A Conversation With Lucille Accetta, RPh, M.P.H., MBA

Lucille Accetta, M.P.H., MBA, RPh, is a new member of the Managed Healthcare Executive editorial advisory board. Accetta is chief pharmacy officer and head of CVS specialty operations with CVS Health. She spoke with Peter Wehrwein, managing editor of Managed Healthcare Executive.

This transcript has been edited for clarity and length.

I saw that you grew up in Yonkers. Could you just tell me a little bit about your childhood?

I grew up in New York, in Yonkers, and I actually had a very ill grandmother with brittle Type 1 diabetes who focused me on how important healthcare was, especially for seniors, and I decided in high school to volunteer in what was then called Yonkers General Hospital and landed in the pharmacy, and I had a really great group of pharmacists who encouraged me to go down that path. That's how I landed in the healthcare profession and really thrived in the pharmacy arena.

You said “brittle” Type 1 diabetes. I am not sure what that means.

She had a really difficult time managing the condition with diet and the insulins that were available at the time. So she had some serious issues with managing diabetes. Grandpa always had to be around to take care of her. I think that really fostered, for me, the need to help educate individuals on the challenges of managing diabetes. We've come a long way in managing diabetes today, but at that time, it was pretty serious. She would fall. There would be issues with her not having enough glucose in her body.

Did the idea of going to medical school occur to you at some point?

I found I progressed in my career; not only was I in the hospital, but I was also in the community, and I found that interacting with patients and educating them about their conditions and teaching them about their medications and showing them how to use syringes really allowed me to get involved in the community with health fairs and diabetes testing and blood pressure testing. I just found that practicing pharmacy really was where I wanted to spend my time: interacting with the community, being a leader in the community around healthcare advocacy and being an advocate on behalf of all of the customers who would come into our pharmacy.

So you liked the hands-on experience—working with people.

Absolutely loved it and still do.

So you went to St. John's University nearby in Queens, so not a long way from home, and you got your Bachelor of Science degree in pharmacy. And before starting at Medco in 2007, you were out there.

I worked at least 15 years in the community and hospital. I did some research. I also went back to grad school to get my master’s in health policy and management. I personally witnessed the challenges that patients had paying for their prescriptions in the community pharmacy, especially the senior population. I really focused my career, saying, “Where could I really support millions of patients?” And I knew that the PBM [pharmacy benefit manager] could develop programs to support patients. If you think about the evolution of the PBM industry, it's all about driving down costs and helping payers understand what their patients, their employees and their health plan members need. From my lens, I felt learning what I did, being in the community, getting my graduate degree and being able to take that to a PBM allowed me to really focus on more cost-effective programs for the millions of patients we serve.

PBMs are now almost part of the vernacular. But when you went to work for Medco, it was a little corner of the healthcare industry. What was it like working at a PBM in the aughts?

It was very much focused around driving down costs for payers who needed support in how to manage their pharmacy benefit. I felt like the programs and services that we were designing and developing were supportive of that entire cost management for payers. At the same time, it was driving and innovating programs and services for patients. If you think back to 2007, it was all about hepatitis C, diabetes care and cardiac care. A lot of programs and services were designed where we had nurses and pharmacists engaged with patients to keep them on therapy and help them understand their disease. The evolution of the PBM has always been fostered around driving costs down for patients and payers and also helping to support patients throughout their therapy journeys.

In 2017, you went to work at CVS; that's when your career took a turn toward specialty pharmacy. Is that right?

I did have time at Medco as well in the specialty [pharmacy] organization. That's really where I started, and then as I evolved my career and came into CVS, I definitely saw the opportunity for continuing in specialty pharmacy. I found that that area of pharmacy was so critically important to patients with severe chronic conditions. If you think about hepatitis C, hemophilia, autoimmune diseases such as rheumatoid arthritis, neurological diseases such as MS [multiple sclerosis], and then cancer drugs coming into the market, specialty was growing in the sense that we had to really invest in that clinical expertise and innovations around engaging patients, because the information that we needed to provide to patients was so critical. Then, over the last few years, we have invested in digital innovation, because our patients really want their lives to be simpler around managing these conditions.

