If you’re a pharmacist, this one is for you!

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In this episode you’ll discover:

• How pharmacists can play a critical role in reducing the burden on primary care physicians who are managing the care of chronic disease patients

• Why value-based entities are the ideal partners for RxLive

• What role drug pricing transparency plays in pharmacists’ ability to help manage high spend on drugs.

Learn more from Carrie and Rebecca: 

Healthcare insights (monthly email) | Telehealth/Virtual Care Mgmt Update (biweekly LinkedIn update)

Website | Carrie on LinkedIn | Rebecca on LinkedIn | NGL on LinkedIn

Learn More

• Key areas to check before adding telepharmacy to your business model

• Connect with Kristen on LinkedIn

• Connect with Mark on LinkedIn

• Learn more about RxLive

Read the transcript:

Carrie Nixon (00:16):

Hi everyone, I'm Carrie Nixon with Nixon Gwilt Law and welcome to the latest episode of Decoding Healthcare Innovation. I am delighted today to be joined by Mark and Kristen Engelen. Mark Engelen is the CEO of RXLive, and Kristen Engelen is the chief pharmacy officer of RXLive. They are co-founders and have the really fun position of being actually a married unit of co-founders, which I always sort of wonder whether that would actually work in my marriage. I think probably not, but it seems to be working for you all and I'm very glad about that. Let me let the two of you introduce yourselves and tell us a little bit about RXLive and really what drove your decision to start this business.

Mark Engelen (01:07):

So thanks Carrie, really appreciate the invite and the opportunity to come and chat today. Like you mentioned, I'm Mark, CEO of RXLive. Kristen will tell a little bit about her story. Obviously Kristen is the clinical pharmacist and the real brains and the operation here. I'm just the dumb business guy, but

Carrie Nixon (01:25):

Wise thing to say, wise thing, yeah.

Mark Engelen (01:28):

A while ago we made the decision to essentially go into the same business line, so we'd have something interesting to talk to each other at the dinner table about. And so I've sort of built my career in the business of pharmacy having worked for PBMs as well as on the EMR side, and sort of really grew up in the sort of early days of value-based care and understanding the intersection of value-based care and primary care in particular, and started to really recognize the role that pharmacy and the underserved role that pharmacy and then by extension pharmacists could play in population health and value-based care. And that was a big part of the origination story of RXLive.

Carrie Nixon (02:08):

And Kristen, I think Mark just mentioned the role of pharmacy and I think that role has been largely overlooked for a long time. I think that's changing a lot right now. Let me turn it over to you to introduce yourself.

Kristen Engelen (02:23):

We're certainly trying to change that. So yes, I am Kristen. I am the chief pharmacy officer and I am a clinical pharmacist. I have been passionate about providing excellent patient care since I started my career as a pharmacist. I worked initially in retail for about a decade and I have a number of special certifications around geriatric care, so caring for the older adult population. And as I worked behind the counter serving people with complicated medication routines and multiple disease states that they managed, it really became clear that there was a gap between communication between providers and patients. And pharmacists have a key role to play in bridging those gaps. So taking that thought and using that to co-found RXLive is really how we got started, was how to improve collaboration between patients, pharmacists and their providers to improve medication management.

Mark Engelen (03:36):

And if we take a step back, Carrie, if I may, some of the big macro trends that are going on right now, we're seeing significant shortages in primary care providers. Pharmacy is a really interesting and unique labor source for clinical care. Given the depth and breadth of training that these people have, they're very patient centered in their approach. And so it seems very logical to us given all of those factors for just pharmacists to have a deeper role within healthcare outside of the dispensing play that they play in today.

Carrie Nixon (04:07):

Yeah, it seems perfectly logical. I mean, people see their local pharmacists all the time both people who have sort of a chronic condition that they consistently take medication for, but also people who are just going in because they have strep throat and they need an antibiotic. And I think the pharmacist is one of the healthcare providers that we probably tend to see most frequently. So it seems like a very obvious match yet it's been a while incoming. So I'm eager to see this progress because I think it is a really natural connection that makes sense for a lot of people. So tell us a little bit about how your business works. Who are target customers and how do you work with those customers?

