Pharmacists have been among the heroes of the COVID-19 pandemic — first, in coming to work even as everyone else was forced to stay home, so that no one had to go without medications. Pharmacy was designated an essential business. Now that multiple COVID-19 vaccines have been authorized for use, pharmacists are vaccinating millions of Americans, demonstrating pharmacy’s ability to positively impact the health of the nation. The question now becomes: Can pharmacists leverage this positive experience to expand, and more importantly, get paid for their clinical services?
Pharmacists Have Faced Challenges Implementing Clinical Services
In a presentation at the January conference of the American Society for Automation in Pharmacy (ASAP), we addressed the question: What is the real root cause that has prevented pharmacist clinical services from success in the marketplace? The roadblock to success for clinical services has been demonstrating a return on investment (ROI) through hard dollar (cost reduction) versus soft dollar (cost avoidance) savings. We examined a few examples, listed, in the chart (on the next page), of pharmacist-delivered clinical services and which type of savings they delivered.
Many studies evaluating the savings associated with pharmacists’ clinical services use the estimated cost avoidance (ECA) metric. An industry standard currently does not exist to measure an ECA.
One study estimated the value of pharmacists’ interventions on cost avoidance in an ambulatory cancer center at $282,741 per pharmacist per year. After subtracting the cost of employing a pharmacist, the net savings was estimated at $138,441, further validating the financial benefit of employing a clinical pharmacist in an ambulatory cancer center.
ECA can only estimate soft dollar savings. This is not necessarily a “bad thing,” but requires pharmacists to target entities willing to spend on soft dollar savings. This is likely limited to organizations at financial risk for both the medical and pharmacy spend, such as accountable care organizations (ACOs), large self-insured employers, and Medicare Advantage plans, where they are working with a fixed capitation amount for all patient healthcare services.
Professional Organizations Support the Services
Both the American Pharmacists Association (APhA) and the National Community Pharmacists Association (NCPA) have advanced efforts to support pharmacist-delivered services. APhA has advocated for the chronic care management (CCM) model, which includes varying levels of complexity and time involved. Both CCM and complex CCM are structured around a reimbursement model similar to medical billing using CPT (current procedural terminology) codes. See the table at the bottom of the next page.
NCPA supports the Community Pharmacy Enhanced Services Networks (CPESN) as a means to support independent pharmacies’ participation in clinical services and contracting with payers. As of September 2020, CPESN had 40 local networks in 45 states, with 2,561 pharmacies. CPESN generated over 422,572 Pharmacists eCare Plans transmitted by 1,968 CPESN pharmacies.
The growth and acceptance of pharmacist-delivered clinical services depend on the volume and type of savings generated, hard or soft dollars, as well as scalability. Where possible, programs should generate hard dollar savings through easily measured metrics. For soft dollar programs, pharmacies need to align with those payers that benefit from soft dollar savings. Pharmacist-delivered clinical services are expected to continue to expand, but require definitive and sustainable reimbursement models.
The Pandemic Silver Lining
On March 29, 2021, President Biden announced the administration was increasing the number of pharmacies in the Federal Retail Pharmacy Program from 17,000 to 40,000 to facilitate COVID-19 vaccination efforts. President Biden stated that retail pharmacies were able to vaccinate large numbers faster and at lower cost than the federal deployment. This announcement reflects the significant changes happening in retail pharmacy. Shifts have occurred in almost every aspect of pharmacy practice, including responding to unanticipated drug shortages, managing COVID-19 exposure for frontline pharmacy employees, complying with sweeping regulatory changes at both state and federal levels, and participating in the largest vaccination effort in this country’s history. The changes are diverse, and pose the questions: Which of these changes are temporary, and which are permanent?
One potential temporary change was the surge in mail-order pharmacy prescriptions during the pandemic. People were hesitant to go out in public. Retail pharmacies responded rapidly by offering delivery services. Prescription rates dropped for products associated with elective surgeries or procedures in Q1–Q3 of 2020. While these sales are now returning to pre-COVID-19 levels, this could change if a COVID-19 surges appear, and it becomes necessary for hospitals to restrict elective procedures.
Permanent changes are not as clear, but trends are identifiable. The pandemic drove the mobilization of pharmacists and pharmacy technicians in nationwide vaccination efforts. Retail pharmacies were awarded federal contracts for congregate living vaccinations. Many states expedited provider status for pharmacists. For example, new Arkansas pharmacy regulations permit pharmacists to test and treat certain health conditions; prescribe and administer vaccinations for patients age three and up; and initiate therapy and dispense oral contraceptives. States created new or provisional approvals for pharmacy students and/or technicians to administer vaccines under the supervision of a pharmacist. With the probable need for annual COVID-19 booster vaccinations to address appearing variants, pharmacists, pharmacy students, and technicians are likely to be permanent additions to national vaccine efforts. Currently over 37 states now recognize pharmacists as healthcare providers, a number that is expected to grow, and efforts are underway at a national level to create federal healthcare status, also creating reimbursement opportunities beyond vaccinations.
Another permanent change to pharmacy operations will be the ability for patients to make online appointments for clinical services. Pharmacies began online scheduling, first for COVID-19 testing and eventually expanding this to include vaccinations. The ease of online scheduling, coupled with the convenience of a local pharmacy, is a high motivator for patients and allows the pharmacy to more accurately project staffing requirements.
We have learned from the past year to expect the unexpected. Retail pharmacy will adjust as the nation’s needs continue to grow, as evidenced by pharmacy’s rapid response to this massive vaccination effort. The real opportunity for pharmacists is to leverage COVID-19 successes to expand clinical services beyond vaccinations and get reimbursed for them. APhA, NCPA, and the National Association of Chain Drug Stores (NACDS) are all lobbying Congress to designate pharmacists as providers in federal statute. It’s time for this next step to take place. CT
Melissa Sherer Krause, Pharm.D., is VP and partner, and Patty Milazzo, R.Ph., is a senior consultant, at Pharmacy Healthcare Solutions. The authors can be reached at email@example.com and firstname.lastname@example.org.