Pill Bill: The Insane World of Specialty Medicine

Special.

What a word! Mentioning that something is, “special,” immediately conjures up excitement and implies that it is an enhanced version of the original. In many cases this is true! For example, the Special Edition Lion King DVD release ran two minutes longer and had a well integrated new music sequence. I am an avid Disney fan and any amount of extra Lion King time qualifies as special to me!

However, there are some cases where calling something special may not be 100% warranted. This old 2013 Nissan Rogue Special Edition is a prime example:

roguespecialedition

A dashing new car you might say! And SPECIAL edition?! This surely must be a super-car disguised as a moving refrigerator!

Wrong. 

In the automotive industry, “special editions,” are anything but special. They are a way to sell the remaining inventory of old models by repackaging them, but not really changing them. In this case, Nissan stuck two extra speakers in the thing, put new wheels on it and called it a day.

In the past few years we’ve heard a lot about specialty medicines and specialty pharmacy. Is specialty pharmacy a Lion King or a Nissan Rogue?

To find out, lets start from the top!

What are specialty drugs and specialty pharmacy? 

Specialty pharmacy is the service of dispensing and providing care for patients with complex diseases taking high-cost, high-touch medications. UnitedHealth Group concisely highlights specialty medicines’ characteristics in a 2012 specialty drug analysis:

  • Complex to manufacture, requiring special handling and administration
  • Injectable or oral, self-administered or administered by a health care provider
  • Costly, both in total and on a per-patient basis; taken by a relatively small share of the population who have complex medical conditions
  • Difficult for patients to take without ongoing clinical support; also challenging for providers to manage

For these kinds of drugs a lot of support is required from the pharmacy to ensure that the drugs are taken according to the best practices. These drugs generally treat a specific state in a disease or an orphan disease. 

Just like a fighter jet can assail a small target with incredible precision, specialty drugs are made to target intensely specific biomarkers. These drugs are true precision medicine

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Image courtesy of Department of Defense – US Government

What’s the big hoopla about?!

These drugs make a lot of people a LOT of money.

CRO_Health_Dollar_Sign_Pills_03-15One of the indications of just how big of an impact specialty medicines can make becomes evident in the 2014 National Health Expenditure Projections, authored by the Center for Medicare and Medicaid Services (CMS). In the report we see a HUGE spike in 2014 prescription drug expenditure that far exceeded the predictions made in the previous year. In 2013 CMS predicted that the national drug expenditure would increase 6.8% in the next year. For 2014, national drug expenditure actually increased by 12.6%.

To put that in perspective, between CMS’s prediction and the actual increase, there is 46% error. In organic chemistry lab, that kind of error was usually followed by, “I did the wrong experiment.”

So what happened?

Obama-headscratch
It’s a headscratcher.

Well just like a big movie opening night can boost annual movie ticket sales, specialty drugs like Sovaldi had their opening  in 2013 and made an absolute killing in 2014. The financial data behind these drugs are simply mind-boggling. 

“A 12-week course of Sovaldi, a hepatitis C treatment approved in 2013, costs more than $84,000” – Prime therapeutics

Full Disclosure – Financial data on specialty medications is ridiculously hard to find. As I scoured through various sources, I got the feeling that the companies getting involved in specialty medicines didn’t want people to have easy access to these numbers!

Lotsa-Tabs
If I had a dollar for every tab I used to find financial data, I’d be able to afford 1 dose of Sovaldi.

Prime Therapeutics, a private PBM covering around 25 million lives, revealed their specialty “net ingredient cost” to be $3,149.25 (Prime Therapeutics Report). Net ingredient cost includes all rebates and network discounts, meaning that this number is highly accurate and representative of the real number they pay. A newly instituted oral chemotherapy clinic’s specialty drug financials, printed in the January 2012 issue of Oncology Issues, estimated average specialty drug prices of $3,127 and accounted an average markup of an additional $1,823!

For reference: according to Investors Business Daily, non-specialty drugs on average cost less than $200.

What led to these drugs becoming so explosively expensive?!


Powder – Keg.

