Rite Aid – Fundamental Rethink of Pharmacy – 13 May
2021
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Specialist:
Title:
Moderator: Nyree Hinton (NH), Third Bridge Sector Analyst
Jesse McCullough (JM)
Former Director, Business Development & Pharmacy Initiatives at Rite Aid Corp
Agenda:
1. Retail pharmacy blueprint and competitive landscape
2. Vaccine administration impact on Rite Aid's (NYSE: RAD) in-store sales
3. E-commerce channel growth and digital strategy
4. Cost and profitability outlook
Contents
Q: Could you provide an overview of the retail drug store and pharmacy benefit management industry, and
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retail pharmacy in general? What are some of the main drivers and competitors in this industry?
Q: What were 2-3 trends you noticed pre-coronavirus within the industry? How that has transformed since
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March 2020?
Q: Could you elaborate on why you think margins are coming down? What has the industry done to keep some
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of its margin percentages?
Q: Where were the highest-margin products and services within your line of business when you were at Rite
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Aid?
Q: What does the trend towards 90-day fills mean for a company such as Rite Aid? Can it supply some of these
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longer-term fills, or are prescription managers such as Express Scripts taking market share?
Q: What’s your high-level overview of Rite Aid’s business and how it’s evolved over the last five years?
Q: How do you think coronavirus has impacted Rite Aid and transformed the business?
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Q: Some pharmacies were given the go-ahead to administer COVID-19 vaccines and given supply earlier than
other vaccines, or other pharmacies. Could you elaborate on that bottleneck, and how some were preferred
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over others?
Q: How well-placed do you think Rite Aid was to handle the logistical and administration challenges around
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cold storage for certain COVID-19 vaccines? Is vaccine administration a profitable business?
Q: How well-placed do you think Rite Aid was to handle some of these logistical and administration challenges
around COVID-19 vaccines? Do you think the company downsizing a few years before became a disadvantage?
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Q: What would you say were some of Rite Aid’s most pressing challenges while you were there? How has
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management addressed those challenges? Do you think it truly addressed them?
Q: How are some of the drugs being measured, and what does that mean?
Q: What are your thoughts
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Q: Who would you say are leading in the competitive landscape and really hitting the key performance metrics?
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Who are some of the laggards, based on dynamics such as market share?
Q: How has the regulatory environment relaxed rules around prescribing people out of state? Do you think
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that could have a positive impact in driving fills? Alternatively, do you think that just distorts the data?
Q: Could you elaborate on the reimbursement pressures you mentioned? Are they truly down to the
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performance contracts?
Q: Is there anything that you think investor communities should know regarding Rite Aid’s management
scheme and ability to execute on priorities? Is there anything you think the investor community commonly
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overlooks?
Rite Aid – Fundamental Rethink of Pharmacy
Transcription begins at 00:00:00 of the recorded material
NH: Welcome to Third Bridge Forum’s Interview entitled Rite Aid – Fundamental Rethink of Pharmacy. I am
Nyree Hinton and I will be facilitating today’s Interview with Jesse McCullough, former Director of Business
Development and Pharmacy Initiatives at Rite Aid.
Jesse, before we start today’s Interview, please state I agree or I disagree to the following statement: You
understand the definition of material non-public information and agree not to disclose any such information,
or any other information which is confidential, during this Interview.
JM: I agree.
NH: Could you provide an overview of your background?
JM: I’m a pharmacist by education. I started off actually working in the stores, spent a number of time
working at a number of stores in western Pennsylvania. From there, I moved into clinical services. In clinical
services, we were looking at developing more non-traditional, at least at the time, revenue streams for the
pharmacy. I would describe traditional revenue streams as your normal filling of prescriptions. When I went
into clinical services, we were developing the immunisation programmes, so pharmacists beginning to give flu
shots. We were also big into pharmacists being paid for cognitive services. We got a lot of traction with that
with the advent of Medicare Part D and the medication therapy management rules that accompanied Medicare
Part D.
From there, I ended up at Rite Aid, where I worked in clinical services probably for the better part of 10 years.
While I was there, I also became well-versed in performance measures. Performance measures were coming
into the scene, especially secondary to Medicare Part D. You have payors now wanting to make sure that
they’re getting value for the dollars that they spend, and they do that by analysing prescription claims, at least
at the time being, and I’m sure it will evolve from there. I had some experience with that. I shifted from clinical
services into business development, where I was looking at a number of new opportunities that actually
coincided with the time that Rite Aid was entertaining some merger opportunities, and at the end of that, I
actually left Rite Aid to go work more hands on in the performance measure space. I did a lot of that with
independent pharmacies. I’ll pause there. Hopefully that gives you enough to get started with, my friend.
