Journal of Clinical Pathways spoke with Sandra Leal, PharmD, MPH, FAPhA, CDCES, executive vice president, SinfoníaRx, A TRHC Solution (Tucson, AZ), and current president elect of the American Pharmacists Association (APhA), regarding how pharmacists are hoping to gain provider status for the services they provide during the COVID-19 pandemic and beyond, potential inclusion in Medicare Part B reimbursement, and the possibility of the association broadening its scope of practice to oncology.
What has APhA done to support the recognition of pharmacists as clinicians? Has APhA pushed states to authorize pharmacists to provide patient care services that will be essential during the COVID-19 response (eg, ordering and administering immunizations, ordering and interpreting point-of-care tests, and initiating medications)?
Dr Leal: APhA has been leading discussions around the expansion of services that are available during this pandemic period. At the federal level with CMS, there have been numerous discussions focusing on the active role pharmacists can take in the COVID-19 response, such as ordering COVID-19 testing, and being reimbursed for these services as part of the different relief packages being negotiated. At the state level, APhA is collaborating with the national alliance of state pharmacy associations (NASPA) to lessen the gap between individual state’s scope of practice language vs what is being allowed at the federal level as it pertains to recognition of the pharmacist to provide essential services and the ability to bill for such services. In most situations, CMS recognizes pharmacists as having a role as an essential provider and should be reimbursed for their services as part of the COVID-19 response, which is beyond the scope of practice as defined by many states. APhA is working as a facilitator to gain clarity from both sides – to bring the two entities together to gain some consistency with respect to recognition and reimbursement.
Additionally, APhA has been busy with continuing education efforts to keep pharmacists up to date with the regulations around the CDC, best practices for the pharmacies filling the role of the essential provider, best practices for safety for the front line pharmacists, and changes in regulations surrounding compound capabilities. In essence, we are positioning pharmacists to be leaders in the health care landscape during the pandemic.
How extensive and varying are the state-by-state regulations on administering and interpreting the “COVID-19 Quick Test?”
Dr Leal: There has been a lot of uncertainty around what the states are allowing and what the federal language is allowing, and much of it pertains to the state’s defined scope of practice for pharmacists. In order for the states to be consistent with the federal guidelines, some state-specific changes would be needed. For example, in states where pharmacists are allowed to administer vaccines, the scope of practice descriptions were usually very specific as to which vaccine could be administered by a pharmacist. Hence, each time a new vaccine becomes available, changes in the language are needed to be more inclusive of the new tests. APhA’s goal is to help states include language in the scope of practice descriptions that allows for the timely inclusion of vaccines as they become available, as well as including any limitations that maybe appropriate, such as defining age brackets to which the vaccine can be administered.
On the APhA website, we have provided a link to NASPA which has compiled a resource for state-by-state information. This resource is really critical because information is coming so rapidly and pharmacists need to be knowledgeable on what their state’s scope of practice will allow them to perform in regard to services.
How has APhA lead the effort at the federal level with regard to assisting pharmacists further their scope of practice?
Dr Leal: APhA's most important endeavor at the moment is to gain clarity with CMS in regard to recognition of the pharmacist as part of the COVID-19 response packages pertaining to testing, as well as a provider for Part B services. This recognition is an essential first step to being reimbursed for the services the pharmacist performs. If successful, this would be the first time that pharmacist would be recognized by CMS as a Part B provider. There has been a tremendous amount of effort put into communications, letter campaigns, etc requesting pharmacists to write to CMS about the importance of this access and recognition so that a network of pharmacists can be developed to function as essential access points for people to get tested for COVID-19.
Once we gain the recognition, we then will turn our attention to coupling these offerings with payment. When the first payment models came out, it was difficult to know how to create a sustainable service. The initial reimbursement was approximately $50 for the test itself, which was increased to almost $100. However, because this is such a new service, pharmacists as well as other providers had unanswered questions, such as how they become a provider of the COVID-19 test; what billing codes need to be submitted and how will they be paid; and lastly, how can they turn this into a sustainable practice as opposed to another task that is added to their already stressed workflow. At the end of the day, if the pharmacies are not adequately reimbursed to fund the additional service, they will not be able to offer it.
APhA has been leading the effort, along with other professional pharmacy organizations, in taking these questions of recognition and reimbursement back to the CMS to insure that pharmacists are represented in the continuing discussions.
What has been the response to your efforts?
Dr Leal: The initial reaction from CMS has been really positive. The administration has been receptive to our advocacy efforts; they have included pharmacists in the initial discussion around testing and they provided clarification around CLIA (clinical laboratory standards) for pharmacists. They increased the reimbursement amounts for testing, not only for pharmacists, but for everyone providing testing. CMS is clearly trying to listen to the concerns and challenges from various organization, especially in light of the multitude of issues they are facing these days.