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Through my super-scientific (not really) processes, I’ve identified three driving factors in this highway-robbery:

  1. High Manufacturing and Distribution Costs
    • Along with the huge capital investment just to discover these drugs, the cost to produce them in mass amounts is high as well
    • A UnitedHealth Group report identifies supply chain complexities as another cost-adding catch
      • These drugs require special care in handling and dispensing…thus tacking on more money on their way to the consumer
  2. Many “Breakthrough” and Novel Drugs
    monopoly-man
    Bills gets you pills.
    • These drugs treat previously incurable or orphan diseases, so there’s no competition
      when they are marketed.
    • Lack of competition perpetuates monopolies
  3. Smaller/Captive Patient Populations
    • Patient populations who need specialty drugs are, as harsh as it sounds, going to die if they don’t take these medications soon…..so they don’t have much choice in the matter
    • The patient/consumer pool for each of these ailments is also much smaller than, for example, a drug that treats high blood pressure – the manufacturers have less income channels to cover their costs, leading to higher unit prices

Imagine you’re the ONLY person in the world who supplied food. To get the food though, you need to travel up 45 flights of stairs and then physically jump through a hoop, all while being shocked by electric eelschallenge

You’d likely feel entitled to raise prices to get the profit you feel you deserve right?

The entire industry is learning to adapt to these new parameters. Companies are forming teams to help pharmacies fight insurance companies for reimbursement on specialty drugs; support networks for patients taking these drugs are thriving, and everyone is making a pretty penny in the chaos that these drugs have created.


Patient Issues.

Lets switch gears now. What about the other side? The patients actually taking the medicines.

She's happy right now because she hasn't found out the price of her new specialty drugs....
She’s happy right now because she hasn’t found out the price of her new specialty drugs…

The finances of specialty medicines have become a huge burden on the patients who need them so badly. These prices have never been experienced before in the market, and because of a lack of flexibility, the system hasn’t developed a creative and affordable solution.

Depending on the disease, disease progression, drugs prescribed, dispenser (specialty pharmacy, physician, clinic etc.) and insurance company, patients needing specialty medicines could be paying steep out of pocket costs and are almost guaranteed to become the worlds best hoop-jumpers.

Proper hoop-jumping form required for full medication reimbursement
Proper hoop-jumping form required for full medication reimbursement

As your trusty data-dumpster-diver I’ve listed some of the main patient issues below

  1. Complex reimbursement
    • High costs of medications and different dispensing venues have created weird reimbursement ratios where some of the reimbursement comes from pharmacy benefit and some comes from medical insurance
    • As you can imagine, this creates a convoluted reimbursement process which means that the time to reimbursement goes up and causes headaches for dispensers and patients alike
    • Shamelessly borrowed from UnitedHealth Group - See their report linked above!
      Shamelessly borrowed from UnitedHealth Group – See their report linked above!
  2. Limited supply programs
    • As if having a life-threatening chronic disease isn’t terrifying and anxiety-inducing enough….health plans may require you to get your life-saving medications twice a month
    • Companies state this is a necessity because of “waste”
    • Waste includes things like people not taking drugs for side-effect intolerability along with…people dying and not being able to use the remaining drugs
    • I’m not making this up (seriously check it out)
  3. Required dispensing channels
    • Because the plans haven’t developed a scalable model for providing mass reimbursements, plans have only negotiated with a few channels for dispensing the specialty medicines to control their reimbursement costs
    • What this really causes is additional stress, as highlighted by this well written New York Times article: “Specialty Pharmacies Proliferate, Along With Questions”

Overall, its not an easy process. But that’s sort of expected right?


My Perspective

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It seems to me that everyone in the market is looking at specialty medicine through the same filter they look at regular pharmaceuticals. I can’t really blame them either. With these hugely improved drugs coming out, the consumers would be outraged if insurance companies took too long to properly develop the infrastructure for paying for them even if their out of pocket costs might have looked different. Despite this initial rush to force specialty drugs into our current healthcare infrastructure, I believe that the true solution is in complete restructuring. 

Specialty drugs require more R&D investment, more manufacturing investment, more distribution investment and more investment in patient support services. As I pointed out in the financial analysis earlier, the average drug costs for specialty drugs are more than ten times the non-specialty drug costs. This is an order of magnitude greater demand on a payment structure that was struggling to keep up before specialty medicines came out. With more patients requiring prescription coverage as a result of the Affordable Care Act, and predictions of specialty medicine comprising up to 50% of drug revenue as early as 2018 (Investor’s Business Daily); an entirely different perspective is required.

efficiency1

In the U.S. drug prices reflect not only the cost of the drug, but a portion of the R&D costs of new drugs as well. R&D activities are further subsidized directly by the U.S. government. As pointed out by Clayton Christensen in “The Innovator’s Prescription,” generic drug manufacturers in countries that don’t subsidize R&D have found a way to run viable clinical trials at costs up to 40% less than the big US brand names. Our brand name manufacturers have gotten lazy. With few constraints on research budgets, they aren’t concerned with running at their highest efficiency.

