 interviewed Susan Lang, MA, MBA, the CEO of XIL Health and former senior executive with Express Grips, on the financial losses that pharmacies have experienced due to the COVID-19 pandemic.

If things continue as they are right now without any changes, what might happen to pharmacies that have been financially impacted by the pandemic?

 Right. So, I think it's like everything—I think the large pharmacies will do fine because they're highly diversified, really smart organizations. I think where you really feel the crunch is in these either very small chains with 25 or less stores or independent pharmacy owners.

We know many small chains have also been part of the vaccination program—who did a wonderful job—but for them, this shifting in resources, this shifting in cost is much more detrimental. They've got to find that money somewhere else. So, I think we've got to look at this very carefully.

We've lost a couple thousand independent pharmacies over the last 2 years. This is really becoming an incredibly critical issue because we're creating pharmacy deserts—just like we have food deserts where there's no supermarkets—we have clinic deserts in rural areas. I spend a lot of time in rural markets, even now, in my career, where you have no care.

So, it's really now coming down to what's your zip code if you have access. We really don't want to create another access problem. So, this is something that we're really going to have to look very deeply at and see if there's a solution, but my concern would be for the smaller guys. I think the bigger companies will do fine.

Right, yeah. That makes sense. Is there any hope in sight for the future for pharmacies that have been facing some of these financial issues during the pandemic?

 Yeah, absolutely. I think, like everything in health care, we're very innovative; the community is innovative. We've got technology coming in, we've got a lot of new companies coming in to help solve issues. A lot of small pharmacies can't invest in technology, so if you can just lease something or go out and partner with somebody, it's great.

So, we're seeing that all over the industry, so I expect to see lots of new models emerge. I think the last 3 years between DIRs, COVID-19, and cuts and reimbursement, and just lots of pressure in the market, and also still increasing volumes coming through those pharmacies.

So, still people are aging, they're taking more medicines. But I think there are a lot of new emerging models, and I think a lot of those will be technology based—some of those will be service based, like we'll see new services combined that we haven't seen in the past, subscriptions to go in and see a clinic and get your generics very inexpensively.

So, I think they could play a huge role in that, and so I think trade associations like NCPA and NACDS are doing a phenomenal job trying to help support and provide resources to them.

Absolutely, yeah. Thank you so much for taking the time to speak with me today, Susan.

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Susan Lang, MA, MBA, the CEO of XIL Health and former senior executive with Express Grips, discusses what might happen to independent pharmacies if things continue as they are following the financial difficulties of the pandemic.

Expert: Financial Burdens on Small Chains, Independent Pharmacies Are Creating Pharmacy Deserts

 interviewed Susan Lang, MA, MBA, the CEO of XIL Health and former senior executive with Express Grips, on the losses that pharmacies have experienced due to the COVID-19 pandemic.

With an annual revaccination likely necessary for the foreseeable future due to COVID-19 variants, Pfizer has projected that vaccine prices will continue to increase. If this does occur, what might this mean for pharmacies that have already been hard hit by the pandemic?

 So, a couple things. One is Pfizer did come out when they did their Barclays announcement and said that they believe there will be a booster because of the variants, and this will be an annual event.

So, we already have that—that is a normal service that all pharmacies provide now, which is they do vaccinations. What is different about the pandemic is most pharmacies did vaccinations for adults, they've now reduced that down to children, so down to age 7, maybe age 5—not infants and not toddlers, but children.

So, they're now doing pediatric vaccinations, and that could mean everything from mumps, rubella, measles, whatever. So, that's normal. So, I think they can handle that; that's not the issue. The issue is what happens to the drug when it becomes part of the private supply chain.

So, Pfizer's already announcing they've made an enormous amount of money. They had a 25% net margin on this, which is an unbelievable margin on the COVID-19 vaccine. So, now when it moves to the private supply chain, does the cost of the drug dramatically increase above what any of the payers are willing to pay you to administer the drug? That's what this always comes down to—is there any margin left at all, or do they get squeezed to the point where every time they put a shot in an arm, they lose money.

This is going to become a really basic issue. So, we really have to see what happens in the private supply chain. We have to see what those prices come out to for the vials, and then we'll have to determine if there is an economic reason for them to continue to give the vaccine.

One would assume and hope that there's enough margin that it covers their cost, but that's not guaranteed yet until we see what the numbers are. So, that's what we're waiting to see you.