[00:02:45]
Q: Could you provide an overview of the retail drug store and pharmacy benefit management industry, and
retail pharmacy in general? What are some of the main drivers and competitors in this industry?
JM: In the market itself, in the United States, you have about 60,000 community pharmacies out there
supporting a population of about 330 million people. One of the big drivers out there is Medicare. You have
people ageing into Medicare. I believe the statistic is something around 10,000 people per day age into
Medicare, so you just have this huge influx of the baby boomers, and older people, generally speaking, take
more medicine, so that’s been a big driver in prescription volume in the space. What you have opposite of that
is the margins that you make per prescription have been decreasing over, I would say forever. Since I started
in pharmacy, that’s been a common theme, but you continue to have pressures on reimbursement that come
through that. When you get into pharmacy benefit managers, I probably am not as well-versed with that,
although I would tell you there are a number of pharmacy benefit managers out there, and they make their
revenue a couple of different ways, one of which is probably on just the transactional margin, but that’s where
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you sit there.
Among those 60,000 retail pharmacies in the US, you have a couple of major chains there, your CVS, your
Walgreens. They each have about 10,000 stores. Then, you start moving into some of your smaller ones and
regional ones, so this is where your Rite Aids, your Walmarts and some of your regional groceries, stuff like
that, you have that. Then, you also have a very healthy number of independent pharmacies, pharmacies that
are owned by mom and pop, if you will. There are probably 15,000-20,000 pharmacies in that bucket, so you
have quite a diversity of pharmacies out there. They all have the same business pressures. They want to fill
prescriptions, they want to make money on those prescriptions, they want their people, their customers, their
patients, whichever term you prefer to use, they want them to be coming back in.
There are other pressures that have come into the market, and this is because of Medicare, but they are
looking at performance measurement of those prescriptions. They look at this in a couple of different classes
of medication. They look at medications for blood pressure control, they look at medications for diabetes
control, they look at medications for cholesterol control, and as such, those drivers affect the reimbursement,
so the better they take care of patients, the less impact it has. The worse they take care of patients, the more
impact that has. I will tell you that you have seen an influx in that space of mail order, people shifting to mail
order, that you have another driver with the insurance carrier, because the insurance carrier is trying to
deliver quality results to their sponsors, so as such, you see mail order getting involved. With mail order, you
often see 90-day fills, so you see longer fills and things like that. A number of different things. It’s never a
boring day in pharmacy, but those are, I would suggest, some of the high points that I would throw out there
to start with.
[00:06:38]
Q: What were 2-3 trends you noticed pre-coronavirus within the industry? How that has transformed since
March 2020?
JM: I would say that within the industry, definitely, there was a shift to 90-day fills, and you could probably
do some calculus with that, that the fewer times you have to pay for the preparation of a prescription, there’s
some payroll benefit, there’s some workforce benefit there. You also have, though, decreasing margins.
Decreasing margins have been a trend for a long time. You have the performance measurements impacting on
that in the Medicare space. You also have this feeling of wellness. Health and wellness seems to be a very
popular term in the industry, and you have a number of organisations that are looking for ways to develop
revenue streams for cognitive services. The foothold that that came was probably about 2006 with the
medication therapy management, however you’re seeing a number of other elements being put out there,
diabetes education, chronic care management, all these things that look at the appropriate use of medications.
Really, I would suggest what you’re looking for, and you even see this if you look at the news, there are a lot of
topics out there on provider status for pharmacists. Some states have taken some action on that, but what that
does is that opens up at least the possibility and future opportunity for compensation for different products
and services. A lot of pharmacies are really looking to how do we take care of the patient? They recognise that
they have some chronic conditions, and what they want is they want patients, I would suggest they want
patients with chronic conditions that are stable and those become repeat customers, time and time and time
again. You don’t necessarily want patients who are super sick and they’re in and out of the hospital, because
that disrupts your work demand there a little bit when you have interruptions like that.
[00:09:14]
Q: Could you elaborate on why you think margins are coming down? What has the industry done to keep some
of its margin percentages?
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JM: Some of the things that you will see is you will often see chasing new generic manufacturers, the margins
come down, and they keep coming down. You have automation, you have different things that have been put
into place to try to offset some of those things. For example, you have dispensing robots in pharmacies to do
the work that multiple people could do. I could not give you any hard numbers on what is promoted for those,
but you have that, and those are efforts to be able to offset some of that payroll margin that you have in taking
care of patients.
[00:10:26]
Q: Where were the highest-margin products and services within your line of business when you were at Rite
Aid?
