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Why Pharmacists Should Advocate for a Single-Payer Healthcare System – Guest Writers Thomas J. Cook and Tashrique Rahman

If you ask a pharmacist or student pharmacist what motivated them to follow their career path, a common answer will likely include the desire to improve people’s lives through quality pharmaceutical care. If you ask a practicing pharmacist what most frustrates them about their pharmacy career, you are likely to hear a litany of complaints about insurance companies (e.g., prior authorizations, pharmacy benefit managers [PBMs], clawbacks, closed networks, direct and indirect remuneration [DIR] fees, etc). These are “features” of the byzantine United States (US) healthcare system, which is centered on private insurers and where an estimated 34.2% of health care dollars are spent on administrative costs versus 17.0% in Canada. Pharmacists and other health professionals spend an inordinate amount of time navigating these “features” instead of focusing on patient care. Fortunately, there is a solution: a single-payer healthcare system (e.g., Medicare for All).

What is a single-payer healthcare system?

When defining “single-payer healthcare system” in the context of recent Medicare for All (M4A) proposals, it may be helpful to emphasize what it is not. First and foremost, despite the scare tactics of M4A opponents, single-payer M4A is NOT government-run healthcare. Rather, as Physicians for a National Health Plan specifies, single-payer is financed through a single, typically public entity, while private entities (e.g., physicians, pharmacists, hospitals, pharmacies, etc) continue to deliver health care to the public. Current single-payer proposals would provide US residents with universal healthcare coverage. Cost savings would primarily come from substantially lower administrative costs as a result of having one payer rather than more than 900. With a single-payer, networks would be eliminated thus providing people with the ultimate freedom of health care choice. 

Healthcare should not be a politicized issue

Some folks may balk at moving towards a single-payer system. They may ask: ‘Don’t we have the most advanced health care in the world?’ or ‘We are the richest country in the world, isn’t our healthcare system the best?’ While the US may have the most advanced health care available, access to that health care is not universal, which contributes to rampant health disparities. Our healthcare system is certainly the best at spending. We have the highest per capita healthcare spending as a function of gross domestic product (gross domestic product (GDP). Despite that spending, as Galvani et al point out, the US “ranks below 30 countries for many public health indicators, including preventable deaths, infant survival, maternal mortality, and overall life expectancy.” While many factors contribute to poor health outcomes in the US, the lack of adequate healthcare access (including those with insurance) is a major contributor. Even though the Affordable Care Act has enabled many people to obtain coverage through Medicare and Medicaid, the National Health Interview Survey estimated the number of uninsured to be about 30 million in the first half of 2020. As the pandemic and the recession continues, extended employee-sponsored coverages and furlough protections are expiring; the number is only expected to be higher. According to the latest estimate by the Economic Policy Institute, 12 million Americans have lost their health coverage.

The support for the single-payer system stems from Medicare and Medicaid which are equally popular public health programs in the United States. The Kaiser Family Foundation reports 77 percent of the public perceive Medicare as an important program. 63 percent of the respondents say medicaid is very important. Support for public programs are similar among party lines (85 percent of Republicans, 89 percent of independents, and 92 percent of Democrats favor Medicare). As M4A is becoming a staple conversation in our healthcare, the attitudes towards the implementation of a single-payer system remain divided. Eight out of ten democrats favor M4A while three-fourth Republicans oppose its implementation. Differences of public opinions are more evident around terminologies that politicians use in their arguments (e.g. universal health coverage, national health plan, socialized medicine etc.). This means political affiliation is swaying more divisive public opinions even though the evidence might be leaning in favor of a universal national program aka a single-payer system. A recent survey representing the experiences of more than 61 million US adults showed that respondents with public health insurance (Medicare, Medicaid, and veterans Health Administration) were more likely to have a personal physician and less likely to report instability in insurance coverage, difficulty seeing a patient or taking medications because of costs, and having medical debt compared with employer-sponsored coverage (79% had employer-sponsored coverage). Individuals with employer-sponsored insurance also reported less satisfaction with their care compared to those covered by Medicare. These findings favor the implementation of a single-payer system that can potentially deliver more cost-effective care than private options.

The data is clear on affordability and access

Affordability has been overwhelmingly cited as the primary reason Americans opt out of healthcare. According to a 2019 survey published by the Center for Disease Control and Prevention, the inability to pay premiums was the most common reason for being uninsured among uninsured adults aged 18-64. Adults in fair or poor health were more likely to be underinsured due to affordability than those in excellent, very good, or good health. A recent survey by AccessOne showed 66% of Americans were concerned about being able to afford health care in 2021. Loss of health insurance can impact certain populations more than others. About 33% of Gen Z and 29% of millennials had their health insurance affected by the pandemic versus 12% of baby boomers.

The national average for a premium benchmark marketplace plan in 2021 is $452 per month which increased from $273 in 2014 (66% increase). Most plans also carry high deductibles and/or co-pays on top of in/out-of-network complexities. A recent 2020 survey showed 47% participants chose their healthcare based on costs. This means people are forgoing necessary interventions/procedures because of cost. Private insurance companies are also notorious for maximizing profit by minimizing short-term costs. Since insurance companies do not have lifespan commitments to their patients (compared to a single-payer system), short sighted cost cutting techniques are implemented at the expense of the patient’s long-term health. Canada (single-payer health system) spends more per capita on prevention as a share of total national health expenditure than the US (6.2% versus 2.8%). As a result, when both countries are compared in terms of chronic diseases, US men have a 28% higher mortality rate from cardiovascular diseases when compared with Canadian men.

What does a true single-payer system bring to the table? Apart from the savings in administrative and billing (roughly $219 billion), clinical and hospital fees ($100 billion), and unified billing system ($284 billion), a single-payer system removes unpaid medical bills for hospitals ($35 billion), eliminates avoidable emergency room visits and hospitalizations through improved access to primary care ($100 billion), and reduces pharmaceutical prices through pharmaceutical price negotiation strategies implemented by the US Department Veterans Affairs ($188 billion). A single-payer system will expand people’s access to healthcare and most importantly save lives. Substantial disparities based on race/ethnicity (American Indians are 2.9 times, Hispanics 2.5 times and Blacks 1.5 times likely to be uninsured compared to whites) and income (individuals are 4 times likely to be uninsured if they earn below the poverty line) will cease to exist. Some estimates show universal coverage can save 68,531 lives (predominantly younger lives) in the US and save 1.73 million life-years annually (adjusting for age distribution based on preventable premature deaths).

