Dan Gorenstein: The pandemic has been long and grueling for health care providers. 

As of early February, the U.S. is averaging about 350,000 new cases per day.

One unexpected twist: The pandemic has raised the profile of arguably the most overlooked medical professional in the country — the pharmacist. 

News clip montage: The government says it will deliver 1 million doses to 6,500 retail pharmacies nationwide…More than 90% of Americans live within a five-mile of a pharmacy…21 national pharmacies are partnering with the federal government…

DG: More than filling prescriptions, these men and women have tested us, vaccinated us and treated us during these difficult days.  

The increased responsibility has strained an industry that’s historically struggled with staffing, tight margins and consolidation. 

Today…a pharmacist in Iowa shares what life is like nearly two years into the pandemic. 

From the studio at the Leonard Davis Institute at the University of Pennsylvania, I’m Dan Gorenstein. This is Tradeoffs.

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DG: Kelly Kent is a 43-year-old mother of two. She’s worked as a pharmacist for nearly two decades. 

In 2019, she joined the independent pharmacy Towncrest as a partner and its chief operations officer.

The company runs three stores, the largest in Iowa City. 

Kelly Kent: I joke with my partner Randy and say, I thought you told me, this is going to be fun. I’m not sure I’m having fun yet. This is, this is stressful.

DG: To understand how COVID has impacted her business, her industry and her personal life, we’ve asked Kelly to walk us through one day: January 14, 2022.

Weather report: Good morning everyone, thanks so much for joining us. It’s winter storm day across much of eastern Iowa and really the entire state is involved in some sort of winter weather alert…

DG: Kelly describes work during the omicron surge as “organized chaos.” 

This January morning, an incoming snow storm promises to make an already busy day even more hectic.

Right before she opens at 9 a.m., two people stand outside to get booster shots. The phones start ringing. 

KK: You can hear people coming in and stomping their feet there’s commotion from my staff too, just, reaching out to each other, “I need this. Can you bring this down to me?” It’s not a quiet place by any means.

DG: Kelly and five employees buzz around this morning — testing, vaccinating, boosting. Then there are the inquiries about deliveries, curbside pickup, filling scripts and ringing customers up. 

It’s a morning that reminds Kelly that Towncrest has been short-staffed for eight months now. 

She steals a few minutes to sneak a peek at her computer to see if anybody’s applied for their pharmacy tech job. Nothing…

KK: It’s just discouraging because I can see the angst in my employees. They’re tired, they’re all working very hard. And we’re basically down a full time person prior to the pandemic. And so when you add that extra workload on there, I mean, it’s just frustrating when I am not able to go back to my staff and say, “Hey, I’ve got an interview scheduled for next week.”

DG: Pharmacies across the country are scrambling to find staff.  

Industry giant Walgreens has 15,000 open pharmacist positions as of January 2022. CVS has nearly 4,000.

We’re talking about a job that pays around $128,000 a year.

A 2021 survey found that 70% of independents — like Towncrest — reported struggling to fill positions. 

Being understaffed at Towncrest has forced employees to cover for sick coworkers and work longer hours to keep up with the pandemic demands.

Deflated, Kelly walks back to the floor. 

She thinks about the two long-time employees who agreed to not take time off last year. Because the store was understaffed, Kelly needed them to work. 

KK: As an employer, it made me sad that I wasn’t able to do that for my employees.  You know, everyone deserves time off. And these two individuals, I know they come to work every day and they give it 110%. They work so hard and we all need time to rest and recuperate and it just, it made me sad that I wasn’t able to offer that to them.

DG: Kelly ended up paying those employees for the vacation time they lost.

Like lots of independents, Kelly has taken steps to make the pharmacy tech position as appealing as possible by turning the role into more of a career than a job. The post comes with benefits. And she raised the hourly wage from $15 to $17.

And she talked to her business partners about working with a local community college to recruit newly graduated technicians. 

KK: Perhaps we can even offer some kind of tuition forgiveness program. I mean, we’re just trying to think outside the box on how we can recruit someone because we want to grow. But it’s very hard to do that when you’re already down staff.

DG: Kelly’s tired. Her staff is tired. And the omicron hits keep coming.  