Drug manufacturers should start playing their long-term game

  1. Work on reducing costs in manufacturing, develop smooth channels for distribution.
    • Developing a super-efficient supply chain will help them avoid falling off the patent cliff when their new specialty drugs go off patent
  2. Focus should be kept on developing a competitive advantage in drug discovery and clinical trials
    • Another key to keeping generic drug manufacturers at bay is to have another ace in the pocket.
    • Even if sales of off-patent drugs were cannibalized by generic manufacturers, another drug would provide a new revenue stream

The world of specialty medicine is a young and developing one, but it’s looking more and more like this world is the whole new world for the pharmaceutical field. It’s important to understand the trends developing and prepare oneself in any pharmacy setting to deal with the issues these drugs will introduce. For now it may be scary, but my advice to everyone is:

Go boldly into this new world. Armed with data, you can achieve anything.

Hat tips:

  • Thomas Walters – Xcenda
  • Caroline Quinn – PharmD Candidate University of Michigan

Thank you all for reading! Please check out these resources for further reading on Specialty Medicines:

  1. UnitedHealth Specialty Trends Report – great analysis of trends from a large PBM perspective
  2. EMD Serono Specialty Drug Digest 2015 – more general trend analysis – they have great visuals in there also!
  3. Managed Care Article – managed care perspective on specialty medicine
  4. ASHP National Drug Trends – overall prescription drug spending trends
  5. IMS Health Specialty Trends Analysis – does a better job of explaining their analysis IMO
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From Corner Store to Corner-Stone of Healthcare; The Future of Retail Pharmacy

CVS-Pharmacy-PhotoPrintPrices Community; retail; big-box pharmacy. Whatever you call it, you know it when you see it: the generic looking buildings at virtually every corner, beckoning you to get your prescription and flu-shot, “in less than 20 minutes!”

You take the bait.

As you step in, it feels like you’ve entered a toddlers brain; with Kit-Kat bars, loofas, generic t-shirts, every flavor of chewing gum in existence and make-up scattered in incomprehensible fashion. I’ve always wondered how these mystical stores stay in business.

Today I’ll be discussing how they do it. Starting with a brief history and quick analysis of a modern pharmacy, I’ll discuss what the business of community pharmacy dabbles in, how they make money, and what they might look in the future.  So make a quick run to your local pharmacy, grab a Crunch bar and some popcorn because this one’s going to be fun! (I’ll be calling it “community pharmacy” throughout our discussion today)


history-compass

The History.

The first pharmacists were most likely cavemen who, despite not understanding any language, could understand pain and sought to alleviate it in others. Studies allude to medicinal plants being used to treat various conditions as early as 2000 B.C. Pharmacists in early days were a mix of the modern, “Doctor,” and “Pharmacist.” Pharmacies as we know them developed from the “apothecary,” model which involved people purchasing chemicals and healing potions from a chemist. Christopher Marshall is considered one of the first, “retail,” pharmacists in the United States. His establishment, “Marshall Apothecary,” pioneered the retail model and additionally trained future pharmacists and manufactured chemicals and drugs.

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Looking back to the earliest models of pharmacy it is clear that pharmacist expertise is derived from understanding, manipulating and applying chemistry to heal patients. Pharmacists of days past understood the ailments of their patients and devised solutions specific to the case. Today the pharmacist is the most accessible healthcare professional in the community. Trusted for alleviating many day-to-day ailments and being the last step in the medication dispensing chain, pharmacists have become the jack-of-all-health-trades. Everyday community pharmacists exercise their clinical judgement and regulatory acumen to confirm that you’re receiving the right medication.


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The Business.

(To understand the community pharmacy business model, I’ve chosen to analyze CVS as it one of the largest and possibly most well-known pharmacy in the U.S.)

So the pharmacist is in charge of dispensing medications and helping you feel like a rockstar, but how does that make CVS any money? Do they make their billions by selling you prescriptions?