How would a single-payer system affect pharmacists? 

Well, the specifics will depend on the details of the system. A unified billing system will spare the countless hours pharmacy professionals spend on processing prescriptions and/or services. That means more time and resources can be dedicated to provide patient-centered care. The increased demand for providers secondary to unrestricted access to care may ultimately lead to expanded scope of practice for pharmacists. A number of states have passed bills expanding pharmacist scope of practice, which could lead to provider status. During the 2021 legislative season, legislators proposed over 200 pharmacist provider-status bills in 43 states of which 32 bills in 18 states were signed into law. If a single-payer system is implemented on a fee-for-service principle, pharmacists will qualify for reimbursements for clinical services provided. Furthermore, there would be no networks in a single-payer system thus truly giving patients freedom in choosing their pharmacy.

Creating a single-payer healthcare system in the US will not guarantee improvements in health outcomes nor in eliminating health disparities. The implementation of such a system via the laws, regulations, and policies will determine how well such a system accomplishes these goals. As Ramachandran et al, recently highlighted, pharmacists must be active participants in shaping healthcare legislation including those surrounding the single-payer healthcare system. Towards that end, Pharmacists for Single-Payer (PSP) is a grassroots organization with the mission of promoting the role of pharmacy professionals in delivering evidence-based, patient-centered care within a universal healthcare system. At PSP, we are working to bring the voice of pharmacy to the single-payer healthcare system discussion. Now is the time for that pharmacy voice to be heard.

Guest Writers Profiles

Thomas J. Cook, PhD, RPh (one of the co-founders of Pharmacists for Single Payer) is a freelance medical/scientific writer, consultant, and medical cannabis pharmacist. After completing his Bachelor of Science in pharmacy at Northeastern University, Dr. Cook pursued his graduate studies in pharmaceutics at the University of Michigan. 

The bulk of Dr. Cook’s career has been in academia where he served as a researcher, faculty member, and administrator. Dr. Cook’s current work focuses on continuing education for the medical professions; consulting for specialty pharmacy accreditation and pharmacy research projects; and providing pharmacist services at a medical cannabis dispensary. 

Tashrique Rahman, PharmD, MBA, is a current Post Graduate year-1 pharmacy resident at Hillcrest Medical Center in Tulsa, Oklahoma. He completed his Doctorate of Pharmacy at Southwestern Oklahoma State University College of Pharmacy and his Master in Business Administration from The Everett Dobson School of Business and Technology at Southwestern Oklahoma State University in 2020.

Dr. Rahman is passionate about single-payer advocacy. He is one of the co-founders of Pharmacists for Single Payer, a board member, and the research coordinator. He lives in Tulsa with his partner, a veterinarian, and their six animals (3 dogs and 3 cats). Dr. Rahman describes the household as a “petting zoo” that he is never going to financially recover from. In his free time, he enjoys riding bikes, kayaking, running, playing his guitar, trying new restaurants, and spending time with family and friends.

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Pharmacists in the Spotlight: Federal Retail Pharmacy Program for COVID-19 Vaccination

The Federal Retail Pharmacy Program for COVID-19 Vaccination will launch this week with a goal to increase access to the vital vaccination across the United States. Early on in the pandemic, pharmacists were identified as trusted members of the health care team to provide testing and education to the public. As vaccines have become available, some states have already engaged pharmacists to assist with vaccination efforts, however, there have been calls to better utilize pharmacist in these efforts.  This program will expand pharmacies’ access to supplies and pharmacist’s opportunity to make an even greater impact on the pandemic. 

What is the Federal Retail Pharmacy Program for COVID-19 Vaccination?

This collaboration between the federal government, states, and numerous national pharmacy partners and networks of independent pharmacies, is part of the strategic plan to help meet President Biden’s goal of administering 100 million vaccines during his first 100 days in office (18 days into his term, 40.5 million doses have been administered in the US). Initially, select community pharmacies will receive limited supplies of the vaccines, the allocation of which is dependent on the number of people in the jurisdiction, number of pharmacies, and reach. For a complete list of participating pharmacies, and which pharmacies based on location will have supply during the roll-out phase, please visit the CDC website. Pharmacies who are not enrolled in the Federal Retail Pharmacy Program can enroll directly with a state or territory’s immunization program to offer vaccination in their communities. 

In addition to improving access, the program is believed to decrease logistical and operational burdens on state, local, and territorial health departments, as the vaccines will be provided directly to the pharmacies from the federal government. The CDC is also offering the Pharmacy Transfer Program, which allows states and territories to transfer allocated vaccine doses to the federal pharmacy partners. However, the states will remain responsible for determining the eligibility of the patients and phases of rollouts within the communities. 

Although this program may be a step in the right direction to improve access to vaccines, the initial list of participating pharmacies is restricted based on limited supplies, and new programs do not come without anticipated challenges. For patients who have not received services at the limited number of pharmacies with access, the pharmacy team will need to take time to create new patient profiles, including adding and assessing allergies, current conditions, medication regimens, and insurance information. The pharmacy team will also need to document vaccine administrations to ensure appropriate tracking, all while maintaining the high level of chronic and acute care needs required by patients. 

In our opinion, the biggest challenge we continue to face during this pandemic remains equitable access for all populations, especially our most vulnerable communities. Although the CDC states that they will continue to collaborate with states and territories to shift vaccine inventory as needed to ensure fair access, how can we ensure equitable administration of the vaccines?

Goal: Improve equitable access to vaccines

The Biden Administration states that the Federal Retail Pharmacy Program is a key component of the Administrations’ strategy to expand equitable access to vaccines for the American public. But will it?

The CDC worked with states and territories to select initial pharmacy locations that would provide access in the communities. Factors that were considered included the “number of stores, the ability to reach some of the populations most at risk for severe illness from COVID-19 (those over 65 years of age, socially vulnerable communities), and alignment with their existing vaccination plan.” Despite vaccine availability in these communities, there’s no guarantee the vaccines will be administered to the most vulnerable populations and providing vaccines in socially vulnerable communities may not prevent people from wealthier neighborhoods from signing up for doses at these locations. 