Susan Lang, MA, MBA, the CEO of XIL Health, discusses how pharmacies that have already been hard hit by the pandemic may be impacted if Pfizer goes through with their projected increased in COVID-19 vaccine prices.

Assessing How Increases in COVID-19 Vaccine Prices May Impact Pharmacies

 interviewed Michael Holden, FRPharmS, FRSPH, associate director of Pharmacy Complete in the United Kingdom, to discuss some of the key differences between the role of the pharmacist in the United Kingdom versus the United States.

So, Mike, could you talk a little about Pharmacy Complete and its role in pharmacy in the UK?

Good morning, Alana. Pharmacy Complete is a training consultancy organization. So, we provide training to pharmacies and pharmacy teams, and a wider audience, and not just in community pharmacy, but in a broader sense, in hospital and primary care settings, where medics sit dominantly, but pharmacists are also working in that field.

We also provide consultancy to pharmacy; we provide leadership through articles and presentations at conferences, and those sorts of things. But we also work as consultants with many of the global majors in the pharmaceutical industry.

Got it, yeah. Could you tell us a little bit about what the National Pharmacy Association (NPA) is, an organization in which you held a national role as chief executive, and what the role of this organization is in the field of pharmacy in the UK?

Yeah, I was with the NPA for 4 years, and we transformed the organization at that point. What it does now is it's the professional trade association for the independent sector of community pharmacy owners in the UK across all the developed countries.

It provides support, it provides training, it provides insurance, it provides an element of lobbying, but working collaboratively with other organizations that represent the other sectors.

Got it, yeah. Could you tell me a bit about the role of the pharmacist on the health care team in the UK, and what are some of the key differences between why patients seek care from pharmacists versus physicians in the UK?

Yeah, we have a very different setup to anywhere in the world because we have the NHS, or the National Health Service, and that provides free care at the point of care, or predominantly free care—doesn't always quite work that way—because people contribute towards medicines, and they contribute or they may buy private health, or they may contribute to dental care or optical care.

But, generally, it's the provider, so the physician in the community that may be working in a general practice. You don't pay to go and see them, whereas in many countries you would either do so either through insurance schemes or by direct payment to the medic.

So, it's a very different culture from that point of view. So, it seemed to be a free service, health is free, and therefore the desire and the ambition of people to buy a service, whatever it may be, from a pharmacy is slightly different. But it is shifting, and we're starting to see a growth in that area, which we can talk about as we go through.

So, that's one of the main differences between most of the rest of the world, I have to say. But we have an emerging role, which is increasingly integrated into the rest of the health system, whereby it's becoming more joined up. In fact, we do a lot of training around this joined up collaborative integration approach at the moment.

Yeah, very interesting. So, would you say pharmacists in the UK are able to provide services such as medication management, management of chronic conditions, point-of-care testing, and immunization screenings and administrations directly to patients? Is that something specific to pharmacists?

Yeah, generally speaking, pharmacists working in a community are not prescribers, but, increasingly, a number of them are, and there's a program being developed at the moment, which is due to be launched soon, to increase the number of pharmacists who will be prescribers in the community to initiate or amend medication that might have been provided for a long-term condition or even an acute condition. But we're not there yet, by any means.

The main role, as far as medicines management is concerned, is around supporting people with adherence to the treatment that has already been initiated by usually a physician, either in hospital or in primary care.

As far as the role on immunization is concerned, pharmacies have been doing flu vaccination for many years now, and occasionally a few other vaccines on the private side of things, as opposed to the health systems’ side, which would be providing travel vaccinations and things like that in many of the pharmacies—not all, but many.

Of late, inevitably COVID-19 vaccinations—which is why I'm in scrubs at the moment because I'm just off to a clinic to do that—are dominating the scene here in the UK, like they are in many other countries.

I know in the US, pharmacies are heavily involved in that, and here we are increasingly involved, but it's not to the same level. So, not every pharmacy will be providing COVID-19 vaccinations; it's only 4500, I think, at the moment who are doing that across England.

Interesting, yeah. Would you say pharmacists are generally understood and acknowledged in the UK as being a direct source of many essential health care services in communities, or are there any issues around pharmacists’ authority to provide essential services that their communities need? I think you addressed this a little, bit but maybe just kind of more detail here would be helpful.

Yeah, it depends on which lens you're looking through. So, if you're looking at it through the public’s lens, then yes, they're highly trusted.

