Biosimilars, staffing issues, and mail-order companies are key trends to watch.
Q: What are some key trends you see coming for pharmacies in 2023?
Doug Long: Well, I guess the first one I would say, revolves around cough, cold and flu, respiratory virus, and COVID. You know, that was a big, big issue in at least the COVID season, the fears of vaccines was huge and 2021, a lot less than 2022. Then you had cough, cold and flu, and the respiratory virus came on the scene in late 2022—made it a pretty big, big flu season. And the question is, what happens next year? They’re talking about doing a once-a-year booster for COVID, which probably is going to happen. We'll have a kind of a take on how the flu season will go based on what happens in Australia. Australia had a big flu season this year, much bigger than it has had in the last five years or so, so it was very intense. That was an early predictor on us. So, that's the first one.
The second one has to do with biosimilars coming to the pharmacy benefits. The first one being humera that happened this month in January, and with one player and as many as six players coming in June and July timeframe. So, that'd be very interesting. And not too far behind that is another big product stelara. And, you know, we predict that there'll be more biological opportunities for loss of exclusivity next five years, and there'll be for small molecules. The other one has to do—you saw the article today in The Wall Street Journal about the reducing pharmacy hours of CVS and Walmart. There's a big manpower issue out there. Hard to know whether it's going to get better or not. Because, you know, certainly, the pharmacists rose to the occasion.
They were the true frontline workers, in my opinion, along with hospital workers, during COVID. They rose to the occasion. They were doing flu shots and COVID shots at the same time. And they really—we just came out with a report that I can send you, “Trends in Vaccine Administration in the United States,” that just came out today from our institute. And, a lot of those took place in retail pharmacy. So, a lot to thank them for.
They certainly stepped up for the occasion, but it's putting pressure on the system. And I think, along with that is going to be a trend in automation. That as much as Central Fill, that people can do to take the burden off the pharmacy, I think we’ll see a big expansion in that. And then the fourth one that Scott can elaborate on, as they call it, the cash business. And the cash business, which is about 9% of the prescriptions, seems to be—you have discount cards competing in that space, you have got Mark Cuban's Cost Plus competing in that space, now you have Amazon competing in that space. So that one will be one to watch. You want to elaborate more on that, Scott?
Scott Biggs: No, I think it’s just going to be interesting to see what happens with Amazon's recent announcement just this week, saying $5-a-month and a prime membership gives me generic prescriptions. So, it's going to be interesting to see what happens with that, and how that really impacts the cash business. We have seen the cash business declining quite a bit over the last several years, so that means it’ll be interesting to see if we'll start to see a reversal.
Doug Long: Well, what this also means is 91% of the business is in third-party. And, those numbers are growing, the cash market is declining, and the analyst reports so far are, of Amazon, is that the biggest concern should be the drug discount card people for that.
Q: There were concerns last year that the flu season and COVID-19 could potentially overwhelm the health care system. Have you seen that, and how has this affected pharmacies going into 2023?
Doug Long: I think you could say that the systems did survive. One of the reasons that they survived is now you have more testing out there. You have more therapy options that you can use to keep people out of the hospital or treat them better in the hospital. So, COVID largely seems to be in check right now. And then, out of the blue came the cough, cold, and flu season and respiratory virus, which certainly stressed the front of the stores and retail pharmacy out. A lot of out of stocks, you know, on amoxicillin, things of that sort, codeine, cough syrups, things of that sort. But all in all, I think that the pharmacies did hold up. It probably put more stress on them, thinking about all the things they have to do now that they didn't do before or weren't able to do before.
Q: How could the expiration of the PREP Act affect vaccine trends?
Scott Biggs: I know NACDS is lobbying very hard to keep that extended and see it go, because they've been very, very important as part of the healthcare continuum and really providing that service that our citizens need. You know, 2021, we saw retail flu vaccines outnumber those administered in doctor's offices for the first time. And we've really seen, we've talked about pharmacies stepping up and they have stepped up. So, I really hope that that will be recognized and the PREP Act will actually be extended, and we will continue using it.
