Welcome to the Evolution of Medicine podcast! On this episode, James talks with Abbi Linde, PharmD of HomeTown Pharmacy, a regional chain of pharmacies across Wisconsin and Michigan. But this team of pharmacists is so much more than just a regional pharmacy network—they are community providers who know their patients on a personal level and are bridging the gap between patients and functional medicine. HomeTown Pharmacy is leading the way in shifting pharmacies from product-based businesses to service-based businesses. If you’re a practitioner listening to this episode, you’ll hear why it makes sense to connect with your local independent pharmacist, and how you can partner to deliver even better patient care in your community. Highlights from this episode include:

  • The HomeTown Pharmacy model and how they’re doing things differently than the average independent pharmacist
  • How pharmacists can play a critical role in building health resilience in their communities, and how that can be a gamechanger for pharmacy business
  • The synergies that exist between functional medicine practitioners and functional pharmacists, and why it is worth it to invite your local independent pharmacist to your next Functional Forum meetup
  • Why drug-induced nutrient depletion is low-hanging fruit for pharmacy business
  • Essential reading for functional medicine practitioners and functional pharmacists alike
  • And so much more!

Resources mentioned in this podcast:

Scaling Community Resilience Through Pharmacies

James Maskell: Hello and welcome to the podcast. This week we are talking to HomeTown Pharmacies, it is a chain of pharmacies across Wisconsin and Michigan. They have 70 locations and through their pharmacy network of independent pharmacists, they are helping to bridge the gap between patients and functional medicine. What you’ll hear about in the podcast is the shift from a product-based business to a service-based business.

Some of the crossover skills that pharmacists have that could be useful in filling that gap and also how pharmacists can play a role in being part of the Functional Forum meetup community, and why as a practitioner, it might make sense for you to connect with your local independent pharmacist. Super interesting half an hour, scaled-up functional medicine coming your way. Enjoy!

So a warm welcome to the podcast, Abbi Linde, welcome Abbi.

Abbi Linde: Thank you.

James Maskell: So last month we heard a story of the transformation of one particular pharmacy in Oklahoma, and I’m excited today to talk a little bit more broadly about the opportunity for pharmacists and pharmacies to really play a role in community resilience. And I guess, I just want to just maybe just for our audience that haven’t heard of HomeTown Pharmacy, can you give us an overview of just the breadth and scope of the operation?

Abbi Linde: Absolutely. So HomeTown Pharmacies are…we’re collection of pharmacies across Wisconsin, and we have three in Michigan, so we’re 70 stores. We’re technically, I think, a regional chain but we really self-identify as community independent pharmacies because we know our patients’ dogs’ names and their parents’ names…we really function like a community practitioner.

James Maskell: And so you have 70 of these different pharmacies, and tell us a little bit about how the model works and how you do things differently from your average independent pharmacist.

Abbi Linde: Absolutely. So the biggest difference is that we’re able to centralize a lot of activity at our home office. So pharmacists are not trained, much like most healthcare providers, are not trained in business and management and HR and accounting, and so what we’ve been able to do…our CEO is a CPA. So to have that business focus at the forefront of our company has obviously been a huge benefit to us. And what we’re able to do is we have an HR department and an IT department instead of the pharmacist owner in each independently community-owned pharmacy, that pharmacist has to be the marketing director and the HR and the accountant and the…all the things and what it allows us to do by offloading all of that to the home office or a lot of it, it allows the pharmacist to really just run their pharmacy and respond to the needs of the community and really just be a healthcare provider in their community setting.

James Maskell: So one of the things we’ve heard over the trend is that the independent pharmacist is struggling, right? Because of reimbursement issues and just the changing landscape of healthcare, where these big players have such a big footprint, whether that be chains like CVS, or whether that be pharmacy benefit managers and all these other people are taking their corner of the pie and only a tiny crumb is left for the independent pharmacist. So tell us a little bit about that, your experience with that, and how you see that you are solving that.