One thing that's happened during the pandemic is that whilst the general practice physicians have been operating, generally behind closed doors, and therefore have been more difficult to access, pharmacies increasingly have become the place where people go to or contact, maybe by phone or even video consultation, in some cases, for minor ailments or common ailments, whether it's a skin condition or cough, cold, headache, bowel condition—whatever it may be, and treatment for that—we do have a specific service within the NHS that relates to that as well, in England.

Increasingly, they're the only health care place that people could walk into [during the pandemic]. We kept our doors open, admittedly with restrictions and queuing and flow, but our pharmacies tend to be a lot smaller than the ones in the US. I've been to the US a few times and witnessed the size of them, scale of them.

Here they tend to be a bit smaller, unless you get to some of the really big units. But the average pharmacy [in the UK] is pretty small, and therefore social distancing has to be managed very carefully. Hand hygiene, mask adherence, and things like that have to be managed very carefully.

But we kept the doors open, that's the main thing, and therefore became a very trusted provider of care from the public's perspective. But also, that meant that physicians were sending people to us. The difficulty there is who's paying for the service. Let's not get into the money at this stage.

But yes, that has accelerated the integration and the recognition of the role of pharmacists in health care undoubtedly, and that's been acknowledged from the Prime Minister downwards.

Yeah, that's similar to what's been going on in the United States as well, in terms of a real shift happening in awareness of the importance of the pharmacist as a direct access point for care.

So, diving in a little bit—independent community pharmacies in the UK, are they facing some similar issues as independent community pharmacies in the US in regard to problems with consistent reimbursement and payment models, and if this isn't happening, what are some of the issues independent community pharmacies are facing in the UK during the COVID-19 pandemic and on into the future?

Yeah, let’s put aside the direct impact of the pandemic in terms of everything you had to put in place to make it’s safe for you, the team, and for the public, but the reimbursement element is a real challenge.

Just prior to the pandemic, some money was taken away from pharmacy and hasn't yet returned. Negotiations are going on around that to try and make a more sustainable model, but the current model is certainly not sustainable financially. So, there's too much being done for no fee, and there's too much being done for too low a fee.

So, the recognition that we've had in from the Prime Minister downwards around how they recognize the importance of pharmacy and health care in the community as the frontline of our NHS is not being followed. The rhetoric's not being followed by actions and money.

Got it, okay. So, that sounds like perhaps slightly different from the exact situation happening in the US, but similar in terms of some kind of financial issues facing specifically independent community pharmacies. Would you say that that would be correct?

Yeah, absolutely. The route to it is different, but the end point's the same. The reimbursement on medicines as well—we have some of the cheapest medicines in the world in the UK, anything up to—when I was working in and around the US area—10 times less than some US products, particularly on the branded size, because we're very generics-driven. But there's still a desire to force those prices down further, cut the reimbursement, and cut any margin that might be made on those.

But again, it's a different funding stream. It's not a co-payment scheme, it's not an insurance-based theme that works through these business managers that you have in the United States, it's a very different setup. But the parallel in the United States, the parallel across the world actually, and certainly the developed countries, is very similar. It's a price down, we want more for less.

Right. Are you aware of any differences in the authorities pharmacists have in the US versus UK in relation to being able to provide direct care to patients in the form of health care services? We've talked about this a little, but just in terms of specifically calling out some of the differences.

So, for example, right now, there's a Supreme Court case that's trying to get reimbursement coverage for pharmacists in delivering some of the services that I mentioned regarding medication management, management of chronic conditions, point-of-care testing.

Before that, Medicare, which is a federal insurance program, it wouldn't reimburse pharmacists for delivering these services. So, issues in relation to that in the US are rather complicated in this regard because it can change state to state, but generally speaking, do you have a sense of what some differences might be?

Yeah, I guess again, it goes back to the way the funding streams come down with no co-payments and no insurance schemes to do so. So, those who have money can buy services or product, and those who don't tend to go to the NHS, and they have more limited choice in that respect.

But because of the culture that we have around the NHS being free at point of care, and the NHS badges on our pharmacy, and then something like 90% of most pharmacies business is with the NHS, as opposed to the direct customer, the challenge we have then is that people expect to get that free when they walk in.

That's starting to change, and pharmacists have to value themselves first before they start asking people to value them, and sometimes we don't value our own time as health care professionals.