Doug Long: And, you know, there's an interesting chart that NACDS has about the progress they've made on a number of fronts in different states, one of them being Naloxone and things of that sort. So, they've certainly made a lot of progress. And they've shown that they’re a tremendous option for the public.
Q: Pharmacies have increasingly become holistic health care centers, with OTC treatments, condition monitoring, and of course, medication management. Do you see this trend continuing?
Doug Long: I think for the most part, it will. I mean, probably the best example of what you're talking about is the health hubs that CVS has. And it’s a very—you know, I happen to shop one down here in Ponte Vedra, and it's a very different feel than going in a normal pharmacy because they have durable medical equipment and a lot of ancillary things and less health and beauty, but a big emphasis on minute clinics in there, and so forth. They're kind of the forerunner. Walmart's done a lot of, done some clinics. Walgreens seems to be very heavily investing in them now with Village, MD. And Scott, what did you see the other day with Dollar General?
Scott Biggs: Dollar General is actually piloting I think in three locations having a medical-van-type set up in their lots, trying to become a health location for consumers.
Doug Long: So, this is, Aislinn, this is part of a general trend is that we've seen that healthcare has come closer to home during COVID. You see, probably the best example is that people decided not to put their loved ones in nursing homes or long-term care facilities, kept them home, and treated with home health care. And you see also that some of the purchases that CVS has made, in terms of buying Doctor practices, is another step in that direction.
Q: Staffing issues dominated the news in 2022. Do you see any potential improvements to this issue in 2023?
Doug Long: Well, I think that what you saw today is that maybe the pharmacy hours are going to be shorter. And I was thinking about this, is it—can you pick up your prescriptions for 7 o'clock or does it have to be till 9 o'clock? You see that pay is going up. You see that the employee-owned organizations have been able to hold on better than some of the others. So, there's still a lot of stress. I think there's going to be a big focus on automation. And you just wonder, is that how many pharmacists—people graduate from pharmacy schools every year, and maybe they're not going into retail pharmacies as much as they used to. Would it be interesting to see where they might be going?
Scott Biggs: The Wall Street Journal article mentioned that CVS was going to be looking at when are the peak hours within their pharmacies and staffing accordingly. So, I think they're going to find ways to staff around those peak hours so that they have the available staff they need there, but it’s also going to have to be automation, as Doug said, and things that are going to help make the flow as easy as possible for the pharmacist to be as productive as possible with what they've got. Central Fill is a big contributing factor for that also, though.
Q: How can pharmacists keep up with all of the changes and prepare for the future?
Scott Biggs: Automation and education are the things that popped to the top of my head, you know. We've talked about Central Fill and other ways within a store that they can—the Central Fill facilities are great and it's very transparent to the patient. They call it in, say they want it the next day. It gets filled at an offsite facility and delivered there. And they're working on getting robots and some stores already use types of robots to do different things. You know, I think through all this—Colleen Lindholz, last year at NACDS Regional, I've heard her say it many times, that pharmacists are learning the practice at the top of their license. We trust the pharmacists so much. They're seeing 10 times more than other health care professionals, and they're going to continue to do that because they're there because they want to serve the community.
Doug Long: I just want to emphasize is that we have a chart that pharmacists or pharmacies see patients 10 times more frequently than they see other practitioners. So the ability to do a lot of stuff is certainly there, as we've talked in previous things. And, to be able to do those services, they need to learn more than what they currently have. But we're both optimistic.
Q: Is there anything you want to add?
Scott Biggs: You know, we talked last year at NACDS Regional that in 2021, 6 out of every 100 prescriptions, were for a COVID vaccine. In 2022, that actually dropped to 2 out of every 100. So, even with all the push on boosters and things like that, there were not as many COVID vaccines administered in 2022. You know, people talk about people just getting tired of hearing about the vaccines and vaccination, to get overtired of hearing it. So, I think we're seeing that impact there.
Doug Long: And that kind of fits into vaccine hesitancy and how that has also spread to shingles and some of these other things you would normally see people getting vaccinated for. You just saw an outbreak of measles in Ohio, and the I think you need 95% of the people to be vaccinated for Measles to keep immunity. And that number is now 93.