JM: I probably can’t speak to that today, but I would say that one of the things that has historically been a
higher margin has been generics. That has been eroded dramatically. I could not give you numbers on that,
because I’m sure even if I had numbers to give, they would be outdated relatively quickly. That really pushes
you to why there’s this demand and interest for different cognitive services, where you can have products and
services offered where there’s minimal, if not zero cost of goods sold. A pharmacist being paid to do
counselling or education, you’re not having to stock a product on the shelf. You’re taking advantage of the
cognitive capacity to be able to generate revenue in those particular instances. Obviously, then there’s the
possibility of services like that that are offered, that make the patients that you serve very, very sticky to your
store and keep them coming back time after time, month after month, quarter after quarter for their
medication needs.
[00:12:01]
Q: What does the trend towards 90-day fills mean for a company such as Rite Aid? Can it supply some of these
longer-term fills, or are prescription managers such as Express Scripts taking market share?
JM: The answer to that is probably yes. Oftentimes, and this varies from one contract to the next, but
oftentimes, you will see contracts that are available that are essentially 90-day refill. If you get in the time
machine and go back to yesteryear, oftentimes, 90-day fills were a perk of doing mail order, however what you
see today is you will see 90-day fills at retail. Sometimes, there are copay advantages for a patient. I can just
speak from my own experience. I have had experience having prescriptions filled at mail order. One of the
things that they promote is that if you use mail order, you would have a decreased copay. Some insurance
carriers would actually have a mandatory maintenance mail order. That all comes down to plan design,
contract design with particular employees. There’s a lot of variability with that.
I would tell you that Rite Aid, this is a Jesse McCullough opinion piece, but I would say that most pharmacies
are looking to take advantage and care for any patients that they can, because the reality of it is that those
patients will end up in their store at some point, needing some care, be it an urgent care prescription. You
don’t have the visibility to the other prescriptions that the patient is filled for to be able to ensure the safe and
effective dispensing of medications, so pharmacies are doing everything they can to keep a hold of that, but
there is, no doubt, pressure from the mail orders and the push to shift patients to 90-day fills.
[00:14:17]
Q: What’s your high-level overview of Rite Aid’s business and how it’s evolved over the last five years?
JM: I tell you, there has been an interest in really driving wellness within the group. You can see that with the
implementation of their Wellness format stores and really taking those to the next step. That has been very
much an emphasis from them. Other major changes, obviously Rite Aid had a number of stores that were sold
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off a few years ago. They have a different size in the marketplace. They’ve had some changes in leadership at
the top, and so you have some of those things that are out there and are impacting, and then, of course, we’re
all dealing with COVID. I would tell you that one pharmacy that’s dealt with COVID is one pharmacy that’s
dealt with COVID. I would suggest that they’ve all been impacted, however the impact varies a little bit from
one to the next, depending on a number of things, not least of which is the staff, but also then just the
customer base and what you have and are looking at there.
[00:15:43]
Q: How do you think coronavirus has impacted Rite Aid and transformed the business?
JM: I’ll tell you this. There has been a dramatic change over the last 12 months in foot traffic, and this is
speaking globally across all pharmacies, that you had some pharmacies that shut down, you had some that
were open, they had limited people in. You had a huge shift to home delivery, you had a huge shift to drive-
through, you had a huge shift to kerbside, so really, some opportunities to have an impactful customer
experience. I would tell you that COVID has absolutely impacted the workforce, and I would suggest to you
that there’s probably not a pharmacy out there that has not been touched by COVID, having somebody on the
staff go down, having a family member of somebody of the staff go down. You have all these different elements
that have been out there, and that has been a major challenge and a major stress for that, because you still
have demand for those services for the dispensing of medication.
When the quarantine first hit a year ago, there was a surge. People were trying to stock up at the beginning of
the quarantine, and that was offset. A little while later, there was a bit of a catch-up, but you see a lot of those
things going on. Most pharmacies have some type of protocol that if you had people get sick, that they would
do a deep cleanse of the pharmacies. Those are disruptive to the pharmacies. You may have a pharmacy that’s
closed for a day for deep cleansing. There are a number of different things that are out there, and then
contrasting that against a customer base that still has needs, still has demands, still has fears. There are
different concerns that are out there, and so I would suggest the last year has been very, very challenging. You
have a number of stores with a decreased foot traffic that likely corresponds to decreased front-end purchases.
