pharmacist will do a
• 40:24
  Speaker 6: thorough initial medication counseling and start to therapy education for
• 40:30
  Speaker 6: the patient. And that's really in addition to that upfront
• 40:37
  Speaker 6: conversation that the provider has already had with the patient
• 40:41
  Speaker 6: before UH determining that they want to put the patient
• 40:46
  Speaker 6: on therapy. Just with all the screening and monitoring requirements.
• 40:50
  Speaker 6: I don't think we've ever come across a patient who
• 40:53
  Speaker 6: was shocked when the pharmacist reminded them that they, you know,
• 40:57
  Speaker 6: will be having periodic echoes and there's going to be
• 41:00
  Speaker 6: possible dose changes and titrations. Most of the patients had
• 41:03
  Speaker 6: acknowledged that this was information that had already been shared
• 41:06
  Speaker 6: to them by the provider clinic staff. And then at
• 41:10
  Speaker 6: that point, it's all about working with the patient to
• 41:13
  Speaker 6: figure out the best form of communication with them when
• 41:18
  Speaker 6: we're going to dispense the medication, and how to ultimately
• 41:21
  Speaker 6: ship the medication to the patient. And you know, we
• 41:25
  Speaker 6: do have patients who live quite far away from Sacramento
• 41:30
  Speaker 6: here in the northern California region, and I do know
• 41:33
  Speaker 6: we do have we have had patients with this disease
• 41:39
  Speaker 6: state who've lived along the California and Nevada border as well.
• 41:43
  Speaker 6: So when you really look at the distance that these
• 41:46
  Speaker 6: patients have committed to not only seeing one of our
• 41:49
  Speaker 6: providers here in Sacramento, but then the monitoring requirements that
• 41:54
  Speaker 6: they need to meet, whether that's coming back to UC
• 41:57
  Speaker 6: Davis facility or you know, an extern all location and
• 42:02
  Speaker 6: then working with our pharmacy team telephonically. You know, there's
• 42:07
  Speaker 6: a huge commitment on the patient side as well to
• 42:12
  Speaker 6: be on these therapies. And you know, our team has
• 42:16
  Speaker 6: always prided ourselves in really communicating and working with the
• 42:20
  Speaker 6: patient to work through those barriers. I think that kind
• 42:26
  Speaker 6: of touches on most of the payer operational and then
• 42:29
  Speaker 6: trying to think, if there's.
• 42:30
  Speaker 5: Really anything else that comes to mind.
• 42:33
  Speaker 4: That's enough. So as we're looking ahead, how do you
• 42:38
  Speaker 4: see the HCM model that you and the UC Davis
• 42:41
  Speaker 4: Health team developed being replicated across other rare or genetic
• 42:45
  Speaker 4: conditions within UC Davis Health.
• 42:48
  Speaker 6: Yeah, So, Sheila, like I said, I know that we
• 42:53
  Speaker 6: have a lot of rare and genetic condition patients that
• 42:56
  Speaker 6: are seen in are established specialty pharmacy service lines with
• 43:00
  Speaker 6: clinic based pharmacists, and those patients live within those established programs.
• 43:05
  Speaker 6: I don't think it's not a priority for us to
• 43:08
  Speaker 6: like pull those patients out into the rare disease team
• 43:13
  Speaker 6: because ultimately that patient can see that pharmacist in the
• 43:16
  Speaker 6: clinic and you know it is able to be supported there. However,
• 43:23
  Speaker 6: you know, one day, I think there could be a
• 43:27
  Speaker 6: therapy out there that would necessitate us pulling that patient
• 43:32
  Speaker 6: population out just because of some of the operational complexities
• 43:36
  Speaker 6: are it takes more time. What if that patient continues
• 43:41
  Speaker 6: to live in a larger program and the resource needed
• 43:44
  Speaker 6: to kind of move through some of these barriers. You know,
• 43:49
  Speaker 6: I alluded to our partnership and work with some of
• 43:54
  Speaker 6: our smaller clinics where patients do have rare genetic conditions
• 44:00
  Speaker 6: Here at UC Davis and I have been having conversations
• 44:05
  Speaker 6: and we're continuing to act actively monitor our opportunity to
• 44:10
  Speaker 6: have access to those therapies.
• 44:12
  Speaker 5: And then.
• 44:15
  Speaker 6: You know that would then potentially be the next opportunity
• 44:19
  Speaker 6: for us. So some things I think about, you know,
• 44:24
  Speaker 6: our our Duchane muscular districte patients, our als patients, like
• 44:32
  Speaker 6: our spinal muscular districtee patients. And then if we ever
• 44:38
  Speaker 6: come across anything else, or if a new therapy comes
• 44:42
  Speaker 6: along that helps us identify a patient population that is
• 44:45
  Speaker 6: seen here at UC Davis and receives care from a
• 44:48
  Speaker 6: provider here.
• 44:49
  Speaker 4: Well, I want to thank you both David and Ruth
• 44:51
  Speaker 4: for chatting with me and sharing this valuable information.
• 44:54
  Speaker 5: Thanks Sheila, Thanks Sheila for the opportunity to really appreciate it.
• 44:59
  Speaker 4: Of course, as a reminder, n SP corporate members are
• 45:02
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• 45:06
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• 45:09
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• 45:12
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• 45:16
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• 45:20
  Speaker 4: e t dot org. Until next time, have a great day.