We go into the profession like everybody in the world to provide care. That's why we do it. Therefore, some people will find it hard to say well that's going to cost because it's a caring profession.

But we have to be real. Particularly in the circumstances I've just alluded to around the financial sustainability of pharmacy, we have to be real about saying this has a value to the individual, to the state, and to the country and the NHS.

So, we need to be saying we're not doing it for free. We need to be saying we're doing it as a charge, and if we don't get a payment for it, we may not do it or won't do it. So, there's a little bit of cultural shift there as well as balancing professional and business, which is always a challenge for everybody.

Bearing in mind something like 55% or 60% of the pharmacies are owned by large corporates in UK, then they make the decision around whether this is an added value service that they don't charge for, it's a service they do charge for, and if they're doing it for free then it makes it difficult for somebody else to charge.

So, we're not always joined up as we might be around that that cultural shift that will then educate the patient that there's a value to this service, and therefore you have to pay for it. But there are people who are leading that change and making a big difference, and we're sort of shifting pharmacy from being a supplier of medicines to being a walk-in clinic.

Yeah, interesting. So, there's a similar kind of shift that's happening in the United States around the role of the pharmacist. And in the US, some of that shift has really taken place during the COVID-19 pandemic, where there's been a greater emergence of the importance of the role of the pharmacist, specifically, like you've been talking about, just keeping their doors open during the pandemic, and the critical role that had for a lot of patients seeking care and services.

So, this kind of change in awareness in the US, how would you say that's—you've mentioned that's happening a bit in the UK—how is that kind of playing out in the UK, and would you say the US is on a similar kind of awareness level in relation to that of the UK or would it be a bit different?

I think it will be a little different because the cultures are different. We're very different, and you haven't got the NHS, and we have—so I know I keep repeating that, but the NHS is 80 years old coming up, it's over 75 anyway, because we had a 75th birthday of the NHS not too long ago, and therefore it's very embedded in the culture of health care in the UK.

But there's loads of private providers out there, and not just pharmacists. You've got various organizations, some of whom have come from the United States as private providers and launched themselves here.

So that cultural shift, and then the point I made around valuing ourselves and time we give, it's not about selling a product, it's about providing a service, and the micro products associated with that service. That's a very significant shift for us in mindset terms from being one of a supplier of medicines, whether they be bought over the counter or whether they be provided on the prescription to one of which is a service provider who happens to provide medicines at the same time.

Michael Holden, FRPharmS, FRSPH, associate director of Pharmacy Complete in the United Kingdom, discusses some of the key differences between the role of the pharmacist in the United Kingdom versus the United States.

Expert: Pharmacy Globally Must Value Itself for Providing ‘Not Just a Packet of Pills, But a Package of Care’

Shingrix is a non-live, recombinant subunit vaccine given intramuscularly in two doses for the prevention of herpes zoster in adults aged 50 years and older.

The 2017 approval of Shingrix was based on phase 3 clinical trials that evaluated the vaccine's efficacy, safety, and immunogenicity in more than 38,000 people. In a pooled analysis of these studies, Shingrix demonstrated efficacy against shingles greater than 90% across all age groups, as well as sustained efficacy over a follow-up period of 4 years. By preventing shingles, Shingrix also reduced the overall incidence of postherpetic neuralgia, a form of chronic nerve pain and the most common complication associated with shingles.


Shingrix is a non-live, recombinant subunit vaccine given intramuscularly in two doses for the prevention of herpes zoster in adults aged 50 years and older. 

Pharmacist Medication Insights: Shingrix for Herpes Zoster

The COVID-19 pandemic had a massive impact on clinical trial research, according to research pharmacist Brian Wortz, PharmD, of Cancer Treatment Centers of America. Trial protocols are constantly evolving, Wortz said, although the pandemic accelerated many changes, including the need for virtual communication.

Because study coordinators were unable to travel, Wortz said researchers were forced to adapt quickly and figure out what they could do remotely. For example, he said they received glasses to wear with cameras embedded in them, which allowed coordinators to see the facility and get a feel for how the research was progressing.

Because study coordinators were unable to travel, research pharmacist Brian Wortz, PharmD, said researchers were forced to adapt quickly and figure out what they could do remotely.

COVID-19 Had Lasting Impacts on Clinical Research 

, research pharmacist Brian Wortz, PharmD, of Cancer Treatment Centers of America, said pharmacists have a unique role to play within care teams. As the drug experts, Wortz said pharmacists may be able to recognize adverse effects before other health care professionals, ensuring patient safety and optimizing their care.