Mark Engelen (04:58):

Sure. Maybe I'll start and Kristen can then jump in. Like we mentioned with this sort of new emerging role of the clinical pharmacist it might seem intuitive, but our target customers are predominantly risk-bearing physician organizations. We think that most major healthcare delivery organizations are going to go through a build by partner decision set over the next decade or so about how do they integrate pharmacists into ambulatory strategies, post-discharge models, expand scale from an inpatient perspective. And so not only does RXLive want to provide services to this cohort of organizations that are looking to expand their clinical pharmacy capacity. And so we have a telemedicine network now of part-time clinical pharmacists that spans about 30 states that we integrate directly into these care delivery workflows. But we also see this persona emerging with unmet needs. So software that serves them, analytics that serves 'em, and really a graduation and a growing up with this function of clinical pharmacy that hasn't existed before needs a sort of tools provider. And so RXLive can come to the table looking specifically at these risk-bearing physician organizations with a very collaborative but broad approach that includes services, custom-built software platforms for the population health pharmacist as well as analytics tools, and then can bring a very flexible solution set to the table depending where an organization is in their population health lifecycle.

Carrie Nixon (06:29):

Yeah, so I find it interesting that you emphasize you're focusing on risk-bearing organizations makes a lot of sense given the shift that we're seeing, but right now we're still very much in a fee-for-service realm. Talk to me a little more about why you decided to focus on risk varying organizations.

Mark Engelen (06:52):

I think there's probably two key pieces here. I think everything to do with Medicare is sort of shifting into a risk-based model. So not only do we have the traditional ACO model, obviously with the shift from direct contracting to the ACO reach model that's going to expand the market there. But even with MIPS, right there's an element of risk being injected into most sort of Medicare and Medicare advantage patient lives and business models today. The other piece of the puzzle is that even though they're starting to change, but the way that pharmacists can impact organizations most from a value creation perspective outside of dispensing is really on the impact that pharmacists have on hospitalizations and readmissions. And so organizations that feel in their business model improvements in those two key outcomes just makes the most sense.

Kristen Engelen (07:44):

And I would just add that when we think about risk-based contracts and value-based reimbursement, that's really the way to reduce healthcare expenditures. And we all know that the United States is notoriously spending a ridiculous amount of money on healthcare and not necessarily getting outcomes that match that expenditure. So having an opportunity to work in a space where we are being held accountable for reducing healthcare expenditures, particularly pharmacy spending, and to Mark's point, hospitalizations, it's really exciting to be working with that is our goal keeps us motivated. It helps to keep the patient front and center because if we are improving their health outcomes, then we're also reducing costs. They go hand in hand.

Carrie Nixon (08:40):

Yeah, I'm sure it's rewarding to work in partnership with provider organizations that are sharing your goals of providing good quality care with reducing costs. And we know that sometimes that can get a little bit lost in the fee for service model in a less integrated model. So it sounds then maybe you all are not having to really truly deal with part B billing or part D billing part D, which is sort of traditionally more oriented towards pharmaceuticals and pharmacists. Can you talk a little bit about that?

Mark Engelen (09:23):

Yeah. What we're trying to bring to the market is a philosophy like Kristen was saying, that is patient-centered, right? So if you step back from the equation around reimbursement and ask the question of where does a pharmacist best fit in the patient journey and life cycle and independent of reimbursement, what would you do? That's where we've started. And we have found that sort of a preventative proactive approach that injects a pharmacist talking to the right patient at the right time creates kind of the broader healthcare value. But we also operate in a world, and we've got to be realistic about this. That does require fee for service billing. That does require quality reporting on both the B and the D side. And so what RXLive is has built from a technology perspective, but then also facilitates from a consulting perspective is for organizations who want to make these investments, how do you still do that while meeting the realities of operating a modern healthcare business? And so we think that technology enables that such that a singular patient driven conversation that focuses on the right things for that patient at that time can also then satisfy whether it's CMR reporting on the part D side or MIPS reporting on the part B side or improvements in HETA scores, but is all then driven from that patient-centered perspective.

