During a crisis like such as the one we are experiencing with the COVID-19 pandemic, healthcare organizations are more likely to achieve success — and do so faster — with an all-hands-on-deck approach. This requires everyone in the organization to step up and do whatever they can to help patients and their fellow team members. No job is too big or too small. If a member of the staff can make a difference in a way that does not increase risk, they are expected to do so. Yet we are seeing one member of the care management team handcuffed, preventing them for maximizing their contribution to this battle: pharmacists.
Pharmacists are performing many critical tasks during the pandemic. An editorial published in the Journal of the American College of Clinical Pharmacy at the end of March identified some of the key roles pharmacists should fill. These include the following:
- facilitating investigational drug studies;
- obtaining medication through compassionate use protocols;
- identifying patients who may be appropriate for investigational agents;
- reviewing and interpreting data supporting drugs approved for non-COVID-19 indications for their clinician colleagues;
- providing accurate data to the providers about safe drug delivery, drug‐drug interactions, and adverse effects if such agents are used;
- planning for, identifying, and mitigating drug shortages; and
- educating patients and the public on effective strategies to prevent acquisition and further spread of infection.
But they could be doing so much more. As we discussed in a previous blog, federal COVID-19 legislation has yet to grant national provider status to pharmacists, thus constraining their abilities to help in the front-line response. This, we wrote, is a "much-needed change." After all, pharmacists are continuously ranked among the most highly trusted people in their occupations, according to Gallup annual survey results. The value of this high approval rating, according to National Association of Chain Drug Stores (NACDS) President and CEO Steven Anderson: "Patients trust pharmacists and rely on their accessibility. Studies show that patients are more likely to do the things that keep them healthy when they have access to pharmacists and pharmacies."
Here are four of the ways that granting pharmacists with provider status would add value during the health crisis.
1. Testing for COVID-19
As the availability of COVID-19 tests is ramping up throughout the country, few healthcare professionals are in a better position to administer these tests than pharmacists. Consider that around 90% of all American live within five miles of a community pharmacy, according to the NACDS. If patients know they can not only receive a test, but have it performed by a professional they trust, they are more likely to choose to undergo the test, which can lead to faster identification, quarantining and, eventually, treatment of new cases of the virus.
The good news is that this an area where we've already seen some significant progress. In April, the Department of Health and Human Services announced it was authorizing licensed pharmacists to order and administer COVID-19 tests that the U.S. Food and Drug Administration had authorized. This authorization came with some limitations: legal barriers on the state level. While many states issued emergency testing authority for pharmacists, this wasn't the case across the country.
But some such barriers are being lifted. For example, California recently announced its Department of Consumer Affairs and State Board of Pharmacy is allowing pharmacists to collect specimens for COVID-19 tests and order tests for consumers. These specimens are delivered to and processed at public health, university, or commercial labs.
Key takeaway: Granting pharmacists with provider status would eliminate inconsistencies and confusion across states about whether pharmacists can perform and receive reimbursement for testing and help expedite the identification of new cases and potential outbreaks.
2. Treating COVID-19
Unfortunately, as of early June (when I am writing this blog), there are no drugs or other therapeutics approved by the U.S. Food and Drug Administration (FDA) to treat COVID-19. There is also no vaccine to prevent the virus. Hopefully, this will change soon. And when an approved treatment and vaccine come to fruition, pharmacists should be in a position to administer both.
But like with testing, rules concerning whether pharmacists have the authority and can be paid to treat infectious diseases varies by state. Recognizing that this inconsistency will likely stifle efforts to respond to the pandemic most effectively, the American Society of Health-System Pharmacists (ASHP) called on state policymakers early in the pandemic to "… ensure that pharmacists are authorized under your pharmacy practice act to initiate time-sensitive therapies, such as antivirals;" "ensure that pharmacists are authorized under your state pharmacy practice act to order and administer immunizations for prevention of infectious diseases;" and ensure that federal and commercial payers "… reimburse pharmacists for providing services within their scope of practice," among other recommendations.
To support its argument concerning granting pharmacists the ability to initiate time-sensitive therapies, ASHP states, "Antiviral therapies often need to be initiated within 48 hours of symptoms in order to be effective at reducing length, severity, and transmission of the infection. This short time window does not allow patients to make an appointment with their physician, wait for the appointment, have a physical and laboratory exam, and then pick up their prescription from the pharmacy."