You have a number of different things that are out there, and just as COVID vaccine comes into the
marketplace, there’s demand, calls coming into the pharmacies every day. I would tell you, this is an anecdotal
story and it was with a pharmacy that said, “Yes, we are getting 300 calls a day,” and I said, “Surely you’re
exaggerating,” and he said, “No, the phone is ringing non-stop with people asking me, ’Do you have the COVID
vaccine? Can I get it?’” You have a number of different challenges with that. I think pharmacy in general has
been put front and centre in the last year, with the care that they have been providing, and now, as the focus
has shifted towards COVID vaccine, there has been a huge pressure, there’s been a huge opportunity that has
been lent to these pharmacies to take care of people. I don’t know if we’re going to talk more specifically about
COVID vaccine or if you want me to go into that now, but there are a lot of challenges, even within the vaccine,
to keep into consideration as well.
[00:19:28]
Q: Some pharmacies were given the go-ahead to administer COVID-19 vaccines and given supply earlier than
other vaccines, or other pharmacies. Could you elaborate on that bottleneck, and how some were preferred
over others?
JM: I would give you a couple of things. Just for context, during my time at Rite Aid in clinical services, we
went through H1N1 about a decade ago, and it’s interesting. Here, you had a roll-out where vaccine was being
distributed by government, federal or state. The federal partners, they looked for large national partners to
use, and I think you probably don’t have to look too hard to find a couple of large pharmacies that were
involved with that. In some areas, they also used some regional players, but those folks were getting involved, I
believe, perhaps as early as the end of December 2020. There were all sorts of challenges with you have a
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supply and demand curve. The demand curve was off the charts, and supply was limited, so there were a
number of challenges that came in those early phases, and hence I would suggest that’s why some pharmacies
claim to be getting 300 phone calls a day. There was a lot of work to vaccinate the first responders. There was
a lot of work to vaccinate nursing homes, a lot of those things that were going there in the beginning.
As we got into 2021, we see more of this moving to the community pharmacies proper, and I would suggest
that they probably got vaccine a little earlier than what they expected. I probably cannot take my hat off and
applaud pharmacies enough for the work that they have done in this particular space. These vaccines, with the
stability and fragility of them, within the vaccine space, there’s something that we call the cold chain. They
have to be maintained at a certain temperature to remain viable. If that cold chain is broken, then you don’t
want to be given the vaccine, and it’s not that it would cause harm, but it probably would not cause any
benefit, and you don’t want to be telling somebody they’re vaccinated when they’re not. Due to that, so many
pharmacies had to get extra equipment, refrigeration, freezing, whatever, had to come up with different
logistics around maintaining that cold chain and that product. When they had the product, the vaccine, it was
delivered in multi-dose vials, and if anybody is not familiar with that, that means you get one vial and you take
multiple doses out of that same vial. There were different rules around once you take the first dose out, you
want to use that whole vial within a certain amount of time, six hours for example.
The idea was you would want to vaccinate a lot of people in a relatively focused amount of time, so there were
a lot of things that went into this. You saw a major shift to online scheduling, and the scheduling had benefits
in a couple of ways. One, to help pharmacies predict what the need was going to be, “Hey, I’m going to give 30
doses today, I’m going to give 50 doses, I’m going to give 100 doses,” whatever that number would turn out to
be, but it also then allowed them to schedule that in such a way that they would be able to safely move people
in and out of the pharmacies. Just as a story from my early days vaccinating, the first day I gave flu shots, I
had 30 people waiting in line. You didn’t want to have that with COVID running around. You wanted to have
30 people, but you wanted to have them come in at a regular cadence so that you could move them through in
a safe way, and do whatever cleaning that you would be doing in between patients that you vaccinated, so lots
of things there as far as that goes. There was also, just after they would vaccinate, the normal perspective is
you would encourage patients to stay around for monitoring to make sure that they don’t have some reaction,
and I’m sure you could probably do a Google search for COVID vaccine reactions and find some different
anecdotal stories. That’s one of those things that’s the standard of care is that you would encourage patients to
hang around, just to make sure everything is on the up and up.
With all that demand, and that is as vaccines became much more prevalent, you saw a lot of pharmacies
advertising that they were hiring, that they were hiring people to give flu shots, so there was a flex that was
happening to be able to vaccinate more people. You also have a shift with this, and you have some states will
actually allow pharmacy technicians to vaccinate. I believe Idaho was the first state to allow that, but you see
that under the pandemic, under the demand, there are different ways that the different states have flexed to
get more people out there to be able to vaccinate, so you’ve seen some of that as well. There has been a lot of
change going through this, and all of this happens and you’re still filling the antibiotics, you’re still filling the
asthma inhalers, you’re still filling the blood pressure and diabetes medicine as that goes along, so there have
definitely been some huge challenges that have come to pharmacy so far this spring.