Abbi Linde: Yeah. A long time ago, pharmacies decided that we were going to tie our services to our drug reimbursement, okay? And we had the opportunity to be Medicare providers and we said, “No, no thanks. We get great reimbursement on our drugs. We’re happy making money on that.” Well, as you mentioned, that has continued to go…the reimbursement for the product has disappeared to the point where it’s negative often. And so not only are we not getting reimbursed for our services, we’re also not getting reimbursed for the product either. So I think one of the things we’re seeing in pharmacy is this shift from a product-based business to a service-based business.

So, Suzanne is talking about how she is utilizing functional medicine. What we’re trying to do is really learn how to educate our patients, to get them healthier and figure out a business model to be able to get paid for that, essentially is what we’re doing. And luckily what we’re finding is that most people really just need some basic education and basic behavior change support, health coaching you could call it, and we’re able to really make some big differences in our patient’s lives. So then what that translates to is, okay, now that we know that we have the confidence, we have the knowledge, we have the ability to help our patients make these changes. How can we put a system in place to get reimbursed for that? And that’s what we’re working on now.

James Maskell: That’s great. Yeah, so this whole year’s been on community resilience and I guess one of the things that I’ve come to know after understanding these different areas is just, how much of a role the pharmacist plays in the lives of their patients, how often they’re seeing them and this opportunity to have crucial conversations with patients that can change their health trajectory away from pharmaceuticals and towards lifestyle interventions. Can you talk about that process from a practical point of view of what that looks like? And then also, how does getting into some of those conversations change the game for the economics of the pharmacy business.

Abbi Linde: That was a lot of questions. So the first thing when I think about…you might have to remind me if I don’t get them all. So one thing when I think about, when we are working with our patients you imagine in a pharmacy, right? That we’re dispensing medications and we’re telling patients how to take them, right? That’s your traditional view of what a pharmacist does, and that has to happen and it has to happen efficiently, right? And we have to make sure that we get people to take their meds when they’re supposed to, not take them with certain things, that’s pretty standard. But a lot of times what comes up in conversation is, “Well, that medication is too expensive. And so I’m just going to have to choose not to take that.” Or, “I can’t get to the pharmacy to pick that up so I’m just going to choose not to take that.” Or, “That causes a side effect that I’m just not willing to tolerate. So I’m going to choose not to take it.”

So some of these, they call it social determinants of health, right? Like they can’t afford it, they can’t get to the pharmacy, they don’t understand it’s too confusing. Those types of conversations come up all the time. So a lot of our time is spent, number one, how can we get these medications cheaper? How can we get people to take their medication? And now what we’re transitioning to is, “Okay. Well, if you’re not willing or able to take that medication, what can we do lifestyle-wise in place of that so that you don’t need that medication anymore?” So that’s one piece of it. I think the other piece of it is, pharmacist now, it’s a doctorate degree. So what they’re trained in, in addition to medicine, right? And the body chemistry of that, is really the communication piece.

So in pharmacy school, we’re trained, okay, so someone doesn’t want to take their medication, how can we use motivational interviewing? How can we use these techniques to get them to actually take the medication? Which translates really well to, okay, we want to eat another serving of vegetables a day, how can we use those same techniques to get people to eat more broccoli instead? So I think those are the conversations that we have above and beyond, like take this medication with food because it upsets your stomach.

James Maskell: One of the things that I’ve been told by pharmacists is that this drug-induced nutrient depletion is low-hanging fruit. Tell us a little bit about your history with that and how those kind of conversations come up and what that means.

Abbi Linde: Yes. So definitely, I would call that the gateway drug for pharmacists, into this functional medicine world. In pharmacy school, we’re pretty much taught that supplements are expensive urine. We’re not given any education on it, we’re just told they’re a waste of money. So we’re in practice and we’re seeing patients on medications, lots of medications, and they just keep getting sicker and consistent side effects keep happening, and pharmacists are smart people often, and you start to wonder, what’s going on here? And eventually you start to see some of the research and some of the data that is…and the mechanisms, understanding the mechanisms of why certain medications cause nutrient depletion, and it’s just an obvious next step.

So we’re always giving consultations about this medication can cause this side effect. So it’s a really, really easy transition, it doesn’t require any additional conversations, it’s just, “And so we recommend this supplement.” Or “And so we recommend that you eat these foods to replete that.” And that’s actually been one of the first things that we did to start helping our pharmacists transition from a very traditional pharmacist to a pharmacist who really looks at the patient as a whole and really tries to improve their health overall, as opposed to just their medication management.

