Whether you've heard nothing, a little, or even quite a bit about telepharmacy, I'm going to make a prediction: expect to hear a lot more it in the coming months and years. Like essentially all forms of telehealth, telepharmacy was experiencing a gradual increase in adoption before the COVID-19 pandemic. Then, within a matter of weeks, usage soared. Now it appears that telepharmacy and the other subsets of telehealth are positioned to continue playing a significant role in helping the United States navigate the challenges and uncertainty of the health crisis and then, once the pandemic is behind us, be a mainstay in the delivery of care.
How did we get here with telepharmacy? What is the role that it's playing in the midst of this crisis? What will happen with telepharmacy following the pandemic? In this blog, we'll explore telepharmacy's history, provide an update on its adoption and usage today in the midst of this health crisis, and conclude by discussing what we believe will be the future for this virtual care service and what will be necessary to achieve telepharmacy's full potential.
While this may sound surprising, telepharmacy is quickly approaching its 20th birthday. In 2000, the North Dakota State Board of Pharmacy reported that 26 of the state's rural communities had lost their community pharmacies and a dozen more communities were at risk of losing their community pharmacies. In response, the board established pilot rules for telepharmacy in 2001 in the hopes that the virtual service could help the state's medically underserved remote rural communities restore and retain pharmacy services.
The following year, the North Dakota State University (NDSU) College of Pharmacy received a federal grant to implement a statewide telepharmacy program and test the new telepharmacy pilot rules. The pilot project proved successful, prompting the state's board of pharmacy to establish permanent rules allowing telepharmacy to be practiced on a broader scale. As NDSU notes, "These permanent rules allow a retail pharmacy to open and operate in certain remote rural areas of the state without a licensed pharmacist being physically present in the store and allows a pharmacist to supervise a registered pharmacy technician at a remote telepharmacy site using telepharmacy technology for the purposes of dispensing prescriptions to patients, providing drug utilization review, and patient education counseling."
The study concluded in 2008, NDSU states, with the pharmaceutical industry recognizing that telepharmacy was a safe and effective method for delivering pharmacy services in areas lacking a full-time pharmacist. This conclusion promoted other states to change or revise their laws to permit telepharmacy.
Unfortunately, not all states embraced telepharmacy. As an American Journal of Medical Research article notes, come August 2016:
- the use of telepharmacy was authorized in varying capacities in just 23 states;
- development of pilot programs that could apply to telepharmacy initiatives was authorized by six states; and
- waivers for administrative or legislative pharmacy practice requirements that could permit telepharmacy initiatives was permitted in five states.
This means that 16 states — or about one in three — did not authorize the use of any telepharmacy or the pursuit of telepharmacy initiatives.
Fast-forward to 2019 and that number had shrunk significantly. Drug Topics reported early in the year that 45 states allowed telepharmacy, but with rules and requirements for operation continuing to vary widely. The future for telepharmacy growth looked "bright," the publication stated. A January 2019 article in The National Law Review noted, "Telepharmacy, while not necessarily a new concept, is beginning to gain more attention in the healthcare industry as a tool to improve patient care and coordination of pharmacy patient care and medication adherence." In June 2019, we wrote, "Telepharmacy is transforming the current way we manage medications by enabling organizations to 'bring in' pharmacists to deliver services such as medication treatment plan assessment, medication reconciliation, patient education, and adherence counseling."
Of course, all of this was before COVID-19 hit.
If there was no pandemic, a section on telepharmacy's role in healthcare today would have sounded a lot like how the previous section ended: optimism about its future but also some uncertainty about how quickly adoption and growth would occur and to what extent. But COVID-19 came along, and the value of telepharmacy — like other forms of telehealth — has become even more apparent, appreciated, and embraced.
The federal government quickly championed telepharmacy as a way for pharmacists to minimize their risk of exposure to the novel coronavirus and reduce the risk for patients during the COVID-19 pandemic. As the Centers for Disease Control and Prevention's "Guidance for Pharmacists and Pharmacy Technicians in Community Pharmacies during the COVID-19 Response" online resource notes, "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."
To further support telehealth, the U.S. Department of Health and Human Services approved the use of telehealth services as part of the Coronavirus Preparedness and Response Supplemental Appropriations Act. This removed many of the coverage, licensing laws, and reimbursement barriers that were stifling telehealth. The federal government also helped fund the "COVID-19 Telehealth Toolkit," which is designed to help organizations implement telehealth during the crisis.
Many states have issued their own public health emergencies that changed Medicaid, private payer, and licensure rules for telehealth. There are too many to list and summarize; fortunately, the Center for Connected Health Policy (CCHP) and Alliance for Connected Care are tracking state-level changes.
On the private payer level, the American College of Physicians (ACP) is doing an impressive job of keeping track of policy announcements from some major insurance companies concerning telehealth and other coverage changes during the pandemic. America's Health Insurance Plans has a database of COVID-19-related announcements from health plans, including those concerning telehealth.
Patients are getting on board the telehealth train as well. A recent survey of Medicare-eligible seniors by healthinsurance.com found that prior to COVID-19, only about 1 in 10 had used telemedicine. During the pandemic, 44% have used telemedicine and about the same percentage say they intend on using it after the crisis is over. That's a 340% increase in telemedicine usage among Medicare recipients since the start of health crisis.
