Building the Future of Healthcare: Expanding Public Access to Community Pharmacy Services Beyond the COVID-19 Pandemic, Part 6

The following is part 6 of 6 in a series of articles titled, "Expanding Public Access to Community Pharmacy Services Beyond the COVID-19 Pandemic" by Jason Ausili, PharmD, MSLS, Head of Pharmacy Transformation for EnlivenHealth.

The Need for Provider Status

According to the U.S. Census Bureau, Medicare (18.4% of population) and Medicaid (17.8%) are the second and third most common subtypes of healthcare insurance in the U.S. population, behind only employment-based insurance (54.4%). The policies and standards implemented by CMS commonly lead the way for commercial private health insurers to follow behind. The lack of federal provider status recognition and corresponding payment mechanisms under CMS have slowed progress on community pharmacy-based clinical service expansion, limiting access to care, especially among the nation's senior and lower income populations. Although there is evidence of recent legislative success regarding pharmacist provider status at the state level, payment recognition by State Medicaid programs and private payers is lagging due to the lack of federal influence. The COVID-19 pandemic has made payment inequity for pharmacists' services more apparent than in the recent past.

COVID-19 testing performed at the point-of-care for Medicare patients highlights an example of this imbalance. When the test is performed by a "qualifying practitioner" (physician, NP, or PA), the provider can bill for the common procedural terminology (CPT) codes for both the test product and the service component in the form of a specimen collection fee. A pharmacist who administers an identical test, evaluates the results, and counsels the patient based on the results, is only allowed to bill Medicare for the test product and not the service fee since they are not considered qualifying practitioners. In the absence of provider status, the pharmacist's role is diluted to the dispensing of a product. It was difficult for many pharmacies to make this a viable and scalable business practice without payment recognition for the service component due to the thin margins associated with product reimbursement.

Pharmacists take an oath upon graduation. This oath promises they will "consider the welfare of humanity and relief of suffering" as their primary concerns and always strive to take care of their community. Federal provider status recognition will help ensure that pharmacists continue to provide incomparable access to high-quality healthcare without risking staffing burnout and business failure.

Eliminating the Expiration Date

Community pharmacists and their teams have played a primary public health service role during the pandemic by making vaccinations, testing, and therapeutics more accessible to the U.S. population. By eliminating barriers to access and increasing convenience, community pharmacists have enabled more people to receive needed care in a timelier fashion. How can we repay them for this amazing public service?

The recognition must start with a concerted effort to solidify the authorities and privileges granted during the pandemic, it must be accompanied by federal provider status acknowledgement, and be supported by equitable payment and reimbursement mechanisms, ensuring the nation's community pharmacists can continue to close the gap on health inequities, heal the public in the wake of this pandemic, and bolster our response in preparation for the next one.

Primarily, the regulatory advancements, guidance documents, and PREP Act Amendments that helped mobilize the country's most accessible healthcare providers should not expire when the PHE declaration ends. The long-term public health benefits of community pharmacy-provided COVID-19 testing, vaccination, and treatment, as well as the provision of childhood vaccinations must survive the PHE.

The U.S. will be healing from COVID-19 long after the PHE declaration ends. Once it expires, pharmacists in certain states, like Pennsylvania, are at risk for losing the authority to order and administer COVID-19 vaccines. This could have significant repercussions on patient access if additional boosters are needed to maintain immunity and weather new COVID variants and seasonal surges.

Lawmakers need to take immediate action to ensure community pharmacists can continue to combat health inequities and disparities during the pandemic and beyond. Legislation is needed to solidify pharmacists' role on this front and to ensure equitable reimbursement is in place to prevent burnout, fostering viable and scalable growth. Without fair reimbursement, the value of public health services (i.e., Test to Treat) provided by pharmacists is reduced to that of dispensing a prescription. Pharmacists — as prescribers of therapies for COVID-19, influenza, and strep throat — must be recognized for time spent analyzing and evaluating patients as candidates for treatment.

Securing Federal Provider Status for Pharmacies

Equally important to securing the current authorities and privileges is obtaining federal provider status. This would recognize the cognitive services provided by these talented professionals and create a reimbursement mechanism within CMS that makes pandemic-related services viable and scalable among community pharmacies. The ECAPS Act is not broad in scope, nor generous in reward, but it is a monumental stepping stone that enables pharmacists to expand their public health service reach into the communities in which they operate. If enacted, this bill would further mobilize pharmacists to provide "Test to Treat " services (COVID-19, Influenza, Strep), vaccinations (COVID-19 and Influenza), and POCT (RSV), and has expansion provisions that allow the Secretary of HHS flexibility to respond to the next pandemic more proactively.

Finally, as the most accessible healthcare provider, pharmacists practicing in medically underserved areas should be recognized federally as providers for all services within state scope of practice laws. The Pharmacy and Medically Underserved Areas Enhancement Act would help ensure that those without convenient access could get the care they need from their local pharmacist. Community pharmacists are the nation's medication experts and have played a key role in educating and managing patients with chronic medical conditions like diabetes, heart disease, high blood pressure and cholesterol for many years. Now is the time to recognize the value of this care through equitable reimbursement that inspires growth and expansion of these services. The CDC's goal to achieve health equity among medically underserved racial and ethnic minority groups will be significantly challenged without the help of the nation's community pharmacists.

Anticipated Challenges

The terms "global pandemic " and "turf battle " should not be used in the same sentence moving forward. The primary challenge that we face in achieving legislative reform is competitive in nature. The AMA has one of the largest lobbying budgets in the U.S. Does a large membership and lobbying budget justify fighting for the status quo at the expense of public health, access to care, and health inequities? This would not be the first time this has happened, and pharmacists are not the only healthcare professionals impacted.

In November of 2017, the AMA opposed "the continual, nationwide efforts to grant independent practice to non-physician practitioners" at a House of Delegates interim meeting. This statement targeted advanced practice registered nurses (APRNs), a group comprising nurse practitioners, clinical nurse specialists, certified registered nurse anesthetists, and certified nurse midwives. The CEO of the American Association of Nurse Practitioners, Dave Herbert, added, "For many years, the AMA has worked to regulate other health care professionals at the expense of patients and consumers."

Although a lobbying group may have protections against antitrust allegations, the organization representing the nation's medical doctors should not take opposition to patient access to care, especially in the face of a rising national PCP shortage.

What Needs to Happen Next

Community pharmacies have played an essential role in improving access to testing, vaccinations, and treatment during COVID-19 and offer the best offense to battling health disparities in the U.S. beyond the pandemic. Patients can conveniently access a local pharmacy, within close reach of their home, without an appointment and outside of normal physicians' office hours. Can you imagine the negative health equity impact if pharmacists were not able to provide these services during the pandemic?

Immediate legislative reform is needed to solidify pharmacists' role as the community caregiver. The current payment incentives are lacking and promote staff burnout over service expansion. Minimal administration and dispensing fees are not only insufficient to promote viability, growth, and scalability, they are unfair. Now is the time to recognize pharmacists as providers and reward them for the time they spend caring for and healing their communities. The policy recommendations included in this series and the corresponding benefit to public health access will dramatically overshadow the self-centered interests of opposing forces.