James Maskell: So I know you play a pretty important role in the 70 pharmacies, like educating the pharmacists about these kind of topics, what’s the learning curve look like and how receptive are pharmacists to these kind of conversations? It’s a bit like being in medicine where you’re being told that none of this is real and then suddenly it gets forced upon you when you realize that the medication doesn’t really make people better in the long term. What’s the perception? I would imagine that maybe the longer people have been at it, the more they realize they don’t have all the tools, whereas maybe when they come out of school they’re just ready to drug everyone.

Abbi Linde: It’s a mixed bag, definitely. Pharmacists are very evidence-based, okay? So if there’s data that shows it, we’re onboard really quickly with things. So I think there was some initial resistance because that’s always just what we were taught. There’s guidelines, there’s medications, we know them, we understand them, but you show them the data and it’s a pretty easy jump to, okay, the mechanism makes sense. We understand the mechanism, so therefore of course, that makes sense. I think the other part of it is, you mentioned, the medications don’t really cure the problem in the long run, right? We’re managing symptoms or we’re trying to prevent progression. It really doesn’t do much and that’s hard for pharmacists, I think once you start to move into this space of looking at what the problem that medications cause, and looking at, like maybe medications aren’t the answer, that, I think where some of the resistance is once in a while is, “Shoot, I’ve been giving people statins and PPIs for the last 10 years of my life. And maybe that wasn’t such a great thing.” Right?

So I think that there is a little bit of a, I don’t know, is that like an ego thing? A gut check, like, “Okay, I was doing what I thought was right. And now I’m learning that maybe that’s not right. And so I have to learn what I need to learn to be able to help my patients.” Because we all really do care about our patients and we’re trying to do what’s best for them, so I think that’s more…it’s not that they don’t believe that the things don’t work and are impactful, it’s can they get around the, “Shoot, I’ve been giving them this for however many years.”

James Maskell: Yeah, absolutely. Yeah, look, and I think the whole of medicine is going through this. And I think that maybe COVID has opened up some of those doors because, I think people are realizing like, “Hey, we have a ridiculously resilient population, right? Everyone’s on these medications. Most of these medications have a negative effect on our health, specifically with regards to our own immune resilience. And we’ve been doing nothing to help people improve their resilience through all the things that we do in lifestyle 101 coaching or, entry point functional medicine, which is where we’re based.” I think it was really interesting what you said about the entry point to functional medicine, because I think functional medicine really started around the sickest people, right? The sickest people who didn’t get help anywhere else, they’d been everywhere else, but go in functional medicine doctor’s office.

But I think we can see that the operating system of functional medicine engaging people into lifestyle, eating different food, looking at the root cause. That’s something that everyone needs, but not everyone needs a full functional medicine workup, they just need someone who’s empathetic, who’s going to help them moving into taking action and doing healthy things for themselves. And I guess, you have this incredible viewpoint over 70 physical locations. Are there stories or data that you’ve tracked that make you think that across that area, that having a nutrition first or a lifestyle first approach across these different pharmacies can have an impact at a population level?

Abbi Linde: Oh man, that data would be amazing to have, we do not have that yet, but we are building that system to gather that data. So probably don’t know much about…well, so care plans, right? In the medical setting, someone gets a care plan, right? You identify a problem, you make a plan to solve it and you have a goal, right? So pharmacies have never really tracked, we don’t document things, it’s kind of a problem. And so part of the thing is that no one knows what we do because we don’t document it appropriately. So there’s this big push right now, it’s called CPESN, Community Pharmacy Enhanced Services Network, to start documenting all the interventions we make, all the recommendations for supplements we make, all of the recommendations to physicians that we make, all of the things. And so over the last year, we have started to track that, where it’s not tied to outcomes currently, but in the future, we will be able to track the interventions we make and the outcomes that we get.

