Historically, pharmacists were community-based healthcare providers who made and prescribed medicines. With rapid shifts in healthcare occurring in the 20th and 21st centuries, pharmacies once again should be considered as low-cost medical homes for patients, panelists said in a presentation at Asembia’s AXS24 Summit, in Las Vegas. Three of them spoke with Specialty Pharmacy Continuum after the meeting.
Pharmacists are potentially the most accessible healthcare professionals, said Ashley Galla, PharmD, MBA, FASHP, BACP, CSP, the vice president of clinical operations at Northwell Health’s Vivo Health Pharmacy, headquartered in New Hyde Park, N.Y. An analysis published in 2022 showed that nearly 90% of Americans live within 5 miles of a community pharmacy (J Am Pharm Assoc 2022;62[6]:1816-1822.e2), she noted, and patients visited their community pharmacies 1.5 to two times more often as they visited their physicians or other healthcare professionals (J Manag Care Spec Pharm 2022;28[1]:85-90).
However, payment for pharmacist services is still a significant barrier faced by the industry, panelists said. “We have to reach the inflection point where we have enough payors willing to pay pharmacists for these services, in spite of the fact that [the Centers for Medicare & Medicaid Services] has not yet recognized us as providers,” said Alexandra Broadus, PharmD, the senior director of clinical pharmacy strategy at Walgreens. Consumer awareness also could use a boost so people recognize what healthcare services they can get from pharmacists. “We’ve done that with immunizations,” she said. “It wasn’t even 20 years ago that if you went to a pharmacy to get a flu shot, it was a nurse giving it to you.”
Dr. Galla agreed, noting that “if we can’t secure the appropriate reimbursement for these high-value cognitive services that we’re providing, we won’t be able to expand our reach and maximize the impact because we’re not going to be able to justify additional personnel. At the end of the day, we must demonstrate positive clinical outcomes and the downstream return on investment to get where we’re going.”
A Patchwork of State Regulations
The challenge is that pharmacists are regulated at the state level, said John Colaizzi Jr., PharmD, FNJPhA, the vice president of pharmacy practice at Walgreens. Each jurisdiction has different rules that dictate its scope of practice, he noted, adding that in some states, pharmacists can administer medications and immunize, and in others they can’t. “If you’re allowed to do something that you can’t get paid for, it’s irrelevant,” Dr. Colaizzi said. “If you can get paid for something that you’re not allowed to do, that’s also irrelevant. You need both of those in parallel.”
Still, some pharmacists are forging ahead with creative care models while also working to prove their worth. At Northwell, through collaborative practice agreements, pharmacists can clinically manage patients alongside a physician provider, Dr. Galla said. Pharmacists embedded in clinics can help manage patients with chronic conditions between physician appointments. “Not only can we get them to their therapeutic goal faster, but by us performing those responsibilities, it frees up capacity for providers to see the more complex patients that require their attention.”
Pharmacies need to demonstrate their value, such as not only showing reductions in hemoglobin (Hb)A1c levels for patients with diabetes but also how those reductions could prevent hospitalizations and reduce the overall cost of care, Dr. Galla said. She recently hired an outcomes and economics researcher with a pharmacy focus to collect, analyze and validate such measures.
At Walgreens, pharmacists—through a patented medication adherence intervention for patients with hypertension, hyperlipidemia or type 2 diabetes—were able to increase adherence by 5.7% to 7.5% and drive an estimated savings of $122 per member per year for Medicare beneficiaries (J Manag Care Spec Pharm 2024;30[4]:345-351), Dr. Broadus said. Her team also has been working to create healthcare cost avoidance models that can be used to demonstrate the value of clinical management programs in the specialty and non-specialty space. Some areas of focus include improving access to HIV testing, in partnership with other organizations, and solutions to improve colorectal cancer screenings and testing for HbA1c levels shared with health plans to help improve measures such as Medicare star ratings.
Incident-to Billing Strategy Can Yield Payments
Since pharmacists have yet to be universally recognized as providers, some working in ambulatory care are using an incident-to billing services strategy to get paid. These services are furnished incident to a physician either in the provider’s office or a patient’s home, she noted. But there are very strict criteria to using this model and significant penalties for incorrect billing, Dr. Galla said. New York recently authorized pharmacists to dispense self-administered hormonal contraception and administer long-acting injectable medications for mental health and substance use disorders, she said, but the reimbursement doesn’t factor in the time required by pharmacists to evaluate and manage patients.
Looking to the future of specialty pharmacy, Dr. Colaizzi said, the pipeline has many provider-administered products—an additional service where pharmacists could play a significant role. “It’s hard enough to get patients to take their oral therapeutics, let alone to have to go find a provider to get their medications administered every week or month,” he said. “Pharmacies now are the primary source of immunizations in this country. They have the same vision for medication administration, and that will help with the pipeline of novel products coming to market.”
The sources reported no relevant financial disclosures beyond their stated employment.
This article is from the October 2024 print issue.