Breakdown.

CVS operates 3 main business functions:

  1. Retail Pharmacy
  2. PBM services
  3. Front store sales

In calendar year 2014, CVS brought in a whopping $139,367,000,000 in net revenue. Because we are trying to isolate and understand the business processes in the stores we see everyday, lets ignore the $88,440,000,000 that PBM services brings in. We’re left with $67,798,000,000. Here’s how the remaining money is broken down

(Note: $88.440B and $67.798B don’t add up to $139.367B because CVS reported $16.871B in losses from “Intersegment Eliminations.” Essentially these losses are from people using the CVS PBM services to fill scripts at a CVS causing double revenue reporting.)

(Psst; hover over the chart!)

Of the $67.798 billion that the pharmacy stores pull in, sales of beauty, OTC and food products account for almost 60% of it!

Contrary to popular belief, CVS makes more money on the sales of things OTHER than prescriptions. The large difference between prescription revenue and front store revenue isn’t caused by a lack of prescriptions either. In 2014 CVS filled 935.9 million prescriptions, an increase of 5.2% from the previous year! CVS’s prescription volume accounted for 23.38% of all prescriptions filled in the United States in 2014. Front store sales in 2014 actually decreased 2.5% ; a direct result of CVS’s decision to discontinue selling tobacco products.

The profit margins for drugs, brand and generic, simply aren’t as high as the profit margins on other items such as beauty products.


What’s next?

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Major pharmacy companies have been cashing in on front store sales for decades now. Despite making billions of dollars, pressure from shareholders and the healthcare market is pushing retail pharmacy to infinity and beyond. Pharmacy companies are focusing their expansion strategies on a few key areas.

1. Retail clinics. Perform a quick Google search for, “retail clinic,” and I can guarantee you’ll find two things

  • CVS Minute-clinics near you
  • Multiple feel-good stories about how customers’ lives were affected positively by visiting a minute-clinic

“Increasingly, these clinics are an integral part of a U.S. health care system in the throes of massive change as payers and providers migrate toward Triple Aim goals of improved patient care, population health and reduced cost” – from “The Value Proposition of Retail Clinics” by Manatt Health

Retail clinics are the natural progression of community pharmacy. Boasting easy access, ample availability, and skilled professionals, the clinics provide services that enhance the community pharmacy business in various ways.

With Nurse Practitioners (NPs) at the helm, retail clinics provide the quickest access to a health professional. Despite the treatment scope seeming limited to minor to moderate health issues, the range is overloaded with patients who currently seek help at Emergency rooms and urgent-care clinics. These patients who desire immediate assistance for less serious issues end up clogging emergency rooms and wasting resources. Contrary to waiting hours in line at the ER, in less than an hour, a patient with or without insurance, can be seen by an NP, diagnosed with strep throat, and leave a retail clinic with an antibiotic regimen and a follow up scheduled for a week later.

Along with the ability to efficiently triage and diagnose ailments, pharmacies are beginning to embed their retail clinics further into their business plans by offering chronic disease and obesity management programs that patients are more likely to adhere to.

Example

Imagine being a diabetic, overweight patient and entering a CVS pharmacy. As you’re picking up your oral medications for the month, your pharmacist calls attention to their new weight and diabetes management program. Your insurance even covers a portion of the $40 charge for seeing the NP to initiate the program. The program includes a bundle of foods, medical devices and a calendar-brochure that is linked to your online schedule of meals and follow up appointments. The bundle is pre-packaged and handed to you with your diabetes prescription on the spot after your appointment with the NP.

Programs like the one I just made up will allow companies to promote their health-oriented focus, while making money on your appointments, prescriptions and the bundle of groceries you just purchased from them. Recalling the profit margins we discussed in the financial analysis above; CVS have just turned your low-margin prescription sale into a higher-margin sale padded by clinic-visit reimbursement and front-store sales! Through their high-margin sale, they are also promoting the healthiest life you can live.