I would say that, just going back to my comment about all the phone calls that the people were receiving and
that high demand, within a population, you have a group of people who I would call the early adopters. They’re
the ones that want to be first in line, and those folks were out there. They were looking to get vaccinated as
soon as they could. You then move into the early majority. You then move into the late majority, and then you
have folks that you really have to work on or perhaps even would refuse to be vaccinated, and with all of this
stuff, you get to do it twice. You have a two-dose series, and I would like to just offer this as some bit of
context. In a normal flu season, you would see that vaccine manufacturers probably produce between 100-130
million doses of vaccine. Those doses become available typically late summer, and you would see those doses
given probably largely from September, even through March of the following year, so you can do whatever
back-of-the-envelope math you would like to do with that. Nobody would be surprised to say that the early
part of flu season is when you give a lot of doses, and as you get deeper, it’s a little more difficult. That goes
back to the early adopters, early majority, late majority and the folks that are resistant.
When we look at what’s going on with COVID vaccination, I believe the federal government has committed to
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purchase 600 million doses, so that’s basically two doses for 300 million people, which is practically the whole
population. You have a huge supply here for those pharmacists to do this, and I would suggest that you’re
seeing more work in less time. Even if we just said we want COVID vaccinations to be done by summer, if 600
million doses were given over the course of six months, that’s quite a bit different than 130 million given over
the course of eight months, just to try to give some perspective as to what’s out there. Granted, I know not
everybody is going to get a flu shot or get a COVID shot. There are going to be some that are resistant, that
can’t for whatever reason, but that’s where you see the demand for pharmacy attention, from, “Do you have it?
Can I get it?” I believe that right now, you’re probably very much, we’re going to be very much transitioning
into pharmacy services where it’s going to be probably a little more challenging to give those shots. You’re
going to see people are going to have questions, and there’s going to be a little more hand holding through that
process, and that’s probably not too dissimilar from a flu season, but you’re going to see it on a different scale
and with a different level of urgency here over the next several months.
[00:29:54]
Q: How well-placed do you think Rite Aid was to handle the logistical and administration challenges around
cold storage for certain COVID-19 vaccines? Is vaccine administration a profitable business?
JM: As we’ve talked about margin before, margins continue to shrink. At one point, it was a very, very
profitable piece, because essentially you get paid for two things. You get paid for the product, and then you get
paid for the service of administering the product. You may not have a whole lot of margin on the product itself,
but on the administration, that has traditionally been something that you’re using the pharmacists’ skill. You
do have a little bit of cost with the supplies, the Band-Aids, the syringes, whatnot. That is one of those
particular elements. Those margins have been shrinking, and then when we get into a pandemic where the
vaccine is supplied by the government, there’s no payment for the vaccine, for the product itself. The payment
would come from the administration of the product, and at least my experience during H1N1 is that you can
bill the patients’ insurance and get paid some administration fee. That may be USD 5, USD 10, USD 20,
whatever that number would be, based on their contract.
There were also questions around people who weren’t insured and how all that was going to play out, so there
are a number of things out there. One is you know you’re getting paid, yes, that’s one thing, but in some
instances, you probably have pharmacies that are vaccinating people with the expectation that they’re going to
be paid or that there would be some safety net for patients who don’t have insurance for that to happen, so
that’s an exposure that’s out there for pharmacies. As a general rule of thumb, yes, you probably make more
administering the vaccine than you do on some other products, just because of that fee for the service.
[00:32:34]
Q: How well-placed do you think Rite Aid was to handle some of these logistical and administration
challenges around COVID-19 vaccines? Do you think the company downsizing a few years before became a
disadvantage?
JM: Downsizing, that probably became a disadvantage for being selected to help earlier on, but they may have
had some stores that were selected state by state to help out. I don’t have visibility to anything like that. I
would say from the administration of product, that would be something that they would have been just as well-
placed as anybody else in the marketplace. You can probably go back and look at investor calls or press
releases where they’ve given millions of vaccines over the years, so giving vaccines is nothing new.
The new thing is how do you store the product? There would be some challenges with getting product, getting
freezers, getting especially the ultra-cold freezers and working through that. We’ve probably all been in a
different McDonald’s in our day. Not all McDonald’s are the same way. They have different floor plans and
stuff like that, and the same would be true for any pharmacy. Any of the pharmacy chains that you want to
look out there, you probably have different floor plans that are with that. There are some stores that it was
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probably very convenient to install that. There are probably other stores that it was much more difficult, and
so I’m sure that there were probably a number of those issues that would have to be worked with, but I don’t
know that that would be something that would be unique to a Rite Aid. I would suggest you probably have a
number of pharmacies out there that had to deal with those same types of growing pains, if you will.
[00:34:42]
Q: What would you say were some of Rite Aid’s most pressing challenges while you were there? How has
management addressed those challenges? Do you think it truly addressed them?