Kristen Engelen (10:41):

And CMSs initiatives this year are focused on improving drug price transparency specifically, and they're initiatives this year. So the intent is to take a more blended approach. And when we're talking about price transparency, clearly the pharmacist has a deep knowledge and understanding of how drugs are priced and how formularies work and what the cost to the patient will be, and all of the different pieces of the puzzle for the spend for the pharmacy side. Providers don't have the same tools available to understand pricing and having a pharmacist speak with the patient ahead of an office visit to talk about things like cost and formulary management really gives the provider a lot of useful information ahead of sending a prescription to the patient's pharmacy pharmacy because then ideally we're going to reduce back and forth on prior authorizations. We're going to reduce the time that it takes for the patient to actually get the medication and be able to take it and we should be able to reduce pricing or prices to the patient and the system.

Carrie Nixon (12:12):

So I love that. It sounds to me, Kristen, in your capacity as a pharmacist, you are actually able to consult with a patient around issues what under your current plan this drug is not covered, but there's a very similar drug that is covered and perhaps you can go into a conversation with your physician the next time and say, Hey, is it possible that I can take this alternative drug because it is less expensive for me, it is more affordable, therefore I am more likely to get it refilled and actually take it. Is that right?

Kristen Engelen (12:56):

And I think that that really is the traditional definition of medication therapy management, and it's where the pharmacist has traditionally worked for the delivery of our services. And Mark mentioned earlier that pharmacists are well positioned to be generalists similar to a PCP. So by partnering directly with the doctor, we are able to facilitate the documentation of that conversation in a timely manner. So both the patient is getting a list, a summary of what we talk about as well as the medication recommendations. And because we work directly with the provider, our note is being uploaded and routed to the provider in their electronic health record. So this is really how we implement our telehealth service by remotely providing that information to the doctor.

Mark Engelen (14:04):

And I think Kristen brings up an important point. If you think about the role of the pharmacist, the human element here and the ability of the pharmacist to counsel and get to the root cause of what challenges a patient have around their medication utilization is really important. So there's all sorts of new technology and data streams that physicians are being bombarded with today around cost and formulary and price transparency. But what our data suggests, and we're hyper data driven organization is that upwards of 60 to 70% of patient adherence. Challenges are much more around motivation and behavior, and they know what the right formulary design is. They're getting their drugs dispensed. There's all sorts of different tools out there to drive the right utilization and regimen design of a regimen that exists. But what a pharmacist can do is sit down and decode those behavioral as well as clinical challenges to maybe redesign a regimen that is more optimal for a patient at both the drug level and then obviously at the price level as well.

Carrie Nixon (15:04):

So I suspect that physicians are not really used to pharmacists playing such an active role with the patients that they see. And I'm curious, how are doctors and practitioners reacting to this model? Are they receptive or do you sometimes get a little bit of pushback with them saying, wait, wait a minute, I'm the doctor here. You're the pharmacist. I need to be quarterbacking this.

Kristen Engelen (15:32):

So yes, we do occasionally get provider pushback. It is relatively new to have clinical pharmacists working in collaboration with PCPs. Having said that earlier, we mentioned that PCPs are having to take on more and more disease state management. So patients who are traditionally going to see a specialist are now actually having a lot of their care provided by the PCP. So cardiovascular disease, chronic kidney disease, diabetes. And what that means is that these patients with these complicated comorbidities are taking more complicated medication regiments. And when we increase the complexity and number sheer number of medications that people are taking, it introduces a lot more risk for medication mismanagement. And that can look like drug side effects. It can look like duplications of therapy. It can look like a rushed decision that leaves the patient wondering what it is that they're supposed to be doing, and do they understand what each of the medicines are for, which then can lead to difficulties with adherence or again, poor outcomes like hospitalizations. There are a number of statistics out there that refer to the rate of hospitalizations that are due to medication mismanagement, and it's upwards of a quarter of hospitalizations are related to improper medication use. So I say all of that to explain that PCPs absolutely see the benefit of working with a pharmacist for that second set of eyes and to ensure that these complicated drug regimens are being implemented in a safe and effective way.