So I don’t have the data now, but we’re in the process to systematize, is that a word? The gathering and the tracking of all that data? I think, big-picture wise, I think you said it earlier, there are one-off pharmacies that are doing this functional medicine approach, right? Whether it’s as entry level or whether they’re certified and doing these full workups. We’re a group of 70, that piece of it hasn’t been done yet and so there’s not really a roadmap for us to implement this. So it’s been really cool to take what we’ve learned from the one-off stores. We’re very close with Dr. Kathy down in Oklahoma as well. I don’t know if you’ve ever heard of her—

James Maskell: Yeah, I met her at the Pharmacy Conference last year.

Abbi Linde: Yeah, she’s amazing. We work with her, we’re trying to learn from all of these expert pharmacists that are doing this and figure out a way that we can transition it down to, like you said, entry-level functional pharmacies, so that we can have that effect on the population as opposed to one patient at a time.

James Maskell: So most people who listen to this podcast are not pharmacists, but they are integrative and functional providers. Obviously for the last six years, we’ve been encouraging practitioners to get into the community, meet other practitioners. I would just love to get your thoughts on where the synergies are for the practitioner community and a pharmacist that speaks the same language, and why it might be worth inviting your local community pharmacist to a Functional Forum meetup?

Abbi Linde: I think that’s super important. So I think one of the big fears, both from our perspective and probably from the prescriber’s perspective is, you do this workup, you make your recommendations to the patient, and then they go to the pharmacy and the pharmacist says, “Just get this mag oxide. It doesn’t matter what kind of magnesium you take.” Or like, “That’s not… All that stuff is baloney, they’re just char…” That’s your worst fear, right? Is that, you’re going to make this recommendation, what you think is best. And then you’re going to send them to the pharmacy and the pharmacist is going to say that…convince the patient that it’s not good, right? So knowing which pharmacies are functional medicine friendly, so that’s one thing, they need to be functional medicine friendly, but also it’s best if they’re knowledgeable so that they can reinforce what the prescriber educated them on or fill in the gaps.

One of the things we do as pharmacists is we don’t just tell patient’s thing. We ask them like, “What did the doctor tell you about this? What is your understanding of what this is for?” Right? And so we’ll ask a lot of those questions, and a lot of times patients are like, “I don’t know, they just told me to take it.” So we’re able to fill in those gaps and reinforce those things. So if the prescriber knows which pharmacies are on board, that’s super helpful. The other part is I know a lot of physicians…well, so some physicians will have product, like supplements in their pharmacies as a source of revenue, but it’s a lot of work to hold inventory and deal with expireds and all of that stuff. So guess who’s really good at managing inventory and dealing with all of that stuff? Pharmacies. So that’s another thing that if you don’t want to have to deal with all of that part of the supplement piece, having a good local pharmacy that has access to all of the quality practitioner brands can be really useful as well.

James Maskell: Yeah. Look, I think in the first iteration of functional medicine, which is up until now, supplement sales have been a big part of making the practice work. What I do see is we’re moving to a phase when, as this goes from being this weird stepchild of medicine to actually medicine, because I think it is coming round to that way, where people are realizing, “Okay, this is the way that we should be doing chronic disease care.” And I think it may become obvious that doctors or people that prescribe won’t be able to profit financially from it, we’re not there yet. If we look at how the system is going to roll out over the next 20 or 30 years, I think people do need to be taking that into account. And I do hear from a lot of doctors that make the switch today, they’re not necessarily interested in profiting from supplements because they just have that relationship with drugs before.

So I think in the future there could be more models like that. I guess one of the things that I’ve seen is, in the best meetups this core group of functional medicine doctors, the functional medicine generalists, should we say, start to build great relationships with specialists in the community because they know, look, “If this patient wants to get a second opinion and they have to go to a cardiologist, let’s send them to a cardiologist that at least understands and knows what I’m doing.” Because it’s important that they understand cardiology from a functional perspective, otherwise your average cardiologist is going to think that this person eating more fat is crazy, but it’s just kind of a thing. So I could see there, that having a pharmacist that understands enough about this to know that this is important, [drug-induced] nutrient depletions as an example, is a great starting point for developing relationships where the patient feels like the care is consistent, or the thinking process behind the care is consistent across all the different providers.