KK: I have literally never worked as hard as I have in the last two years, ever. Like, it’s just constant. And just when we think we figure it out, there’s new guidance or new therapies or, employees are ill for a week. So we’re very much pivoting.

DG: Guidance from federal health officials has proven hard to keep up with.  

In late January, reports surfaced of pharmacists turning away severely immunocompromised people seeking a fourth shot. This was nearly two weeks after the CDC made the recommendation.

Regs keep changing. The pressure is steady. And on days like this — with the snow swirling outside — it’s hard to imagine a new tech ever walking through the front door. Kelly works to keep spirits up…and she’s learned that pizza helps. 

KK: Yeah, it sounds so simple, but it’s funny. The big thing about that is it brings everyone together. The pizza is in the break room. Everyone comes to the break room. They pull down their masks, they’re visiting, they’re laughing. It’s more than the pizza, but the pizza brings them together. 

DG: When we come back, we’ll hear why Towncrest is optimistic about its future even as other independent pharmacies close shop and how Kelly has navigated maybe the most difficult stretch of her life.

MIDROLL

DG: Welcome back. It’s almost lunchtime. Kelly hears her phone go off — a pharmacy group chat in Iowa is buzzing. It’s all about an oral monoclonal antibody treatment produced by Merck.

Even though pharmacies get the drug for free, folks on the thread are furious over how much they’re getting paid. What’s often called a dispensing or incentive fee. 

KK: We’re one of the only pharmacies in our area that’s got this medication available. I’m going to ask for a fee because of the screening that went into this because of the education that I’m providing the patient…because of the documentation I have to keep in place with this prescription. I send that claim through. We were paid 31 cents. 

DG: Kelly spent hours researching the drug and sharing that information with her staff. She made multiple phone calls to providers educating them on the drug and determining patient eligibility.

She then counseled patients on how to take it. All of that time and effort resulted in less than a dollar. 

KK: It’s like a bad dream. I’ve said more than once I’m not sure I want to play this game. This is not, this is not a fun business venture to be in. Like, I want to provide good medicine for my patients. I want to be a resource for them. I cannot afford to do it at a loss.

DG: Payment is a topic that keeps nearly all pharmacies up late…Towncrest is no exception. 

KK: When you look at our reimbursement, the average cost to fill a prescription is approximately $11. I would say my average reimbursement that I receive is far less than that. 

DG: You’re saying it costs you $11 to fill a prescription? 

KK: Correct. 

DG: And you get reimbursed. How much?

KK: There are some medications that yes, I do make that amount. There are a lot of medications, I might make 30 cents. I might make a dollar. And then it becomes a pay-to-play business. 

DG: Kelly says they lose money on about 25% of the prescriptions they fill. 

A quick primer on the pharmacy business: Pharmacies pay upfront for the medications they dispense. Insurance companies, or the entities known as pharmacy benefit managers, then pay them. 

Insurers — in an effort to control their own costs as well as consumers’ monthly premiums — try to keep a tight grip on how much they pay pharmacies. 

Now, pharmacies make about 90% of their money off of filling scripts. But, as more and more prescription drugs go generic, profits shrink…forcing pharmacies to increase the number of medications they dispense to keep the lights on.  

Snow falls as Kelly makes her way to a nearby restaurant to meet her mentor and business partner for lunch. She orders a chicken sandwich. 

Over their meal, Randy makes the case why they’ve got to keep dispensing Merck’s drug.  

KK: I always have so much respect for him because at the end of the day, he will always do what’s right for the patient and what’s right for the patient is to make sure that the medications are accessible.  

DG: What’s right for the patient — as Kelly and Randy know — is not always what’s right for their business. But they do it anyway.

KK: Straight across the street from me is a Walgreens. To the south is a CVS and to the north is a Hy-Vee pharmacy. So my business partner literally says if I took a 9-iron, I could hit all three of those pharmacies.

DG: In the 10 years leading up to the pandemic, about 1,200 independent pharmacies closed. Towncrest knows just to keep pace, they’ve got to take one on the chin sometimes. The two agree to join a campaign that pushes for higher payments for these treatments. In the meantime they’ll continue providing Merck’s drug.