Of those who used telemedicine, 58% say they have used it just once and 30% report using it once a month. Many of those who have not yet tried telemedicine indicated the reason was because they have not needed the service yet.
To say all of this has had an impact on the usage of telehealth would be an understatement. As FAIR Health recently reported, telehealth claim lines increased more than 8,000% nationally, from 0.15% of medical claim lines in April 2019 to 13% percent in April 2020.
While much of the news has focused primarily on usage of the broader concepts of telehealth and telemedicine, telepharmacy has received its own share of attention. Early in the pandemic, Dr. Eric Maroyka, director of the American Society of Health System Pharmacists' Center on Pharmacy Practice Advancement, highlighted for Drug Topics the numerous applications for pharmacies incorporating telemedicine into their practice. These included patient education and counseling; comprehensive medication management; symptom management; helping triage and refer patients to higher levels of care when diagnostic testing is warranted; and the provision of clinical services.
In an article in Pharmacy Today, Dr. Sandra Leal, president-elect of the American Pharmacists Association (APhA), states, "Pharmacists are a great resource for patients who have questions about drug interactions, vaccines, and testing. Telepharmacy allows those conversations to happen in a safer way, with patients located in the comfort of their home, keeping the public and pharmacists safe." An article from the American Pharmacists Association (APhA) notes, "Just like telemedicine has been essential during the COVID-19 crisis, the same can be said for telepharmacy."
On an individual organization level, we are have heard and read about a steady increase in those leveraging telepharmacy. And with good reason: Patients are increasingly seeking telepharmacy services, which is one of the reasons why we just recently announced that Cureatr was expanding our COVID-19 response program by offering complimentary, virtual medication (i.e., telepharmacy) reviews to primary care practices.
It sounds like everything's coming up roses for telepharmacy, right? Yes and no. The "yes" is everything we've described: telepharmacy has seen increased adoption by organizations, embracing by patients, and greater support on the federal, state, and private payer levels.
Unfortunately, the "no" is a big one. It's the lack of federally mandated provider status to pharmacists. As we previously wrote, federal COVID-19 legislation has yet to grant national provider status to pharmacists. This, we said, constrained their abilities to help in the front-line response to the pandemic. We highlighted four of the ways that provider status would add value during the health crisis, one which concerned delivering telepharmacy services.
The blog concluded with this sentiment: "Provider status would enhance these benefits while also eliminating challenges that decrease accessibility and discourage pharmacists from offering telepharmacy services." We strongly believe telepharmacy's "time is now," but view the lack of provider status as a lingering and substantial barrier to unleashing the potential for telepharmacy to make a significant difference in the fight against COVID-19 and achieving larger improvements in the way we deliver and coordinate care.
As is likely apparent, we're quite bullish on telepharmacy. While we anticipate that at least some of the federal, state, and private payer decisions that eliminated barriers and/or improved access to telehealth, and subsequently telepharmacy, during the pandemic will be rolled or scaled back once the worst of the pandemic is behind us (such as waiving some aspects of HIPAA), this will only slightly slow the momentum behind virtual care services.
Centers for Medicare & Medicaid Services Administrator Seema Verma recently told STAT News that she favored keeping in place the expanded telehealth access following the pandemic: "People recognize the value of this, so it seems like it would not be a good thing to force our beneficiaries to go back to in-person visits."
Verma's not alone. Nearly all attendees of the "Value-Based Care Summit | Telehealth20: Virtual Series" believe that telehealth's role will continue to grow in the industry, according to mHealthIntelligence. Concerning the growth of telemedicine, Dr. Andrew Gettinger, chief clinical officer of the Office of the National Coordinator for Health Information Technology, told the Center for Infectious Disease Research and Policy, "There are times when forced change — and I would describe the COVID-19 circumstance as forced change — leads to insights into how things could be done better."
As Healthcare IT News notes, a recent Kyruus survey found that about three-quarters of patients who have received virtual care during the pandemic said they want to see it become a standard part of care.
All of this is well and good, but as long as pharmacists lack federal provider status, telepharmacy will be hampered. There will likely be other barriers to growth and adoption, such as inconsistent rules from state to state and private payers varying in whether, how, and to what extent they choose to cover telepharmacy services, but we believe no obstacle is as significant as pharmacists not being permitted to practice at the top of their license and bill Medicare for their services. In a recent blog, we discuss the value that pharmacists as providers would deliver following the pandemic, which includes a section on telepharmacy.
We'll conclude this blog with the words of Rose Abraham, PharmD, who was recently named Cureatr's director of clinical pharmacy operations. When asked what she thinks will be required to further accelerate adoption of telepharmacy, her answer was as follows: "We need provider status for pharmacists so they can be reimbursed for the many important services they are providing. The pandemic has led to accelerated growth of telemedicine and telepharmacy, and we are seeing the significant benefits of allowing patients to leverage these services. … We have pharmacists who are available and qualified to deliver these critical services virtually. The most significant obstacle standing in their way is lack of reimbursement. It's time to remove that obstacle."