Additionally, people in underserved neighborhoods continue to experience barriers, including lack of transportation, ability to take time off from jobs to get to appointments, and skepticism about the vaccine, which this program does not address.  The CDC does note that this program relies on a collaboration with public health departments to encourage individuals to receive the vaccine and community outreach to educate on the importance of vaccination and where vaccines are available, though no specific plans are outlined. Furthermore, access to or difficulty navigating registration websites, or even the access to check online to see if a local pharmacy will be administering the vaccine, remains a barrier. 

Pharmacists are highly trusted and trained professionals to help with vaccine administration and increasing supplies of vaccines in the pharmacies may help, but innovative approaches such as mobile vaccination vans and partnerships with faith-based organizations may be key to overcoming some of the barriers that remain to equitable access to the vaccine

Free the Pill: Leveraging Pharmacists to Address Contraception Deserts and Enhance Access – Guest Writers Lynda Nguyen and Cortney Mospan

During my three years of didactic learning, advocacy for and the advancement of the pharmacy profession, MY profession, admittedly fell by the wayside. Instead, my focus was solely on my present – exams, organizational activities, internships, etc. Looking at the current state of the profession and patients’ health disparities didn’t seem as imperative as the thought of passing  the next exam. Now that I am in my final year of pharmacy school and getting experience with the real world on my Advanced Pharmacy Practice Experiences, I’ve come to realize that this is the stuff that matters. 

In the Oath of a Pharmacist, one of the vows that a pharmacist makes is to “embrace and advocate changes that improve patient care.” One avenue in which we can do this is by supporting reproductive justice, which is a one’s right to “control [their] sexuality, gender, work, and reproduction.” One of the barriers that reproductive justice seeks to address is access. “There is no choice where there is no access.” Advocating for services such as pharmacist-prescribed contraception can be one avenue to support patients’ reproductive justice.

Contraception and Relation to Health and Poverty

Currently, there are 61 million persons in the US that are of reproductive age, which is considered ages 15-44.  Of these, about 70% are at risk of unintended pregnancy. An unintended pregnancy occurs when a person who can become pregnant is sexually active and does not want to become pregnant, but becomes pregnant due to failure to use a contraceptive method correctly and/or consistently. Unintended pregnancy is linked to adverse health outcomes, such as preterm birth and postpartum depression. The US Department of Health and Human Services included in their Healthy People 2030 objectives a reduction in the proportion of unintended pregnancies and an increase in effective birth control usage.  

A recent study concluded that changes in contraceptive use are associated with pregnancy scares and can increase the risk of unintended pregnancy.  These changes included discontinuing the use of contraception, changing from consistent to inconsistent use of contraception, and changing from a more effective to a less effective method of contraception.  These results further exemplify the need for contraception education and family planning services and the role that pharmacists can play in meeting these needs. Sexual health knowledge has been shown to be suboptimal among medical students, and PharmD curricula likely will need to enhance their training to prepare pharmacists for their emerging roles in reproductive health.

Additionally, not only can pharmacists help to reduce the rates of unintended pregnancy and the associated consequences by prescribing contraception, but pharmacists can also address preconception care which is often overlooked.  Chronic diseases such as diabetes, hypertension, and asthma have been increasing in patients of reproductive ages, and people who have these chronic diseases are more likely to report their pregnancies as unintended.  Pharmacists can aid in providing necessary preconception care such as identifying potentially teratogenic medications and development of a reproductive life plan, lack of folic acid supplementation, and immunization needs. Each encounter would also serve as an opportunity to link patients back into primary care, as there have been decreases over time in patients of reproductive age (with or without comorbidities) who receive primary care.

Contraception Deserts and Pharmacist-Prescribed Contraception

Nearly half of all pregnancies in the United States are unintended, with low-income persons having some of the highest rates of unintended pregnancy due to many factors, including inconsistent contraceptive use. One in four of these patients report difficulties in obtaining contraception from a prescriber’s office due to reasons such as difficulty scheduling appointments (long waits, high copays, inconvenient clinic hours) and concerns about receiving pelvic exams. Oftentimes, contraception prescriptions have been tied to a required pelvic exam, despite the American College of Obstetrics and Gynecologists (ACOG) stating that pelvic exams are not required to receive most contraceptives. Routine pelvic exams are not recommended in asymptomatic patients by the United States Preventative Services Task Force (USPSTF) and cervical cancer screenings are generally only recommended every three years. In North Carolina alone, approximately one in four counties do not have an OB/GYN, and although most of these counties have a primary care provider, 87 counties are health care provider shortage designation areas, meaning patients experience many challenges in overcoming barriers to contraception access. Pharmacist-prescribed contraception can help to fill this gap in service since 91% of patients live within 5 miles of a pharmacy.  

According to Power to Decide, 19 million patients live in contraception deserts. Those who live in contraception deserts “lack reasonable access in their county to a health center that offers the full range of contraceptive methods.”  This means that for these patients, accessing contraception means more than just keeping an appointment. They may have to find child care, take time off from school or work, and/or travel longer distances to access their preferred birth control method. For more on contraception deserts, head to this link. 

As of June 2021, there are 17 states and jurisdictions that authorize pharmacists to prescribe contraceptives via a standing order or protocol. This authorization allows for broader implementation and utility to address public health needs whereas collaborative practice agreements are typically limited to mutual patients of both the prescriber and the pharmacist.  Policies differ depending on the state, but most authorize  pharmacists to prescribe oral contraceptives, vaginal rings, and contraceptive patches. Six states also include prescribing of depot medroxyprogesterone in their protocols. Many of these protocols (64%) also include age restrictions to patients 18 and older. Read more about existing authorities at Birth Control Pharmacist.

One of the first states to authorize pharmacist-prescribed contraception was Oregon. In the first two years of policy implementation, pharmacists wrote 10% of all new oral or transdermal contraceptive prescriptions for Medicaid beneficiaries.  An analysis of the data from Oregon  shows that an estimated 51 unintended pregnancies were averted saving the state $1.6 million dollars.