Screen Shot 2015-07-13 at 1.51.08 PM

Convenience is one of the key propositions of retail clinics. A report by the National Association of Community Health Centers (NACHC) estimates that 62 million Americans don’t have access to primary care physicians because of a, “shortage of such physicians.” The entire primary care field is straining under the weight of millions of Americans who now have access to healthcare through the Affordable Care Act. Retail clinics are making strides in reducing the burden on primary care physicians while developing a more accessible and affordable healthcare market


2. Specialty medications. “Specialty,” medications are drugs that target complex diseases like auto-immune diseases and cancers. They have become the Michael Jordan of the pharmaceutical world. Because of their incredible research and life-saving drugs, drug manufacturing companies are able to price their drugs exorbitantly. And the retail pharmacy companies love them.

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According to Pembroke Consulting, the average profit margin for payers on brand-name non-specialty drugs is somewhere around $20.

At $167, specialty drug average margins dwarf the $20 non-specialty profit margins.

With such high margins and further expansion forecasted, carving out a piece of the specialty drugs market should be top priority for every community pharmacy.


Final thought.

Retail pharmacies are the most accessible healthcare portal in the United States. Because of the current financial model though, they act more as drug dispensaries hidden in the back of convenience stores. I see this model changing in the coming years.

A perfect storm is brewing that will galvanize community pharmacies to become hot-spots of accessible community healthcare.

With the prospect of increased specialty drug scripts and enhanced services through retail clinics leading to higher profit margins in the health arenas, I believe that community pharmacies can become the location many Americans seek primary care. Not only does the primary care pharmacy model work financially, it vibes well with the health-focused strategies companies like CVS are committing to.

So next time you walk into a big-box pharmacy, ask the pharmacist when they’re opening a clinic. If it’s coming soon (it most likely is), grab some Buncha-Crunch and enjoy the show as patients line up and pockets get lined thicker with money!

– Special thanks to Andrew Newhouse for jumpstarting my thinking on this subject!

Pharmacy Benefit Management; the Game, the Players and the Strategies

Real learning.

Have you ever heard a word or a reference made so many times that you begin to understand the meaning without having to look it up? I began experiencing this, “contextual learning,” phenomenon more and more when I made the jump into the healthcare field in 2013. People around me were using complex acronyms and terms such as “patient-centered medical home” or “collaborative practice”, that I understood in the context of their conversations, however I couldn’t define these terms explicitly.

To understand the complexities of the pharmacy industry, I’ve decided to research the entire pharmacy engine, breaking it down one piece at a time.

The topic I’ll be discussing today is Pharmacy Benefit Management (PBM). A quick google search of “Pharmacy Benefit Management,” will lead to some interesting results! For example:

This satirical video implying Pharmacy Benefit Managers are parasitic middlemen who add no value in the healthcare supply chain.

Additionally, many of the top results have varied, and incongruous definitions of what PBM is. Let’s start from the top and find out what they’re really about!

 The basics.

What is PBM?

Pharmacy benefit managers are the entities responsible for the sub-section of health insurance that handles everything drug related. PBM companies are contracted by large health-insurance companies, or self-insured businesses. Generally, they are responsible for drug pricing negotiations, and processing the claims data that comes in from pharmacies when people fill their prescriptions.

How do they make money?

PBM companies make their money by charging a fee to the company they are contracted by, ensuring the fee includes all their costs and a percentage of profit. For example, PBMs negotiate drug price contracts with pharmacies AND with the companies that solicit or contract their business. This is a point that tends to confuse many people so I’ve developed an example to alleviate the confusion:

For simplicity, I’ll be using an HMO plan as the entity contracting PBM services. Our example PBM company will creatively be called “PBM.”

Example

When paying for drugs, an enrollee of the HMO plan will go to a local pharmacy and hand the pharmacist a script and an insurance card. The pharmacy will then requisition a pre-negotiated amount of money (X) from PBM (because PBM handles all the drug related business for the HMO this patient is enrolled in). PBM will then turn around and ask HMO to pay PBM (X+3%) for handling the business and taking care of things. PBM will go home with the 3% from the top of this sale.

In reality the transaction is more complex. PBMs negotiate with pharmacies to only pay Average Wholesale Price (AWP) of the drug, discounted by 12-15%. Let’s recalibrate our example price “X” to be (AWP – 15%). For that same transaction, PBM will charge HMO (AWP – 12%)….which is the same thing as “(X + 3%)” in our simplified situation.  (Please note, “-” is “minus”)

What are some strategies PBMs use to gain an advantage?

