Responding to the COVID-19 Delta Variant

Speaker 1 (00:05): Welcome to 340B Insight from 340B Health. David Glendinning (00:13): Hello from Washington, D.C., and welcome back to 340B Insight, the podcast about the 340B drug pricing program. I'm David Glendenning with 340B Health. David Glendinning (00:24): Before we go to our feature interview, we will note that as of this recording, our legal team is anticipating the first of what likely are several imminent federal court rulings on the 340B contract pharmacy dispute. If you are a 340B Health member or partner, please keep an eye on your email for our analysis of those decisions as they occur. David Glendinning (00:46): Our guest today is Scott Milner, senior director of pharmacy at St. Luke's Health System. Like many of you, Scott and his colleagues have been an integral part of the response to recent spikes in COVID-19 cases. We wanted to have him back on the show to hear his firsthand perspective on the latest stage of the pandemic response. When Myles Goldman recently sat down again with Scott to see how he and his colleagues in Idaho were doing, he had much to say. Here's that conversation. Myles Goldman (01:17): Thank you, David. I'm joined by Scott Milner, the senior director of pharmacy at St. Luke's Health System. Scott, welcome back to 340B Insight. Scott Milner (01:27): Thanks for having me. Myles Goldman (01:29): Scott, it is good to be speaking with you again, but I do wish it were under much better circumstances. We had you on in January, and we spoke about St. Luke's response to COVID and the vaccine rollouts, and with the surge of the Delta variant, we thought this was a good time to check in with you about all of that. Myles Goldman (01:47): But first, just to help refresh our listeners' memories, your system includes several 340B hospitals. Tell us more about who they serve. Scott Milner (01:56): Yes. We are located in the South and South Central and Southwestern area of Idaho. That's where our hospitals are. We do have clinics in Eastern Oregon. We have a [inaudible 00:02:08] facilities here around the Greater Boise area. We have a [inaudible 00:02:11] community in the center of the state in Twin Falls, in addition to a number of critical access hospitals peppered around in different communities. Myles Goldman (02:19): In terms of 340B savings, you use it for a bunch of different things, right? Scott Milner (02:24): We do. We set up a 340B assistance count for different patients to make sure if they needed help with certain medications. We started with some lifestyle and cardiovascular risks trying to make sure that we didn't have any readmissions. We did smoking cessation programs, and then we've gone into other efforts that we have across the system. Scott Milner (02:45): One of my favorite parts is we have about 1,500 patients on a given month that are on assistance from our 340B funds, and we dispense their medications. They financially qualify so they are able to get all the medications they need to try to get better and against stay at our hospitals. Myles Goldman (03:01): Thank you for sharing all those details with us. Talk now more, unfortunately, about Delta. How did the Delta variant affect the communities St. Luke serves? Scott Milner (03:13): You know, it's interesting because most of our COVID time we hear about things that are happening either across the world or across other areas in the country, and so it lags a little bit before it hits here. So we were tracking earlier in the summer how Delta was impacting other systems or other countries and really in August, even until today, it's been really hard and heavy. Meaning, we are seeing more reasons to test. Some of those are related to school and work needs, but we're having more symptomatic patients than ever before, and we have the highest positivity rate. Scott Milner (03:49): In addition to that, we're seeing the Delta variant is just a mess with how many patients it's impacting on a severe level. Many may know that Idaho as a whole has declared an emergency state to deal with the COVID overrunning our hospitals and health systems so we've watched it happen, and then it finally hit us pretty hard. So our hospital has repurposed other rooms, education rooms, some of our infusion rooms got made into an extra ICU bed, and so we're seeing more patients hospitalized than ever in the history of our system, from what I can tell, and then the large chunk of those being very critically ill COVID patients. Myles Goldman (04:27): So there were a few weeks where you saw it kind of approaching, and then the spike happened. Scott Milner (04:32): Yeah, and it was kind of depressing because in June and July, we started to feel like maybe things were going to calm down, and maybe we could have a summer, and, who knows, go to a college football game without any notion of COVID being present. But then as August hit, it kind of hit right with it, so right in time with back to school and everything else. Actually prior to going back to school, the COVID surge started to hit us pretty hard. Myles Goldman (04:56): What new ways have emerged to care for patients with COVID-19 since we spoke at the beginning of the year? Scott Milner (05:03): We've stood up extra monoclonal antibody or MAB clinics to increase our infusion capacity. Part of my role, I oversee the infusion services in the non-oncology space. We saw almost 3,000 patients with about a little over a third of those being COVID-positive patients. Myles Goldman (05:19): Can you tell us a little bit more about those clinics? Scott Milner (05:22): Yeah. You know, in some of our larger facilities where we have a large number of patients, we just couldn't find a really good way to get these