While the impact of pharmacist contraception services is only available from one state during a limited time frame and population, the results are encouraging. Even if the financial savings and unintended pregnancy rate impact is less than suggested in Oregon, patients have shown an interest in accessing their contraception from pharmacists. Results from the Direct Access Study showed that 98% of patients who received contraceptive services from a pharmacist were satisfied and would recommend the service, 70% continued their use of oral contraceptives after one year, 60% utilized pharmacist-prescribed contraception because of convenience, and 50% did not have a primary care provider prior to the time of service.

Resources for Contraception Advocates

There are several resources to help pharmacists be better contraception advocates. Birth Control Pharmacist provides education, training, assistance with implementing pharmacist-prescribed contraception practices, clinical updates, and state specific policies. They also maintain a pharmacy directory that helps patients find direct access to a pharmacist for their contraceptive needs.

Mitchell et al. discuss opposition to pharmacist-prescribed contraception and provide information to help rebut those arguments.  One argument against pharmacist-prescribed contraception is that patients won’t utilize the service. Several studies show that patients are willing to utilize pharmacies for contraception needs due to convenience, greater time efficiency, and easier adherence. Additionally, this report also addresses patients’ desire for broader access to contraception and their willingness to utilize pharmacists for their contraceptive needs. Research has shown that 89% of patients who utilize pharmacist contraception services had a visit with their primary care provider in the previous year, suggesting that these services don’t fragment care, but ensure patients stay connected to primary care.

If you’re wanting to get back to the basics, Bedsider provides a great breakdown of birth control options that can serve as a refresher for you, and can also be shared as a resource for patients. Reproductive access also provides a contraception resource page that can be useful to both pharmacists and patients as well.  The Center for Disease Control and Prevention (CDC) provides guidance for contraceptive use. There are two resources, the United States Medical Eligibility Criteria for Contraceptive Use, 2016 (US MEC) and the United Selected Practice Recommendations for Contraceptive Use, 2016 (US SPR), both of which can be accessed for free using the CDC’s Contraception App.

A Call to Action: Realize Your Role in Contraception Access and Reproductive Justice

In states where pharmacists cannot currently provide contraception, pharmacists can contact their state legislators to educate them about contraception deserts and encourage them to introduce bills that would enable pharmacists to help increase access. Birth Control Pharmacist has compiled a list of research and news articles that can help spark the conversation.

In states that authorize pharmacist prescribed contraception, increasing uptake is crucial. In California, after the first year of policy implementation, only 11% of pharmacies were offering pharmacist-prescribed contraception. Low-income communities have been particularly impacted with many not having pharmacies and low availability, showing opportunity to address equity in roll-out of pharmacist contraception services. In Oregon, uptake was greater, but less than half of pharmacists planned to prescribe contraception if allowed. Pay parity must be achieved to support scaling of pharmacist contraception services — patients need contraception to be equitable in cost regardless of the provider providing it and pharmacists need fair reimbursement for their clinical services. Oregon has been a leading state in pay parity for contraception services with Medicaid enrolling pharmacists as providers after completion of a continuing education program. Pharmacists submit claims through their provider web portal or using the CMS 1500 claim form.

As a healthcare provider, understanding the prevalence of provider bias in contraceptive care is necessary. Taking a patient-centered approach and understanding that “the best contraceptive method for an individual patient is the one that is safe and that the patient is most comfortable using” is critical to practice reproductive justice in supporting patients’ rights to make autonomous decisions. The National Council of Jewish Women has a quick primer to support pharmacists who want to increase contraception access while respecting their patients’ reproductive rights. 

Realizing the importance of advocacy early on in our careers as student pharmacists can ease the transition as new practitioners and improve our ability to be advocates for our patients. Admittedly, I turned a blind eye during my didactic career. Looking back, I wish I had been more present, more aware. We can create positive change for our patients by utilizing our voices, and now that I’ve gotten a glimpse of just how significant our collective voices can be, I wish I had jumped on the advocacy wagon sooner. Pharmacists have the opportunity to not only improve patient care, but to also advance our profession with expanded clinical roles. Why can’t it be us?

Guest Writers Profiles

Lynda Nguyen is a 4th year pharmacy student at Wingate University School of Pharmacy (WUSOP). Her passion for serving in underserved communities, and seeing the value of pharmacists in improving health outcomes in these communities, is what prompted her to apply to pharmacy school. She is the immediate past president of the WUSOP chapter of Student National Pharmaceutical Association, and was recently awarded Organization President of the Year. She plans to pursue residency upon graduation, with an interest in ambulatory care or community pharmacy. She realizes the importance of advancing the pharmacy profession, and hopes to do that by increasing her presence in the advocacy realm.

Cortney Mospan is an Associate Professor of Pharmacy at Wingate University School of Pharmacy and a Clinical Pharmacist Practitioner at Novant Health Arboretum Family & Sports Medicine. She received her PharmD from Ohio Northern University and completed a Community Care Pharmacy Practice Residency at The Ohio State University with practice sites at Uptown Pharmacy and the Ohio Pharmacists Association. Cortney was recognized as the 2018 American Pharmacists Association Good Government Pharmacist of the Year. She is currently co-chairing the Hormonal Contraception Task Force within the North Carolina Association of Pharmacists and is working to advance legislation leveraging community pharmacists to address public health disparities in North Carolina. Cortney’s research focuses on community pharmacist roles and responsibilities in contraception health access and mental health screening.

How to make Congress see the value of pharmacists!

The Pharmacy and Medically Underserved Areas Enhancement Act, or Provider Status, was introduced into Congress about a month ago and since that time we have seen a flurry of discussion about the bill. Advocates are sending letters and meeting with their members of Congress to discuss the importance of this bill for Medicare beneficiaries in underserved areas across the country. Although we are seeing progress with 32 cosponsors on the House and Senate bill combined, there is still a lot of work that needs to be done before this bill will pass. Despite many being excited for this bill, nothing in the bill text has changed since its introduction in the 115th Congress and we expect that the primary opposition to the bill will remain that the cost is too high. This week, we break down why Congress thinks services pharmacists provide are so expensive and how we can prove them wrong.