SIZE MATTERS. As we saw in the example, PBMs negotiate many contracts based on price, and with a larger customer group their negotiating power increases. PBMs will use their scope to leverage greater discounts from the pharmacies, and further will leverage their size to receive direct rebates from drug manufacturers. This strategy explains the consolidation that occurs frequently in the PBM market.fish-eating-fish On March 30th 2015, UnitedHealthcare (parent company of PBM company Optum Rx) announced a deal to buy out Catamaran Rx. According to market-share numbers this means the #3 PBM company in the nation, OptumRx, is combining with the #4 PBM company in the nation. Despite paying a 27% premium for CatamaranRx, I consider this deal a natural progression of the PBM market. When the deal was announced, United Healthcare saw a rise in stock prices, indicating a mass approval.

The PBM market is now dominated by three juggernaut companies:

  1. Express Scripts (29% PBM market share)
  2. CVS Health/Caremark (24%)
  3. Optum Rx (Optum Rx + Catamaran Rx) (22% combined market share)

Fun fact: the PBM market is valued at $263 billion, and OVER HALF of that is controlled by Express Scripts and CVS Health.

VERTICAL INTEGRATION. This strategy is characterized by companies acquiring functions of their supply chain upstream or downstream. CVS Health is the posterchild for vertical integration. CVS as a PBM has developed a competitive advantage because they own a large chain of well-known pharmacies. Owning pharmacies allows CVS Health to understand and control the costs of their supply chain to a degree that is unattainable by other PBMs. To find evidence of this advantage, look no further than CVS’s ledgers: 63% of their revenue comes directly from the PBM business. CVS Health estimates it has 208,000 employees, and of that, around 16,000 work for CVS Caremark Rx (the formal title of their PBM).

7.7% of CVS* accounts for  63% of their business.

Understanding this strategy helps one understand the enormous importance and weight of the CVS conglomerate.

*(Based on number of employee estimates 16K divided by 208K)

My perspective.

perspective

PBMs are extremely influential players in the healthcare supply chain. They directly and indirectly control the environment at pharmacies; the last patient touchpoint in the entire healthcare supply chain. Despite reading articles and exploring company websites, in my opinion, the idea that the large PBM firms are simply middlemen persists.

Smaller PBM firms are making impacts in the market by adding value while providing comparable services to the larger firms. Kaiser Permanente, for example, offers physician-developed formularies, mandatory medication therapy management and claims a higher amount of generic prescription filling to save costs. Kaiser ignores the rebates drug companies offer for covering their expensive brand name medications, passing savings and transparency to customers and contractors.

Pharmacy benefit management is a lucrative business opportunity and the market is dominated by conglomerates making fast money and littered with smaller companies trying to edge out an advantage. Market pundit Jim Cramer predicts the ruthless consolidation to continue on until only a few companies remain. I personally believe that PBM firms need to begin adding more value.

As the trend of insurance accountability becomes more and more prominent with standards such as Center for Medicare and Medicaid Services “Star” ratings, PBM firms will have to begin worrying about how their choices affect patients.

Will covering an expensive brand name drug be better for outcomes or will the well-evidenced generic provide patients greater value? PBMs will need to start asking these questions. At first, the wings of the high-soaring profits may seem clipped, but eventually as patient outcomes and efficient market forces prevail, I believe we will see more accountable PBM firms that add significant value to patients and contractors.

Final Thought.

I firmly believe that when insurance companies began demanding more from PBM firms, CVS Health will become the number one player. CVS Health, with their remarkable network of integrated pharmacies, is best poised to provide greater value to customers. Some of their practices in retail pharmacy are frowned upon, but I truly hope that after acquiring Target pharmacy they will adopt Target’s phenomenal employee and guest experience.

Please feel free to comment, like and share this post! I’d love to hear your thoughts on the PBM market!

Thought Catalog

idea-light-lightbulb-thought-ss-1920Hello world!

My name is Amey Shroff and I’m an aspiring healthcare professional. I’ve been reading and thinking about many different things lately and I’m starting this blog so I have a place to develop my thoughts. From this experience I hope to refine my perspectives and discuss topics I’m interested in! I’d like to start with a Steve Jobs quote:

“You can’t connect the dots looking forward; you can only connect them looking backwards. So you have to trust that the dots will somehow connect in your future.”

This blog is the manifestation of my inquisitions and I don’t know exactly where it will lead me, however I trust that it will be a dot that I can look back upon and connect to something bigger.

Cheers!