Furthermore, pharmacists are in a great position to ensure the safe management of antivirals administered to COVID-19 patients since they can take actions such as screening for drug-drug interactions with the antivirals prior to administration.
To support its argument concerning granting pharmacists the ability to order and administer immunizations, ASHP states, "Studies indicate that when pharmacists are empowered to provide immunizations, they substantially increase the number of vaccinated patients in the community."
Key takeaway: Granting pharmacists with provider status would eliminate barriers to pharmacists safely delivering treatment and administering antivirals and vaccines once they become available. This would help accelerate patient recovery, stopping the spread of the virus, and possibly ending the pandemic.
3. Supporting patients and providers across state lines
Early in the pandemic, the federal government announced it was permitting physicians and other medical personnel to practice across state lines. Some states followed with their own waiving of the requirement that a physician be licensed in the state to provide care to patients. Pharmacists have not been included in these announcements, and that's rather unfortunate.
While there are some instances where pharmacists can provide services across state lines (more on this in the next section), there are significant state limitations on a pharmacy's ability to support patients outside of its state. These limitations are one reason why a dozen U.S. pharmacy organizations jointly released a set of recommendations directed at policymakers concerning the pandemic that included a call for "[Easing] operational barriers to address workforce and workflow issues that prevent full and effective pharmacist engagement in COVID-19 response." Among the actions included in this recommendation were to allow pharmacists with valid licenses to operate across state lines and authorize pharmacists to conduct routine pharmacy tasks remotely as necessary, including those delivered outside a pharmacist's state.
Such flexibility would greatly help patients. Consider that patients may not always go to local pharmacies, may live close to borders and already see providers in additional states, and/or many lack easy access to certain services in their state of residence due to factors including location, cost, and, insurance. If such patients did not need to worry about what pharmacy they should and should not go to, they could make decisions based more on accessibility and personal needs. Flexibility would also help clinicians/prescribers as they could more effectively work with (i.e., coordinate care) and direct patients to pharmacies in the best position to support their patients during the crisis.
Key takeaway: Granting pharmacists with provider status would give them the same flexibility as physicians and other medical personnel to support patients and providers outside of their state. This would better help ensure patients receive their prescriptions and pharmacy services in a timely, effective manner.
4. Delivering telehealth (telepharmacy) services
Telehealth is another area where lawmakers have made some wise decisions during the health crisis, although one could argue these decisions have not gone far enough. The federal government and many states have loosened rules concerning the delivery of telehealth services, including those provided by pharmacists. The Centers for Disease Control and Prevention encouraged pharmacies to leverage telehealth during the COVID-19 response, including stating the following: "Pharmacists who are providing patients with chronic disease management services, medication management services, and other services that do not require face-to-face encounters should make every effort to use telephone, telehealth, or telepharmacy strategies." But pharmacists remain greatly hampered in their ability to deliver — and be paid for — telepharmacy services to patients in and outside of their communities.
The American Pharmacists Association states, "When delivering pharmacy services across state lines via technology, pharmacists are required to adhere to the policies and regulations of the state in which the patient is located. Many states require healthcare providers to hold a license in the state in which the patient resides, which presents a significant barrier to the implementation of many telehealth programs."
In the previously mentioned Cureatr blog, we noted that ASHP stated its understanding was that while pharmacists could provide telehealth services "incident to" a Medicare-eligible provider, they could not directly bill Medicare for these services yet, with ASHP going on to describe this as "… a missed opportunity to provide further resources in the fight against COVID-19."
If pharmacists were considered providers, this would greatly enhance their ability to deliver and be paid for telepharmacy services. These would include patient counseling, drug therapy monitoring, and refill authorization — all of which are helpful at a time when face-to-face interactions should be minimized — as well as medication-related care transition work, such as medication reconciliation upon admission, discharge, and post-discharge.
Key takeaway: Granting pharmacists with provider status would help unleash the power of telepharmacy. As an article in Integrated Pharmacy Research and Practice states, "Telepharmacy has many recognizable benefits such as the easy access to healthcare services in remote and rural locations, economic benefits, patient satisfaction as a result of medication access and information in rural areas, effective patient counseling, and minimal scarcity of local pharmacist and pharmacy services." Provider status would enhance these benefits while also eliminating challenges that decrease accessibility and discourage pharmacists from offering telepharmacy services.