You've described some of the growth in this area. But could you provide some insight into how the specialty pharmacy at CVS has grown and is organized?

It definitely started with certain therapies that were very distinct, and then, over time, the number of therapies that have come to market grew. Fifty percent of our payers’ prescription bill is specialty pharmacy, but it's only really 2% to 3% of the patient population, so we have to really be able to manage these conditions. And yes, it's grown over time because of the complexity of the intake of the prescription itself, the ability to go through benefit verification, understanding what plan design that patient may have, and what's covered under the pharmacy benefit and the medical benefit. Also, the clinical interventions that are required are really complicated. We have drugs that you have to monitor for adverse events and drugs for which you have to monitor adherence to. There has been a lot of growth in the management of the patient, and that's what's critical for us. And we've seen growth in technologies to help support patients as well, more or less, on a digital platform or an application that they can feel comfortable interacting with but also be able to talk to us and our pharmacists. So yes, it has grown over time.

The definition of specialty pharmacy is a little variable. Are you concerned, as somebody in the business of managing specialty pharmacy, that the boundaries are not set and maybe sometimes get changed according to somebody's advantage?

I would say, if you step back, there are fundamentals. They are for complex medical conditions. The drugs require extreme special handling, especially under temperature control. There's a lot of administrative burden that we have to deal with for this particular group of therapies that we really want to support our patients with. There is a lot of coordination of care with patients, coordinating with nursing or coordinating with their prescriber, and a lot of services around financial assistance. So all of these things of navigation, I would say that's how we look at it from a definition. It's not just specialty drugs and delivery logistics. It's also what we want to provide: high-touch care, specialized care, personalized care for each patient whom we service in our specialty pharmacy. So I think that's how the definition lays out — some of the complexities of these drugs and how they have to be supported for our patients.

What is on your priority list at CVS Specialty Pharmacy?

My top priority is to continue to provide the patient with a very simplified experience. The same for prescribers. Our patients are looking for more technology. Our doctors are looking for more technology, so we'll be driving simplification and being very trusted and operating our specialty pharmacy. I think that technology is going to really drive more and more opportunities to simplify and reduce the administrative burden that's out there in healthcare.

What do you mean by simplification?

I would say the challenges that patients face today are more around just getting started, right? We have a lot of technology that's embedded in electronic health records [EHRs] to help answer clinical questions that are required to get patients on therapy, the coordination with nursing, and the coordination with their plan. There is a lot of that complexity behind the scenes that we try to keep patients out of, and we try to manage it on their behalf, as well as for prescribers.

Do you have a particular example in mind?

I probably would say a prior authorization. It’s super easy to do nowadays with technology embedded in the EHR system, being able to read it, and the ability to know this is a medical benefit versus a pharmacy benefit. Those are the kinds of simple things behind the scenes you may not see, because typically, nonspecialty drugs go through the pharmacy benefit, but many specialty drugs can go through both medical and pharmacy.

Earlier this year at the Asembia meeting in Las Vegas, you made the pithy statement that services are being technology enabled but powered by people.

CVS Health is committed to the safe and responsible use of artificial intelligence [AI], mostly to improve the quality of care and the health outcomes. That's key. There's always going to be a human connection in healthcare. That's what's really important in our healthcare system. But the investments in AI are really around the technology to reduce, and I would say No. 1 is administrative burden. A lot of the behind-the-scenes work that patients don't see is a lot of administrative work. Is it the pharmacy benefit, medical benefit, copays, prior authorization or the benefit verification? All of those pieces could be utilizing AI in some fashion. But again, the focus should be very much on enhancing safety and personalizing the experience for the consumer, the patient. The goal is really, at the end of the day, to improve the experience for the members, the doctors, their providers and, obviously, our patients.