Cast in a new light
As the pharmacy profession marks American Pharmacists Month in October, its drive to achieve full recognition and status for pharmacists as health providers continues to gain momentum.
The campaign for provider status and full integration in a collaborative healthcare system enlists the lobbying efforts of virtually all the nation’s top pharmacy organizations and dozens of state-based pharmacy groups. It also goes to the heart of pharmacy’s future, defining the industry’s struggle to evolve beyond the confines of the old prescription-dispensing model and to secure a full stake in the integrated healthcare model now taking shape across the United States.
Specifically, the effort aims to “pursue legislative and regulatory changes to the Medicare program and relevant sections of the Social Security Act … to recognize the direct patient care services of qualified clinical pharmacists as a covered benefit under the Medicare program, regardless of the settings in which they practice,” noted the American College of Clinical Pharmacy. The target is “more patient-centered, team-based and quality-focused care” that provides recognition and a fair reimbursement for pharmacists engaged in that care model, ACCP reported.
The effort is critical to pharmacy’s future. Noting that “a dichotomy exists between what many pharmacists do and what they’ve been trained to do,” the American Pharmacists Association casts the issue as a “paradox in pharmacy between the vision of patient care and the reality of community pharmacy practice.” The gap between that vision and reality for community pharmacy continues to stymie efforts by pharmacists to gain elevated stature as fully engaged members of the health provider network in America — or to gain the recognition and reimbursement that pharmacists need to fully develop the kinds of collaborative practice models needed to transform the fractured, overly expensive U.S. health system.
This, despite the fact that “when pharmacists get involved, overall healthcare costs go down and quality and patient safety improve,” APhA asserted. The group has joined with other pharmacy organizations — including the National Association of Chain Drug Stores; the National Community Pharmacists Association; the American Society of Health-System Pharmacists, or ASHP; the Academy of Managed Care Pharmacy, or AMCP; the American Association of Colleges of Pharmacy; the ACCP; and a number of pharmacy retailers — in a major push to generate support among congressional lawmakers and federal health officials for a change in federal health regulations that would designate pharmacists as recognized healthcare providers.
The focus of that effort is convincing lawmakers to insert new language in the Social Security Act that would define pharmacists as patient care providers who qualify as such for payments under Medicare. “We need the recognition as providers so the healthcare system supports us financially,” noted ASHP CEO Paul Abramowitz at the group’s summer meeting in June.
Also backing “the recognition of pharmacists as non-physician providers under the Social Security Act” is the Academy of Managed Care Pharmacy. Provider status, AMCP stated, would “allow pharmacists to be reimbursed directly from Medicare Part B for providing cognitive services to patients covered under the program.”
“Although current Medicare Part D law reimburses pharmacies for pharmacists providing some cognitive services, including medication therapy management to a select subset of patients, the program is restrictive and encompasses only a small set of the services pharmacists are capable of undertaking,” the group asserted in a position statement. “Most states permit pharmacists to enter into collaborative practice agreements with prescribers, which grant pharmacists authority to manage a patient’s drug therapy.”
“A large body of published literature provides significant evidence of the benefits gained by allowing pharmacists to more fully utilize their expertise within clinical settings as part of the healthcare team,” added the statement. “AMCP strongly believes the inclusion of pharmacists as healthcare providers will enhance their ability to work as part of healthcare teams to address primary healthcare needs and increase the potential of pharmacists to provide these services with fewer barriers.”
NCPA calls the change “long overdue,” and noted, “with this federally recognized designation, pharmacists could finally be recognized for the valuable work they do and for their dedication to their patients.”
APhA agreed. “Provider listing in the Social Security Act is an important component in the ultimate goal of providing consumers and other healthcare providers with access to our services,” noted the pharmacy organization. “For patients to achieve the full benefit of their medications, pharmacists must be part of the team.”