The Congressional Budget Office

So, you may be asking yourself, “How does Congress determine how expensive a bill is going to be?” There is an entire office dedicated to just this, referred to as the Congressional Budget Office (CBO). The job of the CBO is to score a bill or determine its cost to the federal government should the bill become law. Usually, this cost estimate is for a five to ten year time frame. All bills introduced into Congress ideally would receive a score, however, due to the thousands of bills introduced into each session, the CBO is not able to score all bills and must prioritize which bills will be scored. If a bill does not receive an official score, sometimes the CBO will share an unofficial estimate of the cost of a bill with bill advocates and sponsors to give them an idea of the estimated cost of the legislation but is not officially or publicly reported. However, all bills that are signed into law must receive a score from the CBO.

The CBO has faced criticism for scoring bills too high because their analysis does not factor in for the potential of cost savings. An example of this came from a study from The Commonwealth Fund which found that the CBO underestimated cost savings that would come from healthcare reform. The CBO has never officially scored The Pharmacy and Medically Underserved Areas Enhancement Act, however, they have provided unofficial estimates in past sessions indicating that the bill was expected to be very expensive. The concern around this cost has been one of the primary points of opposition the profession of pharmacy has faced when trying to move this bill forward. Given the criticism of the CBO, this high price tag is likely inflated because they are not factoring in the potential for long-term cost savings associated with pharmacist provided care.

Conflicting evidence on the value of pharmacists

If someone was to only look at the cost implications (and not cost savings) associated with pharmacist’s services, the idea of adding another provider group to Medicare could sound very expensive and like a bad idea. Let’s do an experiment to showcase this. Let’s pretend that provider status passes, but participation in the pharmacy profession is low and only 5% of pharmacists are billing for services. Let’s pretend that patient interest is also low and these pharmacists are only seeing 3 patients a week, a very simple patient (billed as a 99211), a slightly more complex patient (billed as a 99212), and a more complex patient (billed as a 99213). Only 5% of pharmacists only seeing 3 patients a week billed at 85% of the Medicare physician fee schedule can’t cost the government that much…right? Well, our little experiment would cost over $122 million every year. Remember, this is assuming extremely poor pharmacist and patient participation and still it’s costing millions of dollars annually.

So, no surprise if you look at it this way, it seems like it would be incredibly expensive. But this doesn’t factor in the known cost savings associated with pharmacist provided care. There have been numerous studies that showcase the long-term cost savings that come from pharmacists being more involved in patient care. This can come from simple interventions like switching from an expensive medication to a therapeutically equivalent cheaper option or from patients having more controlled chronic conditions decreasing the incidence of future expensive complications, hospitalizations, and medications.

It seems like one of the primary points of opposition to the Pharmacy and Medically Underserved Areas Enhancement Act is the CBO estimated high cost of the bill. However, this high cost is not taking into account cost savings which may bring down the cost of the bill to a more palatable level for members of Congress. If only there was a way for pharmacists to advocate for the CBO to factor cost savings into their analysis. Well, you’re in luck, there is!

An indirect way to advocate for provider status

The Preventive Health Care Savings Act (S. 1685) was reintroduced into Congress this past week. This bipartisan supported bill would require the CBO to factor cost savings into their score of a bill if requested by certain members of Congress. InsideHealthPolicy covered the reintroduction of this bill, and that its focus is in preventive care which is known to decrease costs and should be factored into the CBO analysis. By factoring in cost savings into the CBO estimate, there is potential that this could impact the CBO score of the Pharmacy and Medically Underserved Areas Enhancement Act. This bill has been introduced in past sessions at which time the American Pharmacists Association (APhA) has supported it.

While pharmacists are directly advocating to their members of Congress for the passage of the Pharmacy and Medically Underserved Areas Enhancement Act, they should additionally consider advocating for The Preventive Health Care Savings Act. This bill has the ability to indirectly impact the primary point of opposition for pharmacist provider status and could help in the passage of provider status and future health policy bills important to pharmacists.

Your Pharmacy Advocacy Monthly Roundup – April 2021

Another month came and went (and definitely much faster than we realized!). We here at The Grassroots Pharmacist are working hard to make time move slower, but while we work on that, it’s time for another edition of our Monthly Roundup. April was a busy month for health policy, especially for pharmacy, with the introduction of H.R. 2759 – The Pharmacy and Medically Underserved Areas Enhancement Act. We cover that and everything else you need to know for the rest of this month. 

COVID-19:

What Your Patients Need to Know: The Centers for Disease Control and Prevention (CDC) Recommendations for Vaccinated Individuals

Last week, the CDC announced new guidelines for vaccinated individuals. Based on the new update, fully vaccinated people no longer need to wear a mask or adhere to social distancing in any setting, except where required by federal, state, or local laws. The CDC also has said that fully vaccinated people can refrain from testing following a known exposure to a COVID-19 positive individual, unless they are residents or employees of a correctional or detention facility. The CDC has also updated testing and traveling guidelines, so for all of the updates, check out the CDC website below. 

Read More: Interim Public Health Recommendations for Fully Vaccinated People

Johnson & Johnson’s Vaccine Journey: Where Are We Now?

After a temporary pause, the FDA has resumed the Johnson & Johnson vaccine for use in the United States. The vaccine was paused due to reports of adverse events after administration of the vaccine. These adverse events suggested an increased risk of thrombosis with thrombocytopenia syndrome (TTS) within 1-2 weeks following dose administration, specifically in adult women under the age of 50. During the temporary pause, the FDA reviewed the availability data and concluded that the vaccine’s benefits outweigh the known and potential risks. If you are administering the J&J vaccine, make sure you let your patients know that it is safe. However, women younger than 50 should still be aware of the risk of this adverse event and all patients should be informed to report any adverse events after vaccination to v-safe and the Vaccine Adverse Event Reporting System.

Read More: CDC Recommends Use of the J&J COVID-19 Vaccine

Congress:

Bill Introduction: H.R. 2759 – Pharmacy and Medically Underserved Areas Enhancement Act 

The Pharmacy and Medically Underserved Areas Enhancement Act was reintroduced in the United States House of Representatives and Senate as H.R. 2759 and S. 1362, respectively. This bill commonly referred to as national or Medicare provider status would recognize pharmacists as healthcare providers within the Social Security Act and allow for the reimbursement of their services under the Medicare Part B benefit in medically underserved areas. This reimbursement reform would align pharmacists with how other healthcare professionals, such as physicians, advanced practice registered nurses, and physician assistants bill for their cognitive services. Check out our past posts on why pharmacists need provider status, how we could achieve national provider status, and what you can do to advocate for provider status.