Walking back to the store, Kelly’s glad she and co-owners have added a few lucrative lines of business beyond filling scripts these last few years…that includes Towncrest conducting comprehensive medication reviews for insurance companies and doctors.

KK: It’s interesting, you know? Yeah, we’re surviving, but we’re thriving. 

DG: COVID has created a new financial opportunity for Towncrest and others that could invest in the necessary vaccine and testing infrastructure. That’s because the federal government gave pharmacies vaccines for free, and mandated that they be paid at about $40 dollars per shot.

Several trade groups we spoke to said it’s difficult to know if this represents a windfall industry-wide, but both Walgreens and CVS reported large spikes in their net earnings in 2021. For Towncrest, they’ve seen a bump to their bottom line, and it’s helped set the stage for pharmacists to be viewed as direct health care providers. 

KK: For us as a profession, it just allowed us to feel grateful that the service that we were providing was recognized as a service as opposed to providing a drug, and just getting paid for the product. We were getting paid for the patient care service that was being provided.

DG: Some industry analysts think the pandemic has given pharmacists an excellent opportunity to show they are care providers. 

Pharmacists have been advocating for decades that they can do more. The argument goes: Pharmacists are highly trained and if they play a bigger role in direct primary care, it could reduce spending and help people live healthier lives. 

Helping people is why Kelly entered the profession 20 years ago. 

It’s late afternoon — the time when Towncrest vaccinates kids. It’s probably her favorite part of the day. Kelly lets them pick out Band-Aids and offers lollipops. 

KK: I’m thinking of the sweetest little girl I had who had her sucker in her mouth, and you could tell she was five. She was so nervous and so anxious, and you could see tears welling up in her eyes and her mom says, “What do we say?” And then she just very softly she goes, “I am brave. I can do this. I can do this,” and it just makes your heart melt. She was so sweet. And she did, she says, “I am brave.” And then I gave her her vaccine and she was like, “That wasn’t so bad,” and then there’s smiles.

DG: The snow gets heavier…the sounds of the store wind down. Kelly feels the weight of this day on top of all the other days she’s had over these last two years. Sometimes she blinks at all she’s been through. 

KK: The middle of this pandemic, I was diagnosed with breast cancer. And so to, you know, to go through that when I was already feeling so overwhelmed with work and to try to be strong for my employees was very, very hard. Very, very hard. 

DG: Kelly dealt with this life-altering news while navigating a public health crisis. 

She endured treatment while dealing with supply chain shortages, found ways to help patients and keep her staff safe, implemented appointment systems and expanded delivery services. She figured out how to keep the business running with reduced staff. 

She even organized a mass public vaccination event from bed as she recovered from surgery.  

KK: I kept it very private because I certainly don’t, you know, I want to be strong for my employees and I don’t want them to bear my burdens.

DG: Towncrest doesn’t have a cleaning service, so once the doors are locked, Kelly goes into cleaning mode. She walks through the store, picks up Band-Aid wrappers, throws out trash, cleans the bathroom and sanitizes surfaces.

There’s a couple of inches of snow on the ground. She hits the remote start on her car before stepping out. 

KK: I’m struggling with is just to try to…be there for everyone. To be there for my team. To be strength and a voice of positivity for my employees. You know, I’m trying to make sure that I am strong enough for my business partners too. They look to me to be our clinical leader. And then having something left in my tank for my family when I come home.

DG: Kelly’s commute takes about 40 minutes. She usually listens to a church sermon, meditation app or a motivational speaker — anything that is unrelated to health care. 

Kelly pushes all those thoughts about prescription payments and staffing and growing her business to the back of her mind. Tonight, she will simply enjoy a quiet, snowy evening with her family.

She picks up some Chinese food for dinner.

The next morning, Kelly’s daughter wakes up complaining of a sore throat. She’s got COVID.

And, for Kelly, the pandemic hits keep playing.

I’m Dan Gorenstein and this is Tradeoffs.

Tradeoffs’ coverage of the impact of COVID on the U.S. health care system is supported, in part, by the National Institute for Health Care Management Foundation.