Val had the opportunity to meet with Dan Scales, Pharm.D., owner of Scales’ Pharmacy in late July 2016. Scales’ Pharmacy was established in 2014 and is located in Denver’s Uptown neighborhood. Dr. Scales has built his pharmacy into a thriving specialty business. After a fairly lengthy career with a retail chain, he noticed there was a lot less time focused on patients and more time focused on how many prescriptions could be filled. Deciding to break out of the system and show that independent pharmacy is still a feasible business strategy and that it does better for patient care in the long haul, Dr. Scales has targeted an audience of more complicated patient cases.
Scales’ Pharmacy has a Focus …
“If you can show the value to one patient that has twenty drugs, then you don’t have to spend time on twenty separate patients. So decreasing the total patient size but still retaining that complicated patient that really does need that extra bit of TLC allows you to do a lot more good for those particular individuals. With that in mind we focused in on HIV and HIV care.”
Since political and social issues are associated with the disease state, Scales’ Pharmacy deals with those aspects affecting patient care on top of managing the chronic disease states. They also provide a lot of services for active prevention, doing things like STD screens and their PrEP program – pre-exposure prophylaxis program -working within a collaborative practice arrangement to minimize the chance of disease spread and minimize the amount of patients that have to live with the disease.
The Scales’ PrEP program is for individuals currently negative of HIV but who have the potential or the risk factors to become positive either because of their sexual activity, potential drug use or other forms of potential contact. Scales has set up a collaborative practice arrangement with a nearby provider. The provider does the initial screening to ensure the patient does have the necessary risk factors of becoming exposed. Then Scales’ Pharmacy performs all the laboratory monitoring and follow-up.
“My pharmacists and myself are all phlebotomists, so we do the actual venipuncture lab draws in the store to monitor for renal function panels and for other potential side-effects of the medication that we provide which is TRUVADA. “
They also do the STD and quarterly HIV screens to make sure the client is still HIV negative.
Becoming a phlebotomist in Colorado is straightforward. Value Pharmacists has found that phlebotomy training is available at several Colorado community colleges and at Emily Griffith. The definition of medical services under the Colorado Medical Practice Act does not include gathering data. For example, performing a phlebotomy, measuring vital signs, and gathering historical patient information is not subject to the Medical Practice Act Rules.
“Colorado has pretty minimal requirements to be labelled as a phlebotomist, but what we did was go to the state health department, discussed my long-term plans where we could also function as a lab station for some of their programs. So the state actually funded myself and my staff to go through the training. … there is no licensure in the state of Colorado. All that is required is that you go through a certified training. So we have certificates of completion of that training.”
… and offers more Specialty Services
In addition to HIV care, Dr. Scales and his pharmacy also provide more “standard specialty” services such as immunizations, MTM, med-syncing, and pill box filling. They also perform pre-emptive client management:
- Monitor patient refills and when the last fill is completed they reach out to the doctor pre-emptively a month ahead of time to make sure that patient always has refills on file.
- If a denial is imminent, they contact the patient and give them a full 30 days or 90 days to make those office visits and take necessary steps to make sure there’s no interruption of medications.
- Patient profiles are managed with extreme detail. Constant reviews of profiles and DCing meds, making sure active meds are available; reaching out to all of the patient’s providers to make sure they all know what else is going on within that patient’s care and acting as a centralized hub for that client. Within their patients’ complicated care system, with multiple providers, Dr. Scales wants the infectious disease physicians to also know what’s going on with their primary care.
Scales’ Pharmacy does not charge for these services now. The vast majority of their clientele is not well off. They could not afford a service like that out of their own pocket and it still needs to be done. Instead, the pharmacy pursues grant funding and similar programs to help with some of those costs. Scales has been “somewhat successful” in navigating those processes.
“I’m working with the health department to at least get the materials and things we need, if we ever need materials to get product to a client, so we can at least get those costs covered, but we tend to do most of those services on our staffing time and we do that on our own.”
Dr. Scales is hoping to leverage some of the services with the other payer groups in the long-term. He doesn’t really like the term specialty.
“We … deal with a lot of HIV clients here and a lot of transplant medicine and a little bit of oncology, but we really take on the patient as a whole. We very much don’t like to just do the specialty drugs. We like to do all the meds for one particular patient so we can really have the best impact on them. Those patients are typically in need of a lot of services. Their needs are high because their diseases are complicated and it gives you a quality access point to help manage not only their medical life but also make an impact on their .. life.”
However Dr. Scales does see specialty pharmacy as a “whole wide world out there.” The opportunities for independents, that have a little bit more time and availability, are there for making significant impacts on client care. So it’s very important to differentiate yourself as far as specialty versus non-specialty.
