Pharmacy Leader Interview: Nilesh Desai, Baptist Health

Kristen Engelen: Welcome to the first edition of The Collaborative Practice Pharmacist Leadership Series. Each interview celebrates the role of the clinical pharmacist and spotlighting the future of pharmacy practice. 

I’m Kristen Engelen, the co-founder of RxLive and a clinical pharmacist with about a decade of experience in clinical pharmacy practice.

We founded RxLive four years ago to elevate the role of the clinical pharmacist in value-based care, innovate AmCare technology for pharmacist efficiency, and deliver patient-facing medication therapy / disease management (MT/DM) services via telehealth.

Nilesh, I’m delighted to have you speaking with me this morning.

What I’d really like to start with is just a little bit about your journey. I know that you worked with Hackensack Meridian Health for many years, and now you’re with Baptist Health. Tell me a little about that transition and what inspires you in the role that you’re playing now.

Nilesh Desai: Thank you for having me and pleasure to meet you. Over the years at Hackensack – at least in the last 15 or 20 years – I’ve seen pharmacy grow significantly. Human capital and drug budgets have been skyrocketing. And obviously the thing we all struggle with is medication adherence, the whole value-based proposition that pharmacists can bring to the table. 

I think it was around 2010 when we implemented our EMR at Hackensack. MedRec was one of the biggest concerns. You know, back then you would write the med list on the progress notes, and then someone would copy it over into an order and just move on. 

But with Epic, things changed. Epic requires converting all those medication histories live into the system – and then converting them into real orders. We realized it was a big struggle because providers didn’t want to do it, and that often led to incorrect med profiles.

And on top of that, patients would seek care from multiple providers. When that happens, patients end up with polypharmacy. So, how do we correct this? Answering that question is the biggest struggle. Obviously, it would require an army of pharmacists to really manage these patients.

So when I left Hackensack and I took this role at Baptist, part of the strategy was considering how to take control of the entire med management process. Pharmacists know the medications. Providers don’t want to take on medication management. Nurses don’t want to do it, either. So I found the best strategy is for pharmacists to do it. 

It’s a great vision, but there are questions. How do I justify the costs for the FTS that I’m going to need? Where does technology come into play? How do we make this operationally more efficient? 

I’ve seen different models across the country. People can deploy pharmacy technicians for med history, for example, but they’ll still need the pharmacist to reconcile the medications. 

When I joined Baptist, one of the questions I had was how to expand the footprint of the ambulatory pharmacy to promote value-based care. And how could we connect close to 400 clinics across the system? 

We did an initial study many years ago and it turned out that four out of ten medications listed in a patient’s med history are inaccurate. Depending on their course of treatment, we may touch a patient’s medication profile eight different times – or more. So it’s no wonder it’s so hard to get med profiles right.  Imagine a patient on 20-25 medications – what a mess it would be.

So setting up the specialty pharmacy and mail order facility was step one. And then centralizing all our inventory management pieces.

I still don’t have all the answers yet. But if patients can have only one med profile for all their care across all their providers, that’s a start. We’ll need a lot of technology to drive that.

And it’s going to take a combined effort between our care centers, our clinic-based pharmacists, and our ambulatory pharmacists that are out there. It’s going to require a team that sees the whole, big picture.

KE: One of our business advisors, Dr. Robert Kropp, says that with investment in clinical pharmacy there’s a one to ten dollar return on investment. RxLive has found that to be true as well. 

What has your experience been with developing the justification and business model for investing in your clinical pharmacy initiatives?

ND: Getting a med profile right can save a lot of money by preventing adverse events and avoiding medication errors. 

And it also saves money by supporting better medication adherence – because patients are more likely to take their medications when they’re prescribed the right medications.

Clinical pharmacists are the experts. That’s why we need to monitor medication management and med profiles.

It’s also worth asking, who’s the captain of the ship? When I’m monitoring patients, for example, I’d rather have them fill their medications at the Baptist pharmacies. This way patients get all their medications in a one-stop-shop. 

I think that’s where we need to be. Because people go to different pharmacies to get their prescriptions filled, but when that happens we lose the ability to monitor their complete profiles. It’s best to have a team centrally overseeing those patients.

KE: Are there any technology innovations that help patient populations that you’d like to highlight?

ND: Currently we are working with our EMR administrator to put some of these things in place. It’s a work in progress. This is not a done deal yet, but we definitely need to arrive at a solution so that information is flowing all the way from outpatient to inpatient back to outpatient.

KE: I heard you say that there are 400 entities that are part of the Baptist Health System. Are they all using compatible electronic health records, or are there a variety?

ND: Everyone in the network uses the same EMR, so that is a big benefit for us.

KE:I’d imagine so. You’ve been talking about integrating inpatient and outpatient medication reconciliation. What is your patient experience like in the transitions of care?

ND: Over the years, I’ve seen how pharmacists play a big role in TOC. We have the expertise, we have the knowledge. We need to educate the patients. 