patients seen. We tried to do it at the end of the day when our other patient populations had left, asking nurses to say later. It's been difficult because some of those nurses actually have been pulled into staff of our hospitals because our hospital staffing teams are stretched very thin. Scott Milner (05:46): So one of the things we did is we actually, with REGEN-COV being able to be administered subcu, instead of just the IV, we set up pharmacists-mediated or pharmacists administering REGEN-COV in a subcu fashion. We talked about it a little bit in July, but there was not a demand, and then the first week of September, we said it's time. So we've stood up three clinics to accommodate the REGEN-COV patients, and two of those, my pharmacy team members and peers are, it's not typical or common, but it's within our scope. So they're administering, they're helping draw a label, administer and then clean the suites. And our nursing peers are, when they can come and help there, they're present with us. But then sometimes they're pulled into the other nursing duties they needed. Scott Milner (06:32): So, yes, we've been able to find resources, but it's come at a cost, both at a financial cost to the system, and then also, to be very frank, an emotional cost to some of our team members. It's sometimes very hard to care for patients who are very sick. It's hard to have a patient come into our clinic and realize that the COVID progression has taken them to a point that we can't give them therapy. We get them into an ambulance and find out that they're admitted or on hospice and just that we're a part of that story, it takes a toll. Myles Goldman (07:02): Are there other ways the health system has adapted to add resources? Scott Milner (07:06): Yes. One of the things with the emergency status that we're at today, we've had to stand down a lot of what we call elective procedures. If someone takes offense to that, and I hope they do, because screening for colon cancer and endoscopy or getting a knee or a hip replaced because it's been giving you issues for a long period of time, and now that surgery or that procedure's been prolonged, it's a lose-lose scenario. So we have patients who have been scheduled for a different procedures or medical to treat something that they have a need for, but now those procedures had to be stood down as well. So, yeah, we've had to redeploy people. I have my 340B team and some of my other people that help with medication assistance, it's not like we stood up a clinic, we could hire positions. So some of my business teams we've said, unfortunately, COVID is a higher priority than doing some of the medication authorizations or some of the other work. So we've had to redeploy even our pharmacy business specialists and our business team. Scott Milner (08:05): Some of the things that we've tried to do to offset the manufacturer, things that they're doing in the 340B space, we've had to redeploy my 340B team and say, "Hey, I know that you normally do this work. I need you to come over here and help me draw and label syringes and make sure patients are treated." So a lot of things have been stood down and deprioritized to make sure we're treating COVID patients first and foremost, and that's been painful. It's hard. People like their day job, but also it's been really inspiring to see them step up to that task and make sure that they do it with a good attitude. Some of my employees that I've asked to be redeployed, they put on the gowns, the PPEs, the masks, it's not romantic. You come out with your face looks all murky and it's like wearing a garbage bag. You're sweating all day because you're side-by-side with 11 COVID-positive patients in a suite, and they've been champions. They've done a really good job in making sure that we can get done what we need to. Myles Goldman (09:02): I know I'm so thankful for what they're doing and, obviously, in many other hospitals, too, across the country, and you brought up a couple different points there that I want to make sure we get to in this conversation. I'm glad you mentioned patients with chronic conditions because what do you think the continued threat of COVID-19 mean for those patients with chronic conditions having the ability to manage their health in the long run? Scott Milner (09:29): You know, I mentioned that we have 340B assistance for patients that qualify. We have a number of programs that help patients, and we're not talking about someone that just doesn't want to pay a bill or they have insurance and good paying jobs. The bulk of these individuals are sometimes people that make 10 to $15 an hour or their insurance is really in a plan that puts the patient at risk, and they're choosing between paying a mortgage or rent or getting care, and so we have patients that fall into that bucket frequently. Scott Milner (10:02): What's really been hard in the last month is that we've redeployed individuals, we've asked ourselves, do we have enough people to treat our existing infusion patients? Do we need to turn therapies away so we can treat the COVID patients? Fortunately, we've not had to ration that care yet, but now we're running into, well, who's helping these individuals with their authorization, with some of the other financial implications that if they don't get that covered, that the bill will foot to them, and then they're going to be faced with the decision of do I get care or do I pay for whatever scenario? Myles Goldman (10:37): Can you tell us more about what St. Luke's has been facing from the drug manufacturers denying those 340B discounts on community pharmacies? This has been going on for more than a year now. Scott Milner (10:48): Yeah, and it couldn't happen at a worse time, again, and