Mark Engelen (17:36):

The point, and I think a lot of the pushback is really around misaligned business models. And so it's about focusing on working with the right organizations who incentivize their providers around value-based care delivery in an appropriate way. I'll also add that there's different personas to physicians. And so one of the things that we focus on is around providing transparency and data and reporting to then empower physician leaders to drive protocol driven practice of medicine. So one of the key features of our platform is the ability to start to report out on physician acceptance rates of pharmacist recommendations. And we don't do that to shame providers, but rather to start a collaborative discussion around protocol design to ask questions that say, Hey, if we're supposed to be your pharmacist and enabling you to practice medicine and we want to practice pharmacy in the way that you practice medicine, why are you not adopting these recommendations that might be guideline driven? And how can we adjust the way that we communicate with your patients to reflect the way that you practice medicine, both at a micro level and then to enable organizations to do that at a macro and to a global level as well.

Carrie Nixon (18:44):

Yeah, I mean, given the historically fragmented nature of patient care the statistic that you cited Kristen, about at least a quarter of hospital readmissions being due to some sort of medication mismanagement doesn't surprise me at all. And it sounds like you all are really targeting an audience of physicians that are almost already bought in the notion that this has got to be a coordinated effort on everyone's part to make sure that we're looking at outcomes and make sure that we're looking at reduced costs. Kristen, you mentioned medication therapy management, and we have also talked about how often these patients are suffering from some sort of one or more chronic diseases. I work with a lot of companies that are specifically in the chronic care management space. How does chronic care management and medication therapy management and the other types of models that are out there, how are they different or how can they work together?

Kristen Engelen (19:59):

So they absolutely can work together and ways that chronic disease management is implemented by pharmacists that are already engaged with provider systems like ACOs or oftentimes we find pharmacists in clinical care settings in hospital networks as well as university settings. They traditionally are doing disease state management and collaborative drug therapy protocols with the physicians that they work with. So perhaps they are focused on just diabetes. So when a patient is seen by the pharmacist in that setting, they'll specifically be monitoring their diabetes and the titration or adjustment of their diabetes medications to improve their A1C or blood sugar control. How that's different from what we do is we take a more comprehensive approach. So when we speak to a patient, we aren't just going to be focused on their diabetes, we're also going to be talking about their kidneys and their blood pressure and their supplements and ensuring that they're able to afford each of their medicines.

(21:17):

So it's more comprehensive. It doesn't mean that we don't manage the diabetes piece. What that would look like then is a discussion about blood sugar management and how the medications can be adjusted to reach their target goals. What also is different today, but what we are looking to explore and expand and really are excited about is with the changes and the telehealth landscape of late, there are some opportunities to establish collaborative drug therapy protocols in some states, depending on the regulation in the different states that are remote. Traditionally, pharmacists have had to be on site with direct supervision from a provider in order to send in medication change recommendations. But we think that's going to be changing.

Carrie Nixon (22:19):

Many, many of the changes that were sort of unveiled during covid. I think we're seeing that some of these changes might actually be useful in the long run. Excellent. So I want to end our discussion by asking you all if you can point to what you would view as one of your biggest successes with managing medication and helping patients in working with physicians to making sure that patients are having the right medication regimen. I'd love to hear an example of what you view as one of the biggest successes that you've had thus far.

Mark Engelen (23:07):

Do you want to maybe take a patient case approach and micro and then I'll share a macro share?