To drive progress on the move to boost pharmacists’ provider status, APhA allocated $1.5 million to “a multifaceted initiative by the profession to gain recognition for pharmacists as healthcare providers.” The effort, said the group, seeks to ensure that:
- Payers and policy-makers give patients access to pharmacists’ clinical services and recognize pharmacists as healthcare providers who improve access, quality and value to health care;
- Patients have access to pharmacists’ clinical services through Medicare/Medicaid, other federal and state health benefit programs, integrated care delivery models and/or private payers by listing pharmacists as providers and/or properly valuing these services in payment models; and
- Every patient’s health benefit plan package includes pharmacists’ clinical services as a core component.
The drive for provider status isn’t limited to big organizations and retail pharmacy chains. Individual pharmacists, including Sandra Leal, a PharmD and certified diabetic educator, and even student pharmacist Steve Soman have launched petition drives to convince President Barack Obama, the U.S. Congress and health policy-makers to support provider status and adequate clinical care compensation for pharmacists.
Meanwhile, pressure is building at the state level for legislation granting pharmacists professional provider status. In California, for instance, the California Medical Association in August agreed to drop its opposition to a bill in the state legislature that would expand the role of pharmacists after negotiations with the California Pharmacists Association, or CPhA. If enacted, the bill would boost pharmacists’ authority to order and interpret some tests of patients’ drug therapies and initiate routine vaccinations, among other duties.
“This exciting development reflects the recognition in the provider community of pharmacists’ high level of training and expertise, and of the contributions that pharmacists can make to patient care,” CPhA stated.
Pharmacy gained a powerful ally in the drive for provider status when the U.S. Public Health Service, or USPHS, and U.S. Surgeon General Dr. Regina Benjamin went on record urging policy-makers and health regulators “to support and implement existing, evidence-based and cost-effective pharmacist-delivered patient care models as the demands within our healthcare system escalate.”
Importantly, USPHS also noted that adequate reimbursement for this higher level of pharmacy practice was essential to making it work. “For pharmacists to continue to improve patient and healthcare system outcomes, as well as sustain various roles in the delivery of care, recognition as healthcare providers and compensation models reflective of the range of care provided are needed,” noted the agency, which is part of the Department of Health and Human Services.
In June, Rear Admiral Scott Giberson, chief professional officer for USPHS pharmacists, reiterated that support for provider status for pharmacists in a speech to the ASHP in Minneapolis. “Pharmacists are the second-most highly trained health professional … based on years of formal education,” Giberson noted, and are “a primary key to cost containment,” with a demonstrated “average return on investment of $4-to-$1 over the last two decades.”
Giberson added: “Pharmacists are likely the most underutilized healthcare provider in the nation. We may be missing an opportunity to address health system burdens with one of the nation’s most capable providers.”
Rite Aid’s Wellness format passes 1,000-store mark in second quarter
CAMP HILL, Pa. — Rite Aid posted its fourth-consecutive profitable quarter Thursday as it reached a milestone in its store conversions and saw growth in the latest expansion to its loyalty program.
During the second quarter of fiscal year 2014, the number of stores in the chain that have been converted to the Wellness and Genuine Well-Being formats passed 1,000, with the total number of stores converted totaling 1,019 — including 114 under the newer Genuine Well-Being format — and expected to reach 1,200 by the end of the year. In a conference call with financial analysts to announce the quarter’s results, CFO Frank Vitrano said Wellness stores’ front-end same-store sales led non-Wellness stores’ by 3.4%, while same-store script count led by 0.9%. One key part of the Wellness format is the Wellness Ambassadors, specially trained staff who help customers with questions they have about health and wellness products and also help to funnel them toward the pharmacy; as of the end of the quarter, there were 1,700 Wellness Ambassadors working in stores.
Wellness65+, a supplement to the Wellness+ loyalty card program aimed at elderly customers, had 930,000 members enrolled as of the end of the quarter, and president and COO Ken Martindale said that seniors had been "very receptive" to it. Part of the promotional efforts around the program included a tour around the country, with 65 events in eight markets, thus allowing employees to build relationships with senior customers. Other wellness-related programs include flu vaccinations, and chairman and CEO John Standley said they were off to a "strong start" in the 2013-2014 flu season; the company aims to vaccinate 2.5 million people during the fiscal year.