I want to point out that there are some manufacturers that are really good players in this space. I think that sometimes maybe that isn't acknowledged. While there are some that are easy to pick apart their names and who they are from the media or from challenging HRSA or some of the legal battles that continue forward, we do have some manufacturers that are good and I just want to let everyone know that those manufacturers, I specifically make sure they know we appreciate them. We appreciate their support. We also are very vocal about what we're doing with those funds because it's not like this is a taxpayer-funded program. So as the manufacturers that meet with us, we say, "Hey, by the way, this is where the dollars are going. This is how it's contributing to our area and our patient population." Scott Milner (11:34): But really in the last year I feel like it's a bit chaotic. Every time we feel like we know which manufacturers are having issues, another one adds to the letter. We then try to figure out how it's going to work. I'm seeing that our independently-owned pharmacies honestly are the ones that are probably hurt the most because of whether it's they have to submit information or determine some of the claim information, either to a PBM or on behalf of the manufacturer. Many of these independently-owned pharmacies are struggling to understand and they feel very threatened. There's been a few that have tried to say, "Hey, I don't know how to deal with this. We're just keep our stores open," and they've tried to terminate so we go back with them and we work. We try to make sure that they don't shoulder that risk, that they know that it's our program, that we're the ones that hold the compliance, and that we'll do anything we can to maintain it and make it equitable for both of us to continue forward. Scott Milner (12:29): But, again, the more complexity that it adds, the more staff that it adds, the more risk that it adds in what the manufacturers are calling for. So right now, it's impacting a lot of our rural communities because, again, the independently-owned pharmacies in those areas who are key community members are very much struggling to keep up with what are we doing with this now and what's the current update. Then we're also working with our legal team and external legal consultants to issue letters and work with our elected officials to make sure we're clearly communicating the damage that this is having. Myles Goldman (13:00): That's all good to know. Meanwhile, while this is all going on with caring for patients during Delta and the drug manufacturers denying the discounts, as you've just spoke about, we're still hearing a lot about the vaccines as well. Are vaccination distribution efforts continuing and, if so, how is that all working? Scott Milner (13:20): We send out about 46 coolers a week to various sites across Idaho and lately the demand has been high. We're starting to see the boosters populations come through. In fact, I think I read two articles today saying that boosters are outpacing first and second doses in a lot of areas, and we're no exemption to that. So in Idaho we have a large unvaccinated population, and then we have a very vigilant population that's making sure that they take their opportunity taking their shot, so to speak. So right now our booster demand is high, which is nice because we also have of our flu vaccine campaign, which is up because it's October, it's that time of year. So our vaccine work, again, in July, we thought it's going to kind of cool off, maybe taper away, but right now, it's ramping back up. If we just administer boosters to the patients and the people that we've administered so far this year, we had 120,000 shots coming, in addition to anyone who decides to get a first or second. Scott Milner (14:17): I also want to point out since we talked, we did something awesome in May as well. We actually purchased an RV, and I actually got the opportunity to drive it around this wonderful state of Idaho. Because, again, we did large volume, thousands of patients on a given Saturday, but we found patients in different areas of our state or communities or sometimes people that had a language barrier. So we drove to them, took the vaccines to them. It was very different because if we got 10 or 20, we counted that as a victory. We partnered with the Mexican consul here in Boise. We did a day at their building. We had patients that continued for the next two weeks as we drove around the state that heard through their networks that, "Hey, you partnered with the Mexican consulate so when you came into my town, I went and got vaccinated." Myles Goldman (14:59): You must have so many stories from driving that mobile clinic around the state. Is there any one story that just stands out to you? Scott Milner (15:09): One of my favorites, there was a day where we're at a high school and we were really busy first part of the day, and then we're there until late into the evening. There was one of high school kids who had walked past and he asked us, "What are you doing?" "Oh, we're doing vaccines," and asked a few other questions. And I was like, "Have you been vaccinated?" He's like, "No, I don't think my family would let me." I was like, "Well, how old are you?" He's like, "I'm 18." I'm like, "Well, talk to you with your family, know we'll be here until 7:00 or so at night." Scott Milner (15:37): About an hour and a half later, a car pulled up and he got out and he's like, "Can you tell the same information you shared with me to my mom and grandma?" So I walked over to the car and I said, "There's no cost to you. There's the process. Here's the information." They have lot of questions about things that they've heard