JM: From the vantage point that I have, if it hasn’t been clear before, just let me highlight and underscore in
boldface, this is a Jesse McCullough opinion on that. Some of the main challenges that you had were how do
you stabilise script volume, your prescription volume, and you also want to maintain your margins. Within the
vantage point that I had, looking in a performance measure space, you wanted to see those prescriptions filled
regularly to be able to have the most positive benefits you have for your customers and for your business. I
would say a couple of things.
One, with the downsizing of Rite Aid, I actually think that was a good thing. I would give it to you, I’ll try to
explain it to you mathematically here if I could. A lot of times, when you look at performance contracts, and
performance contracts change every year, and even if I knew, I couldn’t comment on what the performance
contracts this year look like, but sometimes, those contracts are set up by the store and sometimes they’re set
up by the network. When you have evaluations where your store, where your group is looked at as a chain,
where Rite Aid is looked at as a whole, the bigger you are, the more average you look. The same would apply to
a Walgreens, the same would apply to CVS, the same would apply to Walmart and any large group. The more
people you get in, the more your performance reverts to the average. Oftentimes in those performance
contracts, what you’re called to be is you’re called to be above average. Whenever you actually have a
reduction, that moves you away and allows you to help differentiate yourself.
That still moves to operational execution, and they have put in a number of different programmes and services
over the last several years. One that was advertised heavily was their refill synchronisation programme called
OneTrip Refill. When you have medications synchronised, what that does is that allows you to be able to see
when those prescriptions would be filled, and it allows you to have a number of different synergies, from
understanding what your workload is going to be to understand what your inventory is going to be, and there
are a number of benefits that can spring from that, not the least of which then is to be able to provide a very
pleasing customer experience, going through that process. With anything when you first start something, it
takes time and repetition, time and repetition, time and repetition. As scenarios like that improve and mature,
and I’m sure that they’ve taken feedback on what people liked and what people would like to see improved and
that they’ve taken that to heart, like any retailer would do, they’re much further down the road today than
what they were three or five years ago.
[00:39:18]
Q: How are some of the drugs being measured, and what does that mean?
JM: Within healthcare, there are all sorts of different measures. If you ever drive by a hospital and you see a
banner hanging from the side of that, where it says top rated in, fill in the blank, top rated in kidney care or
open heart surgery or whatever, evaluations in healthcare are nothing new. They’ve been around for a long,
long time. What you have is you have payors who are holding their providers accountable for delivering high-
quality care. That’s what they are intending to do. Within the pharmacy space, how does that look? What does
high-quality care look like? This is an evolving space. One of the things that they look at, and this is specifically
in the Medicare space, but I would just suggest that where Medicare goes, Medicaid, by state, will go, and you
will see commercial plans go. This is another opinion, but I fully expect that this will be very, very
commonplace in the next several years, is that you’re looking at this as a whole across the industry and not just
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in a subset of the business. They’re looking at how well you’re taking care of patients. You look at some of the
most costly medical conditions that are out there, and you quickly come to diabetes and you come to
cardiovascular disease. Patients who are not taken care of, they have heart attacks, they have strokes, they
have kidney failure, they have amputations, they have all these horrible things happen.
One of the things that they look at is they look at how well are these people taken care of, and they do that by
looking at the frequency of medication fills. What they would look at is what you would like to see, in an ideal
world, is you have somebody who is prescribed something, and then let’s just say they’re filling it for a month
at a time. When 30 days go by, you would like to see another fill for that. When another 30 days go by, you
would like to see another fill for that. 30 days go by, you’d like to see another fill for that. If a patient is taking
that regularly, we would make the assumption, at least, that that patient is more likely to be better controlled
than if they’re not. If you have a patient that gets a prescription filled today for 30 days but they don’t come in
for 90 days to get it filled, then we would make the inference that they’re probably not taking their medicine
for quite a few days. If they’re not taking their medicine for quite a few days, they’re probably not getting the
benefit from that.
NH: What if they just switched pharmacies for maybe a month or two?
JM: That’s an interesting question, and the way those measures are tracked and calculated is actually at the
plan level, so as an insurance carrier, I would be able to see that you fill your prescription at pharmacy A this
month and pharmacy B next month, pharmacy C the month after. You would be able to see those claims come
in. Within a retail pharmacy like a Rite Aid, you don’t want to see people leaving your store to go to your
competitor. You want them to come back in and continue to use your services. That’s where some of these
refill systems that they have, the synchronisation, the auto-refills that you see advertised, the refill reminders
that they have in their app, that’s where some of these things come in, and the idea is you want to do things
that will keep people thinking, “Come back to this particular pharmacy to get your prescription.”