Read More: Pharmacy’s Top Priority: Medicare Provider Status Recognition

Bills We Are Tracking:

  • HR. 2759/S. 1362 – Pharmacy and Medically Underserved Areas Enhancement Act.
  • S. 1309 – A Home Health Emergency Access to Telehealth (HEAT) Act.

Articles We Are Reading: 

Pharmacist Reimbursement for Test and Treat – Guest Writer Parsa Famili

My interest in discussing how pharmacists should be reimbursed for performing diagnostic tests, including rapid strep, influenza, and H. pylori tests, as well as the pharmacists ability to furnish medications to appropriately treat the patient based on the test results, stems from the passion I developed for advocating for these services with our state pharmacy association in February. As members of the Texas Pharmacy Association, student pharmacists, including myself, pharmacists, and corporate leaders across the state participated in the Virtual Pharmacy Legislative Day at the State Capitol, during which we encouraged passage of a bill that would allow pharmacists to be reimbursed to “test and treat.” Specifically, the legislation would permit pharmacists who have protocols with physicians to write prescriptions for medications based on whether the patients receive a positive result from a CLIA-waived test like the Strep or flu test. As a reminder to our readers, a CLIA-waived test is a simple laboratory test that does not have as much risk of leading to a result that is not correct. Pharmacists in the state of Texas cannot prescribe medications for patients who receive a positive test result from the individual tests that the pharmacists perform on the patients. We believe that the legislation that we advocated for would prevent delays in care and allow the patients to recover faster from their symptoms while decreasing the spread of contagious diseases like strep or the flu. We also believe that the legislation would increase the patients’ access to high-quality care, reduce the amount of money the health care system has to pay for patients’ potential health complications from the diseases, and improve overall health outcomes for the patients. By allowing pharmacists to prescribe medications to patients who receive a positive result from a CLIA-waived test, we believe that the legislation would allow the patients to receive the proper treatment in a timely manner for their diseases.

An issue bigger than one state

The legislation that is being advocated for in Texas can and should be a priority for pharmacists across the United States. Right now, pharmacists in at least 16 states across the nation can perform diagnostic tests for conditions such as strep and influenza. In the states of Idaho, Illinois, Michigan, Minnesota, Montana, Nebraska, New Mexico, North Dakota, South Dakota, Tennessee, Utah, Vermont, Washington, and Wisconsin, pharmacists are permitted to prescribe medications to patients who test positive on a CLIA-waived diagnostic test pursuant to their collaborative practice agreement laws. Additionally, three states, Idaho, Kentucky, and Florida, have passed specific legislation that allows pharmacists to prescribe medications to treat strep, flu, and other non-chronic minor conditions upon receiving positive results from the diagnostic tests. Each of these states have different requirements, such as whether or not they use state-wide protocols or if it is through an agreement with a physician that these services can be provided. However, all result in the same increased access to pharmacists services and optimal care for patients. 

While it is wonderful that several states already allow pharmacists to have such authority, it is imperative that we push for legislation in the other 34 states and the District of Columbia to allow pharmacists to prescribe medications based on a positive diagnostic test result for acute and minor health conditions that a patient may have! That way, pharmacists can have even more power and direction to improve the health outcomes of patients and provide timely, accessible care to patients. In turn, pharmacists can play a vital role in minimizing the costs associated with the patients’ health conditions in the form of treatment for complications associated with untimely care and additional office or emergency room visits.

The impact of expanding access to test and treat

In the long-run, allowing pharmacists to prescribe medications to treat acute and minor conditions like the flu and strep would deepen the trust that pharmacists have with patients and other health care professionals. Pharmacists could also provide more information to patients about their medications and address any questions or concerns the patients may have. Because patients see pharmacists as approachable and non-judgmental in general, it would also be a boon in terms of providing more of a blame-free zone for the patients to discuss their health problems with regards to the minor and acute health conditions with the pharmacists. Having pharmacists integrated into this model would also provide an easy and accessible provider to follow-up with the patients to ensure appropriate treatment outcomes. Above all, pharmacists can improve the health outcomes of patients by alleviating the patients’ diseases effectively and efficiently.

Limitations to keep in mind

Some problems to keep in mind as we start to consider the idea of pharmacists providing “test and treat” services: the fact that patients generally still consider the physician as the one who primarily diagnoses their diseases, the fact that patients may not know that pharmacists can prescribe medications, and the fact that patients generally are unaware of the expanded role of a pharmacist. The end result is that the patients would feel less confident and comfortable about pharmacists prescribing medications to them. It is particularly important to consider these barriers as we continue to develop and implement these services. Going forward, it is crucial that pharmacists educate their patients about their roles in providing care and improving overall health outcomes while emphasizing that pharmacists have the expertise and training to prescribe the appropriate medications for the patients to treat their conditions. That way, patients can feel more confident and trust that the pharmacists can best manage their acute conditions in collaboration with other health care professionals.

Advocate for a positive future

The future for pharmacists in terms of prescribing medications for acute conditions like the flu or strep after obtaining results from diagnostic tests is bright. Pharmacists have the ability to shape health care for years to come if they gain the ability to conduct diagnostic tests and prescribe medications to patients based on the results of the tests. As we have seen during the pandemic, it is essential for pharmacists to be at the forefront of managing patients’ acute conditions. By doing so, the patients could avoid a trip to either their physician’s office or to the emergency department for a preventable situation. Pharmacists can already administer vaccines and conduct health screenings for other conditions like blood pressure or blood glucose checks. Pharmacists have the appropriate knowledge about medications and health conditions to make decisions that best manage the patients’ conditions. The legislation that we advocated for in Texas is just the beginning of a long road to prove to both health care professionals and patients that pharmacists can play a pivotal role in managing patients’ health instead of being health care professionals who just dispense medications.