Abbi Linde: Absolutely. And we don’t think the same way that physicians do, right? Physicians are diagnosticians, right? They come up with a diagnosis and they come up with a care plan. We look at it the other way, we’re used to getting the diagnosis and the plan and then tweaking to make it work for the patient or to really maximize the treatment. So our brains look at problems and patients in a different way. And so any time you can have a group of people who look at things from different perspectives, it’s going to help you see things that you didn’t see that first time around.

James Maskell: That’s absolutely true. Yeah, that’s critical. So just as a last word, Abbi, I’m really interested in this topic of community resilience, right? Creating a more resilient people, more resilient population, more resilient communities, what do you think is the role of the independent pharmacist in that community resilience? And I guess what have you guys proved in your network of stores about the innovation that’s required to survive, thrive and be relevant in this new era?

Abbi Linde: So I think that for us, the role of the pharmacist has been to really optimize medication management, that’s kind of been historically what we’ve done. And at HomeTown we’re really good at that. We’ve gotten really efficient in our pharmacies and we really take care of our patients and their medication, but I think what we’ve been transitioning to, and I think what is coming, like you mentioned, everywhere, is this focus on, let’s get all of the low-hanging fruit covered for the physician. So let’s get people eating vegetables, let’s get people walking, let’s get people sleeping and let’s get people moving their bodies and pharmacists have training on all of those things already. So we can really be that consistent checkpoint. We see our patients, I think the most recent number is 32 times a year, they come into our pharmacy or we’re delivering to their house.

So when it comes to behavior change and population health and building wellness, you need those frequent touchpoints. And so if we can utilize pharmacy to be those touchpoints and to be that…have you heard the term community health worker, I’m assuming?

James Maskell: Yeah, definitely.

Abbi Linde: So our drivers are going to patient’s houses and they can…if you haven’t taken trash out in six weeks, they can see that. And so if we can be the person who’s seeing, being that touchpoint and being that consistent reinforcement of identifying problems and then helping with the behavior change, I think we’ll be able to really build something.

James Maskell: Awesome. Well, I know you guys are very familiar with our sponsor here at the show is the Lifestyle Matrix Resource Center. And I know that they have a couple of resources on the Lifestyle Matrix, that’s sort of the roadmap series to supporting and supplementing dietary nutrients, you want to just talk a little bit about how you use that in the practice there?

Abbi Linde: Absolutely. So we call it the green book. So did you say, the Supplementing Dietary Nutrients, I think is the official name, right?

James Maskell: Yep.

Abbi Linde: So the green book is really key in our training. So whenever we have somebody that is a little bit more…so two types of pharmacists will recommend the green book, someone who is a little more resistant and says, “I don’t think there’s enough data.” Then we give them the green book and show them the massive amounts of references that they can go read all the things on PubMed, if they want. And then once they get through, once they’re on board and they get through the basic training that we’ve created, then we give them the green book again. And we say, “Okay, now read through this to get all the nuances and get all of the nitty gritty of all the data.” So it is a huge part of our training.

James Maskell: That’s great. So if you want access to that, we’ll put the details in the show notes so that you can grab that resource. Tom Guilliams is such an incredible resource for all this stuff and I’m glad that we have all of those resources and yeah, look, I’m super excited to connect with you, this month actually we are looking at organizations that are taking this medicine to the next level because they have a certain amount of scale, that they’re developing a certain amount of scale. And yeah, it’s just really exciting to have you guys on the podcast. Thank you so much for all the work you’re doing to set an example of what’s possible.

And I’m really excited over the next few years to really start to engage pharmacists into this complete community model, and lots to learn from the individual clinics that have been doing it and are certified and are seeing patients and offering a service. But also I think that there’s definitely a potential for filling in the gap locally between the patient and the functional medicine doctor, which is getting the lifestyle going and supporting patients in activating into health. So thank you for your leadership on that, and I’m excited to work with you on that continued project.

Abbi Linde: Great. We are all really excited as well.

James Maskell: All right. This has been the Evolution of Medicine podcast, we’ve been with pharmacist, Abbi Linde, we’ve been talking about the HomeTown Pharmacy chain, 70 pharmacies in and around in Wisconsin, taking nutrition to the people through those models. This has been the Evolution of Medicine podcast. Thanks so much for listening and we’ll see you next time.

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