APhA, as well as other national pharmacy organizations, have been very active and engaged in making sure that they represent the pharmacy profession as a pivotal access point for people that need testing – not just for symptomatic cases, but also antibody testing for determining who has had the virus in the past. The conversation will soon be steered into contact tracing of the infection, and eventually continuation beyond COVID-19 to care and management of chronic conditions, as well as adherence to the medications since many of the patients at risk for COVID-19 also have chronic comorbid conditions.
In short, pharmacists are a key stakeholder, not only in the current pandemic crisis, but also in ensuring that the continuation of care post pandemic as access points for care is absolutely critical to be successful in controlling this pandemic situation. In addition, pharmacist can play a significant role from a public health perspective with regard to the impact of future vaccines when they becomes available, and making sure that people will have the vaccine available.
Is APhA working to making sure that Medicare Part B inclusion is permanent rather than an emergency legislation to manage this single event?
Dr Leal: We absolutely are looking for pandemic representation. However, our efforts to be recognized and seeking reimbursement for services has been going on long before the pandemic. This has always been on the table; APhA has fought very hard for provider status. It has always been our first goal to make sure we are considered part of the care team and that we are recognized for the clinical services we deliver. The pandemic has simply further exposed the criticality of what we are hoping to gain. It has shown a spotlight on how essential pharmacists are as a profession, not only in the US, but globally.
The International Pharmaceutical Federation put together a report for the World Health Organization on the value of pharmacy internationally and the critical role pharmacists have served during the pandemic. Thus, it is essential that some of the changes and flexibilities allowed during the pandemic are retained post-pandemic and we leverage what we have learned about the importance of the access points for care and the value of the services that pharmacists provide. The clinical services, the access, and value that pharmacist provide are very essential, and will to continue to be perceived as essential to address this pandemic and future situation like this.
The value pharmacists provide is not just limited to the community pharmacist. There are pharmacists in the emergency rooms, hospitals, compounding pharmacies, etc that are trained by colleges of pharmacy that push their students to go out into the community and provide services that are in need. There has been so much incredible work by the profession as a whole that has really impacted this situation in a positive way. We need to take what we have learned and continue the momentum post-pandemic.
You mentioned that other pharmacy organizations are doing their part to advocate for the profession. Is APhA working with some of these other organizations (eg, AMCP, ASHP, or NACDS)?
Dr Leal: APhA has been trying to make sure that we unite as a profession as we advocate as a united voice and a single message to be successful to promote the profession. At the end of the day, we will be stronger and more successful if we are together in our communication as one voice advocating for the profession. In our communications and campaigns, we have multiple signers representing multiple organizations as a sign of our unity and solidarity.
For example, one of the biggest changes that has happened during this pandemic is the regulatory restriction lifts on telehealth and telemedicine. Unfortunately, pharmacists have not been added to the list of providers that can provide telehealth directly. This is not to say that pharmacists are not providing telehealth services, but rather to point out that pharmacists are providing telehealth services, yet are not recognized nor reimbursed for these services. This is another point of advocacy that all of the organizations are attacking together.
Is there any effort by APhA to move into a scope of practice for oncology and establishing practice standards?
Dr Leal: There has been discussion and considerable interest about making progress in the oncology landscape. One of the areas that APhA has been working on is a pharmacy profile, in which pharmacists would be able to access and document all of their training, credentials, board certifications, etc. APhA can then offer advanced training for pharmacists who want to pursue a career path to impact special populations. As the profession is evolving, we are thinking about the new ways that pharmacists are going to be utilized, or have been utilized, as a part of the treatment team, as well as being part of the solution before the prescription is written and to help the patient achieve the best clinical outcome.
The changes that are happening in pharmacy are incredible, but even more incredible are the changes that are happening in medicine as a whole. Providers in physician groups are faced with a myriad of challenges as they shift from fee-for-service to value-based payment. There has also been a lot of consolidation, closures, and a constant drive for better data.
As pharmacists, we have to look at the changes in health care as they happen and think about how we position ourselves to drive the best value and outcomes for patients. To do that in an effective way, we will likely have to take charge of some of these specialty areas like oncology.
Are there any other important points or parting messages you would like to make at this time?
Dr Leal: I have been active in petitioning pharmacists to be active in their state associations because the state level has local implications that impact their practice. I have also been pushing for them to be active in national organizations. It is important to be active at both the state and national level because they truly help each other. The state experience is critical to the federal language and federal experience. Similarly, the states need to know what is happening at the federal level to collaborate and learn from the federal experience. It is also key for states to talk to each other to learn from their experiences as well as the language they are using that could potentially enhance practice abilities. This networking, collaboration, and activation within state and national organizations is key to continue to move the profession forward.