somewhere in the media and I shared some of our safety information from the vaccines we've administered. And I watched all three of them get out of the car, come and get vaccinated. Scott Milner (16:02): So I saw that enabled us to take some of the barriers away in ways that we knew that if we brought it to people, there would be those that would be like, "All right, I'll get it since it's here," but it was really fun to actually talk to people on their turf at their food market or whatever venue that we went to and be able to enable the opportunity. Myles Goldman (16:21): Well, that's all wonderful to hear about the successes you had, and you just mentioned people having questions about the vaccine. You told us the last time we spoke that the vaccine's great side effect is hope. How have you been able to communicate that to people who have questions? Scott Milner (16:39): You know, the hardest thing is in the last few months, things like vaccine mandates have been in the news, and that's added a lot more tension to the discussion, and some of it's good, and some of it's bad. On one hand it's forced some people to do some research, and I've had a number of conversations with friends and family and coworkers, all inclusive, about what the data really is. Scott Milner (17:03): Now I've had some friends who chose to remain unvaccinated who, unfortunately, have passed away, and it happened very fast. I had a coworker sat in my office in August and told me that she felt that the vaccine was poisoning the people around us, and I begged her to be vaccinated. I answered the questions, and she cited a number of sources that she's turned to, and I begged her to talk to one of her primary provider that she trusted to get that provider input or information. Unfortunately, she contracted COVID and has passed away. We have her memorial this weekend. Scott Milner (17:36): So I think on one hand we continue to have a lot of discussion. Every time I get into a dialogue around this and people say, "Well, vaccines are political," the plea I always have is I ask them what their sources are. I ask them to turn to medical professionals that they know, not someone who is a guest speaker on a podcast, even like this. Don't even trust me if you're listening to my voice. Talk to a doctor that you know and trust. Scott Milner (18:00): I always share that in our hospitals while we're max capacity, we're yet to be full of people with vaccine injury. Unfortunately, the flip side, what we are full is we have, by and large, a large population of unvaccinated individuals who contracted COVID, who are critically ill, in many cases, fighting for their life. So while vaccines brought hope in January, unfortunately, the overtones of... It's a little heavier right now and not all conversations are welcome. Myles Goldman (18:29): Well, Scott, I'm very sorry to hear about your friends and your colleagues. This must be so difficult to be going through all of this. How have you personally been able to keep going and keep doing all the great work that you're doing on a day in/day out basis? Scott Milner (18:45): You know, there's two things. One of the things I love, I have the ability to actually coach one of my kids in a sports team. Absolutely, that's one time of my day or my week when I go to practice and I focus on and my daughter and her peer players, and make sure that we're ready for the next game or tournament. I feel like that's helped me separate some of the tension from my work. Scott Milner (19:07): One of the things that I'm fortunate is since COVID came about we actually came home from the 340B Coalition in San Diego, early 2020, and immediately dug into COVID work. I didn't take a lot of time off for a long period of time. In fact, working a lot of weekends and those Saturdays were sun up to sun down, plus some. I have a boss who actually required me to take the bulk of July off. I had all this PTO saved up and all these reasons why I couldn't leave and she semi-told me, forced me to take it. So most of July, I only worked one or two days a week. So I was able to backpack with my family, my kids, variety of places from Wyoming, Montana, Utah and Idaho, parts of Northern California and Oregon. Myles Goldman (19:51): I'm glad you've certainly gotten some well-deserved downtime and all of that. Scott, I just want to thank you for taking this time, especially in a period where you're still on a day in/day out basis dealing with all of this, taking the time to speak with us today. Scott Milner (20:06): No problem. Thank you. I appreciate the work that you guys do in helping us with our 340B program, and then telling the story of what it's like out here on the front lines. David Glendinning (20:15): Our thanks again to Scott Milner for continuing to tell his powerful story. We remain immensely grateful for him and the rest of the dedicated professionals serving on the front lines of this pandemic. We hope that Idaho and the rest of the nation soon will be back to the points where backpacking trips and ball games are the norm again and not just a brief respite from weariness and heartbreak. David Glendinning (20:39): We want to help you tell your stories from the 340B world. If you have an idea for a future episode, please email us at podcast@340bhealth.org. We will be back in just about a week with our next episode. As always, thanks for listening and be well. Speaker 1 (21:02): Thanks for listening to 340B Insight. Subscribe and rate us on Apple Podcasts, Google Play, Spotify, or wherever you listen to podcasts. For more information, visit our website at 340bpodcast.org. You can also follow us on twitter at 340bhealth and submit a question or idea to the show by emailing us at podcast@340bhealth.org.