Guest Writers Profile

Parsa Famili is currently a third-year pharmacy school student at Texas Tech. He is passionate about expanding the services that pharmacists provide to patients! Parsa was the Policy Vice-President of his APhA-ASP chapter last year. In addition to APhA-ASP, he also serves as a Pharmacy Legislative Week Representative, is a member of the Public Policy Council as a part of the Texas Pharmacy Association, and is a member of Phi Lambda Sigma. In addition to health policy, Parsa is also interested in possibly pursuing any of the following after graduation: retail pharmacy, ambulatory care, or critical care.

Provider Status Explained: What Pharmacists can do to advocate for Provider Status

Last week we got some incredibly exciting news  with the introduction of H.R. 2759 – The Pharmacy and Medically Underserved Areas Enhancement Act — into the United States (U.S.) House of Representatives. This bipartisan piece of legislation was introduced by Representatives G.K. Butterfield (D-NC) and David McKinley (R-WV). As a quick reminder, this bill would increase access to pharmacists provided care in medically underserved areas by allowing for the reimbursement of services under the Medicare Part B benefit. We have already covered on the blog why pharmacists need provider status along with how pharmacists can be recognized as healthcare providers on the federal and state level. With this legislation officially introduced, now is the time to cover what we can do to advocate for this monumental advancement in patient care.

The necessity of grassroots advocacy

For many seasoned members of the profession, the introduction of a provider status bill in Congress may cause them to roll their eyes and say, “Here we go again. Another campaign that won’t work.” We can understand that reaction, as there have been nine provider status bills introduced in Congress over the past 20 years (107th, 108th, 109th, 110th, 111th, 113th, 114th, 115th, and now the 117th Congress). Although it can be disheartening not to see the passage of a bill, it is important to recognize that this is just a part of the legislative process as the advocacy and education that happens during each campaign builds momentum.

The long-term goal is to recognize pharmacists as providers under the Medicare Part B benefit. However, we cannot lose sight of the short-term goal: to provide education on the value of pharmacist-provided care. As we have described in previous posts, educating the public is an incredibly important piece of advocacy. If we can educate more members of the public on this issue through this advocacy campaign, it would be a major success.  Ideally, this education would result in their support of our perspective on the issue and could further translate to additional advocacy efforts to elected leaders. Grassroots advocacy is in itself a form of influence. You hope that your perspective will influence your elected leaders in a way that will move them to active support. Influence takes a long time and often requires the formation of a relationship.

Addressing opposition through action

It may be surprising to think there would be an active opposition to pharmacists being recognized as healthcare providers, but unfortunately there is. The American Medical Association (AMA) passed official policy in 2012 within their House of Delegates (HOD) opposing expanded pharmacist scope of practice and pharmacist provider status. Just to be clear, there has been no indication yet that the AMA opposes H.R. 2759. However, as the AMA is a membership organization and the membership passed policy in their HOD, there should be no expectation that they would change their lobbying efforts without similar action in the HOD or action from their Board of Trustees. 

The AMA is definitely unrivaled when it comes to lobbying power. As you can see from the data pulled below from OpenSecrets.org, the pharmacy profession’s political action committees (PAC) and lobbying expenditures are significantly lower than many medical associations. Before you panic and think there is no possible way to overcome all that political leverage, know that your voice as a constituent is more powerful than that of a lobbyist. In fact, research from the Congressional Management Foundation has proven exactly that. But it is important to note that you have to use your voice in order to tap into that power. If you want examples of bills the AMA lobbied against but were eventually passed, look no further than Medicare, Medicaid, and the Affordable Care Act. This number goes even higher when you consider the numerous types of regulations that executive agencies have issued over objection letters from the AMA. Although it took a long time for these bills to pass, it is important to recognize that opposition is no reason to remain quiet. It may actually be more of a reason to speak up!

In addition to the importance of grassroots advocacy and connecting with your elected leaders is the importance of joining and regularly contributing to professional associations. Of course, before making a contribution to any PAC, it is important to research the PAC. We recommend reading their most recent annual report and ensuring that their donations align with your expectations prior to becoming a contributor.

Communicating with your elected leader

We have covered in previous blog posts different ways to connect with your elected leader depending on the amount of time you have to invest, from 60 seconds to an hour. A great resource to utilize is the Action Center provided by the American Pharmacists Association. By entering in your contact information, you can quickly find your Congressional representatives and will be provided with a template letter. Now, the next step is incredibly important. Instead of just pressing send, take a few moments to personalize the letter. Research has shown that standardized form letters are a less effective method to influence legislators, but taking a few moments to share a personal story and why this bill is important to you and your patients will go an incredibly long way.

Connect to elected leaders’ constituency

As elected leaders in a representative democracy, our members of Congress have an inherent self-interest to support legislation that can directly improve the lives of those constituents who live in their district. Therefore, when advocating for an issue, it is vital to connect the impact of whatever you are advocating for to the constituency of the elected leader. Don’t make promises that constituents will vote for them if they support a piece of legislation (AKA quid pro quo), but help elected leaders make the connection that a piece of legislation will benefit their constituents.

The Pharmacy and Medically Underserved Areas Enhancement Act would directly increase access to care for Medicare beneficiaries in medically underserved areas. For the purpose of this blog post, we don’t need to get into too much detail around underserved areas. But you should know they are designated by the Federal government, there are different types, and they are areas that don’t have enough medical professionals to support the population. Therefore, an easy connection you could make for an elected leader is that the Pharmacy and Medically Underserved Areas Enhancement Act would increase access to care for their constituents specifically in these needed areas.  

If you look across the continental U.S., you can see that a significant majority of the country is designated as underserved. We created the map below which shows these underserved areas in purple.

Let’s take a closer look at a case example of Ohio. In the below map, underserved areas are designated as a shade of blue, with darker shades of blue depicting that an area has been designated as several different types of a medically underserved area. We overlaid this over a map of Ohio’s 16 Congressional Districts which have been labeled with their respective number. As you can see, there are underserved areas in every member’s district, but some members have more underserved areas than others. For example, Representative Steve Chabot from District 1 has nearly no medically underserved areas in his district as compared to Representative Steve Stivers from District 15, whose almost entire district is an underserved area.

Helping your elected leaders to see how this legislation directly connects back to their district is vital. Follow these links to search for medically underserved areas and health professional shortage areas in your home state.