I see a big gap in care transitions because patients aren’t educated about the medications they’re prescribed. Plus, some patients can’t afford these medications. Clinical pharmacists taking ownership of med profiles helps address this.

Clinical pharmacists understand the patient issues. They understand patient financial capabilities – whether they can afford the meds or not. 

And so pharmacists have the ability to build a better relationship with all patients. They can help educate patients, and assist in finding coupons and discount programs, to offer continuity in therapy. 

Following up with patients is key. And that’s why centralizing pharmacy care is important. When Baptist patients know it’s a Baptist pharmacist calling, they’re more likely to trust the information they receive because we’re regularly in touch with our patients and understand their care plans.

Pharmacists need to build that relationship – we need to build that bridge to support our patients.

KE: It’s always exciting when you have proof points that you can share with leadership so that you can move that forward.

ND: Exactly. And it also helps having me there with our leadership to support these initiatives by connecting the dots for them. 

Ours is a vision a lot of people are looking into and supporting what we’re bringing to the table as pharmacy. And I think the next two or three years are going to be very, very important for us. 

The next piece is addressing conversations with the payer. A lot of patients aren’t answering payers’ phone calls. So the payers look to us for help. I think we have an opportunity to take that and run with it. I think it’s going to be great.

KE: So, partnering more closely with payers themselves to deliver the service through your Baptist Health teams?

ND: Correct

KE: I know when you started with Baptist Health, the first initiative you chose to implement was specialty pharmacy and distribution. Tell me a little bit about that decision point and what you’re doing currently in that space.

ND: COVID was just starting up when I started at Baptist. But apart from COVID, we had to do the pharmacy program assessment. So it took me about six months to see where we could really scale up pharmacy.

I realized there’s a huge benefit to maximizing specialty pharmacy, managing the whole portfolio of medications, having a mail order facility so we can provide that service to patients – so they don’t have to run around looking for medications – and having financial assistance attached to it.

So, that’s where the journey started. And then I said, obviously we need a lot more NPs to do what we need to do, but how do we justify that? Let’s bring in more revenue streams and then we can make a stronger case to say here’s what it is. So that’s how we build our case to get the ball rolling.

KE: So, has specialty distribution helped to build the profits of the pharmacy team?

ND: Well, in some capacity. We still haven’t expanded to the fullest yet. We’re helping build a big central pharmacy services center which is going to help address some of this. Then we can go on to the next phase and address med rec, etc.

KE: I heard you mention patient assistance programming as well as it pertains to specialty. I certainly know as a pharmacist that’s a big piece of the puzzle when we’re talking about specialty medication spend, because 50 percent of pharmacy spend today is in the area of specialty. 

And that trickles down to the patient as well. Tell me a little bit about the structure you implemented to assist with the best price for the patients that you’re serving.

ND: We’re actually partnering with a company called Atlas Health from the patient systems perspective, so we can automate. They have a very structured way of partnering with manufacturers to provide coupons and other assistance programs. 

The thought process is, can we connect the dots and see if the patient can afford the medication they need? And then if they can’t, but they still need that medication, are there alternative options or other regimens that we can provide.

And again, patients need a champion to do this. If they don’t have that champion, they’ll experience a delay in getting the medications they need.

What is supposed to be a one or two day turnaround time for some of these medications can end up being an eight or nine day therapy turnaround time. You need someone to take ownership of the patient and manage any issues with their medications. 

Using technology helps drive down turnaround time significantly. If we can come in under two days, I’ll be very happy for those patients to start taking their medications because it will improve their quality of life.

KE: So, I hear you say that it’s important to have a champion. When you’re talking about a champion in this context, what type of role are you referring to?

ND: Pharmacists.

KE: Is there anything else that you’d like to share about what inspires you in your work, or something that you’d like to share that you’re proud of?

ND: My inspiration for every day is how I can get us to where our patients don’t struggle for things. Basic things. It should be as simple as going to a store and getting milk. Medication procurement or getting medications. And from a professional perspective, how do we grow the pharmacy where we need to be practicing? And how can we automate all the things that we can to make it so we can really focus on the patients.

KE: I love that vision. And support that vision. And agree that being able to reduce the burden to the patient when it comes to anything pertaining to medication access is really important. And it’s a significant problem in the United States of America.  And for anyone reading this that doesn’t have the context, when we talk about specialty medication we’re really talking about difficult to manage disease states – cancer, autoimmune – these things where folks really need their medication in a timely manner in order to improve their quality of life. In order to improve their chances of recovery. It’s not a small thing.

If you’re thinking about a parent who has a child who has cancer and needs access to specialty medication, having to wait eight or nine days for something the doctor ordered eight or nine days ago is unacceptable.

ND: Exactly. I believe in simplicity. So let’s keep it simple. Let’s not make it so complex that we’re trying to climb Mt. Everest.

KE: That makes sense. We have reached the end of our time here, Nilesh. Thank you so much for sharing your morning and your experience in the world of pharmacy. It’s been a pleasure speaking with you today.

ND: Thank you. Likewise. Hopefully we’ll get to connect and talk more.