Kristen Engelen (23:12):

Sure. So we like to tell stories. So the story when we are able to share specific examples, it just helps to paint this the picture. So a patient that I worked with here in Florida

(23:32):

Who had multiple providers who also had a language barrier because he primarily spoke Spanish, was hospitalized as a result of medication mismanagement. And following a discussion with myself, clinical pharmacist was able to identify a number of medication problems with this patient. He had heart disease, he had diabetes, he had breathing problems, and he was seeing multiple providers. And what happened in his case is none of the medications were being recorded by the different providers that were seeing him. And so there were some significant drug interactions, and he also didn't understand what each of his medicines were used for. He was not taking one of his important heart medicines because he had misunderstood that he needed to pick up two prescriptions from the pharmacy and he had only picked up one. So he'd never received the medicine that the cardiologist had written for him. And no one would've ever stumbled upon this unless we had the opportunity to sit down and really comb through each of the medications and provide education on what they were used for and why he was having this significant problem. His potassium levels were completely out of whack, and it resulted in feeling terrible. He was having stomach upset, he was feeling lightheaded, and no one quite knew what to do with him. So being able to talk with me, the pharmacist, and then I coordinate back with his primary care provider, what I found, we were able to get his medications adjusted and he was able to get the care that he needed.

Carrie Nixon (25:32):

So such a simple thing, like a simple, tiny little thing but it takes some unraveling to figure it out, right? You've got to unravel and figure it out and get the right thing in place, and it makes such a huge difference. I love stories like that that really do paint the picture.

Mark Engelen (25:47):

And one of the interesting things about pharmacy is that there's not only an intersection with prescription medications, but supplement use. Lots of people are using medical marijuana now that has all sorts of implications around it. But what is so illuminating about Kristen's sort of micro story is that it then translates at scale to this happening across thousands of patients across massive patient populations. And so the challenge has always been, I think a lot of people know how to practice clinical pharmacy, but the variability and how it's practiced and the ability to then scale the right way to practice it is challenging. And so Kristen's stories is part of a much broader population health pharmacy strategy that starts with getting the right data on all these patients, picking the right patients to have the conversation successfully, engaging with the patients, successfully getting physicians to actually adopt the change recommendations. And if you do all of those things well, then you drive outcomes. And so you talk about success stories for RXLive. We just published our first paper in the Journal of Telemedicine, eHealth, that showcased meaningful and statistically significant reductions in hospitalization rates in a Medicare, ACO population. As a result of that whole process being well implemented, that starts with the stories that Kristen just shared.

Carrie Nixon (27:09):

Yeah, terrific. So tell us where you are right now in the trajectory of RXLive. Are you in the middle of a raise? Are you focusing on any particular sort of new market right now? Just give us an overview of where things stand and where you're looking to go in the next year.

Mark Engelen (27:28):

Sure. So we are fortunate to have just closed around with some pretty important strategic partners. We are delighted with a number of recent wins in the ACO space. We've got some really exciting deals that we think are about to close, both on the payer side as well as furthering our penetration of the risk-bearing physician organization. We've got some really amazing partnerships that we're building to start to look into the self-insured employer space, because obviously drug spend and management and self-insured employers is really important. So we're at a phase of our life cycle where we're well capitalized, we're investing heavily in our team and have a really clear direction and product market fit. So it's a very exciting time for us.

Carrie Nixon (28:18):

<laugh> a good place to be. Amazing. Congratulations too. It's not an easy thing to get there. I know.

Mark Engelen (28:26):

Indeed. And thank you for being part of the journey too, Carrie.

Carrie Nixon (28:29):

Yeah, absolutely. Absolutely. Well, a pleasure to speak with both of you. I really appreciate it. Everyone, please look for information on RXLive in our show notes and follow us wherever you get your podcasts. And we will talk to you again in a couple of weeks with the next episode of Decoding Healthcare Innovation. Thank you.

Mark Engelen (28:48):

Thanks, Carrie.

Carrie Nixon (28:50):

Thank you.