Within that, just to go back, you are looking for prescription fills on a regular basis. Within the medical
literature, the standard that is used is 80%. If you have medicine to cover 80% of your days, that’s where they
feel that you have benefit, and so that’s where a lot of these performance contracts come in. What they do is
they look at, of all the patients that you’re filling, what percentage of your patients get their medicine filled at
least 80% of the time or better? I’ll pause there. Obviously you want to have that as high as can be. If you have
a score of 100%, that would say that 100% of my patients get their medicine filled 80% of the time or better.
That’s the goal, and you can find all sorts of published benchmarks out there in Medicare for where that is in
these different classes of medications.
Where this all comes from is it comes from the individual patient. With the individual patient, you have to be
looking at the individual patient, saying, “What do I have to do to get this patient to 80%?” There’s part of that
which is matching to make sure that the drug is appropriate for the patient. If the patient has a drug that isn’t
prescribed correctly, that’s probably another whole consultation conversation there, but if we make the
assumption that it’s prescribed correctly, what we’re looking at is what can we do to keep that going? The
reality, though, is that you have a bunch of people that miss days. That’s human nature, is that they miss days.
They have valid reasons in probably most cases why they missed, and so what comes next is the number of
fills. If you had 90-day fills, if you had three 90-day fills in a year, you would say that’s 75%, and if you’re
looking at 30-day fills, you would say if I had 10 out of 12 30-day fills, that would be 83%.
Those assumptions are correct, however when you get into the nuance of the measures, it gets much more
complicated than that. That’s been a fascinating area of study for me over the last couple of years, but I can tell
you that there are many patients that, by getting a prescription filled one day too late, will actually be
considered non-adherent for the year, and that would actually funnel into some of these contracts, where they
would say, “If you’re able to have 50% of our members take their medicine 80% of the time or better, we’ll pay
you this rate. If it’s less than 50%, it’s that rate.” The benchmarks are much higher than that. They’re probably
in the 80% or 90% today, but that’s very much where the emphasis is going, is looking to drive medication use,
and to do that through pharmacies. They do that just by looking at the number of fills and the cadence of fills,
to be able to do a calculation to see if they have medicine to keep them protected.
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[00:47:50]
Q: What are your thoughts on this formula as a whole? How accurate do you think it really is? They say if you
take your medication, you’re assumed to be a much healthier individual, but if someone stops, they may stop
because they are actually healthy.
JM: Right now, I would say that just where we are in the maturation, and again, this is just my opinion on it,
it’s the hand that we’ve been dealt right now. You have performance measures out there because there’s
variability of performance in the marketplace, and you and I can probably both do a quote search online and
find quotes that what gets measured gets improved, what gets measured gets done. There are all these
different things, so the fact that you’re measuring it, you’re going to see some improvement in this over time.
What’s going to happen is if you give it enough time, then what you’re going to find is that there’s not a whole
lot of variability in the marketplace.
I’ll give you an example. Years ago, hospitals were evaluated on how they treated patients who had heart
attacks. When they were discharged, were they discharged with a certain medication? They did that for a
number of years, and when they started, it was terrible. By the time it was done, what they found was that
there was really no variability among providers, and that that point, they said, “What’s the sense in measuring
this? We’re measuring something to find out that there’s no difference from provider A to provider B.” I share
that story with you because there is still variability in the marketplace. Over time, we’re going to find that
these performance scores are going to normalise at whatever rate it is. We’ll just say 90% for the sake of
argument. Once you cease to have that variability among providers, it’s really not going to make a whole lot of
sense. To more formally answer your question, at that point, you’re going to be able to see, we have 90% of the
population that takes their medicine at least 80% of the time. Are we seeing fewer fill in the blank? Are we
seeing fewer heart attacks, are we seeing fewer strokes, are we seeing fewer kidney failures, are we seeing
fewer amputations? Those things will come in, but we’re in the process of learning probably a little more
concretely what that’s going to look like.
[00:50:54]
Q: Who would you say are leading in the competitive landscape and really hitting the key performance
metrics? Who are some of the laggards, based on dynamics such as market share?
JM: There are definitely some leaders. The leaders tend to be smaller, more regional, and that just goes back
to the comment of the bigger you are, you have more data and you would more normalise towards the mean,
so you do have some of those regional players that have done well. They’ve also been able to react a little more
quickly. Unfortunately, sometimes the bigger companies seem to take a little bit longer to move, and so if I was
an independent pharmacy and I was running my own store today and I decided to change, I could change it
today. If you’re doing that for 100 stores, that’s going to take a little bit longer. If you’re doing it for 1,000, it’s
going to take longer. If you do it for 10,000, I’m going to guess it’s going to take longer yet. There’s some
flexibility that is out there.