As the drug experts, Brian Wortz, PharmD, said pharmacists may be able to recognize adverse effects before other health care professionals, ensuring patient safety and optimizing their care.

Integrating Pharmacists in Care Teams is Critical For Patient Safety

 oncologist Susan Miesfeldt, MD, of MaineHealth, discussed the importance of genetic testing and counseling for breast and ovarian cancers as well as barriers that must be addressed in order to reach more patients eligible for these services.

Miesfeldt worked with a team of experts in a recent nationwide effort to improve these services, with a poster of their results presented at the American Society of Clinical Oncology (ASCO) 2021 Annual Conference. Various groups around the country tried unique approaches to expand genetic testing and counseling, and Miesfeldt said the MaineHealth team used the well-established ECHO approach.

Miesfeldt pointed to several barriers to genetic testing, including clinician education, public education, and a lack of health systems infrastructure to ensure proper genetic services. Notably, Miesfeldt said infrustrature must be built in order to ensure that patients’ families have accurate and timely information about their genetic testing results, in order to provide preventive services when necessary.

Oncologist Susan Miesfeldt, MD, of MaineHealth, discussed the importance of genetic testing and counseling for breast and ovarian cancers as well as barriers that must be addressed in order to reach more patients eligible for these services.

Education, Access Are Major Barriers to Genetic Testing for Breast, Ovarian Cancers

In his work with Cancer Treatment Centers of America, research pharmacist Brian Wortz, PharmD, said he works within a broad care team of physicians, nurses, data coordinators, study coordinators, and others.

Clinical trial participants often have even more questions than patients receiving standard-of-care treatments, so working within the team to answer their questions and provide optimal care is essential for research pharmacists, Wortz said.

Clinical trial participants often have even more questions than patients receiving standard-of-care treatments, so working within the team to answer their questions and provide optimal care is essential for research pharmacists.

Working as a Part of a Care Team is an Important Skill for Research Pharmacists

 interviewed Susan Lang, MA, MBA, CEO of XIL Health and former senior executive at Express Scripts, on some of the issues pharmacies are experiencing around staffing to support COVID-19 immunizations and how these issues may change post-pandemic.

What are some of the issues pharmacies are experiencing around staffing during the COVID-19 pandemic and during ongoing vaccinations?

 So, staffing has been really difficult. We've got pharmacies that are recruiting other people's pharmacists to make sure that they can get everything done. So, they have sign-on bonuses, they have, again, increasing their costs, whether or not those folks will stay, whether or not you have an ongoing need.

So, you have this enormous shift right now in human capital, but once people are vaccinated, does that go back to normal? What happens with those folks or do you have additional strategies where you would want to keep that level of staffing?

So, I think it's been really challenging recruiting, it's been really challenging retaining people. People are on the front line. I know some pharmacies have paid hazard pay because you don't want your staff to get sick, and they're sort of frontline people, so these are the people that are the most at-risk. Any caregiver who's face to face with you and is sitting very close to you is the most at risk.

So, I think it is very challenging, and I honestly think I've seen some really creative and really good thoughts around human resources, around keeping folks safe, around making sure people want to continue to work.

But I will say, overall, that problem was solved, which is why we've been able to administer so many vaccinations, and it's solved because you have caregivers that are deeply committed to their communities.

This is what people sign up to do, this is really their sort of mission. So, I think there were initial bumps in the road, and I think they figured that out over the first couple of weeks and couple of months.

Susan Lang, MA, MBA, CEO of XIL Health and former senior executive at Express Scripts, discusses some of the issues pharmacies are experiencing around staffing to support COVID-19 immunizations and how these issues may change post-pandemic.

Managing the Increase in Pharmacy Staff from COVID-19 Immunizations in a Post-Pandemic Landscape

Dupilumab is a fully human monoclonal antibody that inhibits the signaling of the interleukin-4 (IL-4) and interleukin-13 (IL-13) proteins. Data from dupilumab clinical trials have shown that IL-4 and IL-13 are key drivers of the type 2 inflammation that plays a major role in atopic dermatitis, asthma, and chronic rhinosinusitis with nasal polyposis.

Dupilumab is a fully human monoclonal antibody that inhibits the signaling of the interleukin-4 (IL-4) and interleukin-13 (IL-13) proteins. 