As the chain cycles through the customers it gained during the dispute last year between Walgreens and Express Scripts, same-store script count was flat compared with second-quarter 2013, but offset by organic script count growth. Pharmacy same-store sales were up by 1.7% and included a 2.5% negative effect from new generic introductions. Standley said during the call that new generics have been stronger than expected, but cost increases for generics have also been higher, and the company expects that to put pressure on the company’s guidance over the next two quarters.
Sales for the quarter were $6.3 billion, up from $6.2 billion in second quarter 2013, while profits were $32.8 million, compared with a $38.8 million loss a year ago. Same-store sales were up by 1%, including the aforementioned increase in pharmacy comps and a 0.3% decrease in front-end comps. The chain operated 4,604 stores.
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A shot in the arm for pharmacy
Results from a nationwide survey last year revealed that adults get immunized in pharmacies more frequently than anywhere else, other than physician offices. This should come as no surprise considering the convenient hours, ease of access and frequency of visits to pharmacies. But what is the legal status of pharmacy-based immunization, and what are the roles of the pharmacist?
Status of pharmacist immunizers
Thirty years ago, less than 10 states authorized pharmacists to administer influenza vaccines. By the end of the last decade, all 50 states, plus the District of Columbia and Puerto Rico, allowed pharmacists to immunize. As the numbers of authorizing states has grown, the number of pharmacists getting trained to immunize also has grown. According to the American Pharmacists Association, more than 200,000 pharmacists in the United States were trained to administer vaccines.
State law governs healthcare practice, including immunization practice, and each state has different regulations regarding immunizations. As a general rule, pharmacists have the authority to immunize based on a protocol with a physician — similar to nurses and physician assistants — or by prescription; however, the specifics vary by state, especially with regards to the age of the patient, the immunization process and the particular vaccine. Protocols are basically contracts that specify who has delegated the activity (i.e., a physician), identifies the pharmacist who is authorized by the protocol, states what types of vaccines the pharmacist is authorized to administer and defines procedures and criteria for pharmacists to follow, including when to refer the patient elsewhere and what to do in emergency situations.
Currently, 44 states/territories allow pharmacists to administer any vaccine; South Dakota allows only influenza and zoster (shingles); New York and Florida allow only influenza, pneumonia and zoster; and five other states allow some combination.
The role of the pharmacist
APhA adopted “Guidelines for Pharmacy-Based Advocacy” in 1996, establishing the role of pharmacists in the immunization process. These guidelines were reviewed in 2012 and contain five points:
- Prevention — Pharmacists should protect their patients’ health by being vaccine advocates;
- Partnership — Pharmacists who administer immunizations do so in partnership with
- their community;
- Quality — Pharmacists must achieve and maintain competence to administer immunizations;
- Documentation — Pharmacists should document immunizations fully and report clinically significant events appropriately; and
- Empowerment — Pharmacists should educate patients about immunizations and respect patients’ rights.
APhA identified pharmacists as having three main roles in immunizations. The first is acting as an advocate, and educating and motivating patients to get their flu shot, for example. The second role is as a facilitator — hosting others who vaccinate in the pharmacy. Some pharmacies have done this by inviting nurse practitioners or physician assistants in for a scheduled vaccination clinic. The third role of the pharmacist is as the actual immunizer. Currently close to 20% of adults get their influenza vaccine at the pharmacy, and this number is likely to grow as health care changes.
What does the future hold? Aside from such common immunizations as influenza and pneumonia, we will increasingly see pharmacists immunizing for other diseases — such as zoster, pertussis, tetanus-diptheria, typhoid, chicken pox, hepatitis, meningitis and more. Some pharmacies have travel clinics specifically to immunize patients against travel-related disease, and as new vaccines are developed, such as the HPV vaccination, more collaborative opportunities are created for pharmacists to work with other healthcare practitioners to protect the health of patients.
Ann W. Latner, JD, a former criminal defense attorney, is a freelance medical writer in Port Washington, N.Y.