That said, I would really look at the tools that are made available to those pharmacies to be able to do that, the
visibility that they have and to be able to move forward with that. I think you can go back a couple of press
releases ago or you can go to the investor calls. Rite Aid has had a strategy that they’ve talked about on those
calls where they’re looking at it here. They are looking at ways, and how they do that today, I don’t have the
foggiest clue, but I do know that’s on their radar, based on what they have shared on investor calls, to be
looking at that with the idea of continuing those fills to be able to drive their performance score, to be able to
maximise the value of the contracts that they have and the people that they serve.
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[00:53:25]
Q: How has the regulatory environment relaxed rules around prescribing people out of state? Do you think
that could have a positive impact in driving fills? Alternatively, do you think that just distorts the data?
JM: I apologise, I couldn’t comment on regulatory changes at this point. That’s not something that I’m
familiar with. Obviously, if you make it easier to get the prescription, you would think that would be positive,
however my guess is there’s nuance to that that I’m just not familiar with that.
[00:54:08]
Q: Could you elaborate on the reimbursement pressures you mentioned? Are they truly down to the
performance contracts?
JM: This is my take on it, is that with these performance contracts being used in the Medicare space, and
they’re being used with private insurers, so fill in the blank, Blue Cross, they have their Medicare contracts.
They may also have state Medicaid contracts, and they also have commercial contracts. They have all these
different lines of business, and if they’re going to be seeing benefits, which I would expect that they’re going to
learn and see benefits in the Medicare space, that you’re going to see this transition into other spaces as well. I
would also just make a comment, when you look at budgetary challenges of payors, the states, with some of the
stimulus bills and stuff like that that has been put out, how do we fund the states? If you look at states, their
number one or number two line items on their budgets are typically education and healthcare, Medicaid, so
you have these pressures where they’re going to be looking to get value, and if there’s a way that they can
measure that and drive value, again, a Jesse McCullough, I think you’d be foolish not to drive value. If I’m an
insurer like a Blue Cross and I’m saying, “Hey, I’m seeing success in the Medicare space, I’m seeing success in
the Medicaid space, doesn’t it make sense to go here?”
I see that expanding over the next several years and becoming more and more prevalent. I would suggest that
from a pharmacy operations perspective, that probably makes sense, because right now, when you have, even
without COVID with the resources that you have, you’re saying, “Who do I need to talk to?”, it’s easier to say,
“You need to talk to the patient with high blood pressure,” as opposed to say, “You only need to talk to the
patient with high blood pressure who’s also on Medicare.” It allows for streamlining of your programmes, of
your workflows, of your engagement. There are just some benefits that come with that.
[00:57:05]
Q: Is there anything that you think investor communities should know regarding Rite Aid’s management
scheme and ability to execute on priorities? Is there anything you think the investor community commonly
overlooks?
JM: I would encourage them just to be aware of the performance measurement and scoring, and how that’s
impacting pharmacies. I just don’t think enough people are tuned into that. They may weight it in a different
way than what I do, and that may be true and that may be fine. As far as Rite Aid, they’ve gone through the
transition of downsizing. They’ve also gone through a new CEO, and whenever you bring in a new CEO, I
would suggest that you have a lot of folks that are re-energised. With that, you’re also comparing and
contrasting that against a global pandemic. I wish I could give you some type of relevant insight from going
through a global pandemic before. I cannot, but I would say one of my mentors gave me this phraseology, and
he says, “How will you emerge from the emergency?” I like that. As they come out, I think that you’re going to
be able to see the impact of that leadership coming out.
I wish I could tell you it would be the greatest or I wish I could tell you it would be the worst. I don’t have any
insight to that, just given all the conditions and stuff that are going on, but absolutely would recognise that. I
would hypothesise, though, that you’ll probably see some additional changes, coming out of the pandemic, just
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people that have been in these high-stress environments. I, for one, would not be surprised to see different
changes come down, and I don’t know exactly what those changes would look like, but for a group of people
who are front-line workers engaging the public during this, there may be some different changes that come,
and that’s going to give the opportunity for everybody to continue to differentiate themselves in the
marketplace.
[00:59:50]
NH: We will now end the Interview. Let me close by saying thank you, Jesse, for your input. A very complex
Interview and space. Always happy to learn more about it. Thank you, clients, for joining Third Bridge
Forum’s Interview today. If you would like to arrange a private meeting or consultation, please contact your
relationship managers. Goodbye.
JM: Thank you, sir.
Transcription ends at 01:00:14 of the recorded material
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