Early Adapter for Naloxone
Dr. Scales also attended original stakeholder meetings for Naloxone protocol and was involved with the input and writing of the legislation. His pharmacy was the first one to sign on with the protocol and go live in Colorado. He leveraged RxPlus contacts and those in some other groups to try to get some other pharmacies on board as well.
“We’re in a particular neighborhood where it is a high use area. We had a guy in his mid-twenties die outside of our store about two months before we opened. I performed CPR on him before the ambulance got there. He ultimately ended up not making it. So, from the get-go we’ve been pretty involved with that community and wanting to make sure we could have an impact with them.”
The observable success of Scales Pharmacy since their opening, they’ve “sextupled in business over the last year”, can be attributed to these aspects of his practice and more.
“I think a lot of it has to do with our involvement in the community that we service. We’re not just a pharmacy that is the pharmacy that supplies meds for HIV clientele.”
- Scales is involved with four or five different health department work groups.
- He sits on several councils for AIDs service organizations.
- He is a member of the board of directors of RxPlus, to help navigate how pharmacy as an industry is practiced here in Colorado.
- He is regularly involved legally and legislatively to remain knowledgeable of the upcoming rule changes and looks for ways to effect change that way.
- He demonstrates an increase in the value of pharmacy services to leverage providers, the health department and others to potentially see the benefit behind some of the pharmacy legislation.
Dr. Scales believes in
“constantly hitting the pavement and making sure we’re involved with everything. Not just sort of sitting back and letting it roll in but … instead of waiting for scraps fall down from the table, building a whole new table that hasn’t existed before. Creating a market space that we can thrive in and really showing the value to what we’re doing.”
Views of Collaborative Pharmacy Practice
Dr. Scales sees the 2016 Collaborative Pharmacy Practice passage in CO (SB 135) as helping further the relationship they have with providers. “I think the biggest element of that is going to be with the state authorized collaborative practice arrangements. There are some things I know that the departments that we work with are very interested in rolling forward and would like to roll them out in much bigger ways. But we’re set up in a unique environment where we have a bit of extra training in certain areas; we have phlebotomists, we have a bit of extra knowledge in certain aspects of how they work that will end up rolling in a fair amount of business to us just by the nature of being able to create new services with our existing partners.”
Since Scales Pharmacy provides STD treatments, passage of SB 135 may increase access to those individuals that have potentially been exposed to not only HIV but also to syphilis and gonorrhea. In working with the health department to create a collaborative practice arrangement, Scales would be allowed not only to test those that have been potentially exposed but also to deliver treatment on protocol immediately. Immediate results eliminate a seven day delay period when they may have been exposing others also.
In helping the Colorado state board of pharmacy to collect promoted, collaborative practice arrangements from other states, Scales feels his pharmacy will be one of the first to offer those added services as well.
He’d like to see other stakeholders, medical and provider boards, support pharmacists. Having those groups understand the value added benefits of pharmacy, helping promote pharmacists knowledge and skills and leveraging the community aspects of collaborative practice arrangements to allow increased practice possibilities, providing pharmacy
“with a stronger support structure for being reimbursed and paid for those things.”
Speaking of the Value of Pharmacists
While Dr. Scales is occupied at the prospering Scales’ Pharmacy , he suggests that Value Pharmacists stay abreast of what independent pharmacies are trying to do.
“Keep pushing forward with what you’ve been doing with the legislative and lobbying side of things; getting the word out; and helping in places where we can’t be because we can’t be everywhere all the time; to make sure you know the voice of us and the other pharmacies that are trying to do what we’re doing and making sure that you’re making our voices heard.”
Value Pharmacists’ involvement will help promote the unique value offered by a community pharmacist as they serve as the most accessible provider that a patient could possibly see.
- No required appointments.
- No screening receptionist.
- Available by phone.
- Available by walk-in.
- Medical knowledge that no one else with that level of accessibility has.
- It’s comfortable and stigma-free to come in or ask a question because everyone comes into the pharmacy; not just sick people. People come in to get a bottle of water or get some Advil for their headache or to pick up medicines for chronic diseases.
It is through leveraging their accessibility and stigma free environment that Scales’ Pharmacy provides the most care they can for any client.
“Whether that’s them just coming in because they’re having mental health issues, they don’t feel comfortable going anywhere else; they want someplace that is a welcoming environment, they can come in and talk to because you’ve established that rapport or whether it’s something to do with STD testing or other point-of-care testing make it a little bit more normalized for them to know their numbers and know their status of disease states they may have; or again just a simple question about how do they eat healthier, eat right. The accessibility we have, that stigma [sic] associated with us is very important and it’s one of the most under-utilized things in the pharmacy department, pharmacy as a whole, especially in that community setting.”
Value Pharmacists is grateful for the time Dr. Scales granted us to share his wealth of information about his thriving practice. Thank you, Dr. Scales!