Advocate smarter, not harder

Given the bill’s focus on pharmacy, it is no surprise that the majority of our profession supports this legislation. However, it is important for our members of Congress to hear our support from us. But, if you only have minimal capacity to advocate for this important bill, consider the impact individuals outside the profession of pharmacy could have. Physician or nursing colleagues,  and even patients, can provide an incredibly effective voice in supporting this bill. Support of physicians can especially help to showcase that the potential opposition of the AMA is not truly representative of the physician community. So many pharmacists have incredible partnerships with other members of the healthcare team and with their patients. It is important to help members of Congress see that the passage of this legislation is not only important to members of the profession of pharmacy, but also to other members of the healthcare team and to our patients.

The focus is the patient

One of the reasons we started this blog is because we have seen a lot of misinformation shared on social media regarding health policy issues that impact pharmacists. We have seen a lot of posts similar to the one below that implies that provider status will dramatically increase pharmacists’ salaries.

The impact of provider status on the pharmacist salary likely deserves its own blog post, but regardless, this should not be the motivation for passing this legislation. The Pharmacy and Medically Underserved Areas Enhancement Act would increase access and efficiency of healthcare. We advocate for this bill because it could help patients. End of reason to care about an issue. Period.

How to track advancements of provider status

If you are interested in staying up to date on this legislation, there are several options for you. Of course, we encourage you to follow the blog as we will keep providing updates as they happen. Joining professional associations will also allow you the opportunity to stay informed on this bill. Another way is to track the legislation yourself and sign up for alerts on Congress.gov.

Now is our time to act as advocates for increased access to pharmacist-provided care. There have been decades of efforts providing education to members of Congress on the role and value of the pharmacist. We can build upon that education to reach for the ultimate success of the pharmacist recognized as a provider under the Medicare Part B benefit. Grassroots advocacy never stops, and the future for patient care holds so much opportunity.

We The People: Voter Suppression and Its Effect on Pharmacy & Health

Civic participation, including voting in local, state, and federal elections, ensures that all people can advocate for issues that concern them, including education, transportation, and of course, health. The impact of an individual’s right to vote is enormous. Voting specifically allows all American citizens the right to choose who will serve them as local and national leaders and in numerous ballot measures. Ballot measures and the subsequent decisions of those elected leaders can have short-term and long-term implications to the practice of pharmacy and access to health care for individuals living in the United States. 

Fifty-six years ago the Voting Rights Act was signed into law by President Lyndon B. Johnson, which was enacted to remove barriers to political participation by racial and ethnic minorities and prohibit any practice that denies the right to vote on account of race. However, in 2013, the Supreme Court case Shelby v. Holder invalidates Section 5 of the Voting Rights Act, which required that counties with a history of discriminatory voting practices obtain congressional approval before making any changes to election policies. Since then, numerous laws have been passed that prohibit many individuals from being able to participate in this fundamental right. 

In addition to not reflecting the voices of all of the people, voter suppression can have a significant effect on the health and well-being of those who are silenced. Not only does this impact the over 114,000 pharmacists who are racial minorities, but more importantly it can impact millions of our patients. As healthcare providers, it is important we understand the different elements that influence health and advocate on behalf of our colleagues and patients to ensure overall health and well-being – including opposing the silencing of our community members through voter suppression. 

Voter Suppression Efforts

Democracy is described as having four basic elements: a political system for choosing and replacing the government through free and fair elections; the active participation of all people in politics and civic life; protection of the human rights of all citizens; and a rule of law, in which the laws and procedures apply equally to all citizens. Therefore, voter suppression of one or more specific groups of people compromises our democracy. 

There are several efforts being made to suppress voting, primarily for minority groups. Voter registration restrictions, including requiring specific identification to register or limiting the times during which individuals can register, may influence voter participation. Voter ID laws create significant barriers, especially in the states that have strict photo ID laws, with over 21 million United States citizens not owning a government-issued photo identification and as many as 13 million citizens not having ready access to the documents required to obtain an ID. Additionally, the cost to obtain an ID or the documents required to obtain an ID leads to additional burden on low-income communities. You can learn more about your state’s voter ID laws here. 

More significantly, states have been found to wrongfully purge eligible voters from the voting rolls. Voter purges are often conducted to remove voters who have changed addresses or died. However, if not done appropriately, these purges can prevent eligible voters from being able to cast their ballot. A NYU Brennan Center for Justice report describes error rates in voter purges as high as 17%. Other forms of voter suppression include the various rules for convicted felons in each state, as well as gerrymandering, AKA redistricting states to manipulate the results of an election. This often favors one political party and therefore dilutes the power of the voice and confidence in the vote of the minority group.

Voter Suppression and the Relationship to Health

In “The Right to Vote, the Right to Health: Voter Suppression as a Determinant of Racial Health Disparities”, Anna Hing outlines the various ways in which voter suppression harms health and well-being. Several of these pathways are listed below:

1.     Voter suppression creates group-level exclusion. This exclusion primarily reduces voter turnout for racial minorities. Silencing of various groups may result in passing of policies that influence known determinants of health, such as who receives public assistance, how schools are funded, public transportation, and zoning of neighborhoods. 

2.     Disenfranchisement influences an individual’s social position in society. Disenfranchisement can lead to individuals experiencing loss of control and disempowerment, which not only has a direct impact on well-being, but also can lead to less resources to defend against increased discrimination and subsequent stress.

3.     Voter suppression may take place through psychosocial processes which influence health. These psychosocial processes, such as more commonly checking identification for voters of color than for White voters, may lead to consequential effects of discrimination and psychosocial distress. Additionally, negative coping behaviors to overcome this distress, such as substance use, may adversely affect health. 

4.     Voter suppression may manifest as physical violence, hate crimes, or secondary direct effects on health. If a voter has to wait in line in extreme heat for many hours because other poll sites have been closed, they may be at higher risk for adverse events, such as asthma and COPD exacerbations, or hyperthermia. 

5.     Health disparities reinforce voting disparities. Those who are ill are less likely to vote. For example, premature death of African Americans translated into one million Black votes lost in the 2004 Presidential Election.  

6.     Simply put, voter suppression determines who can and cannot vote. This can create stigma for those who cannot vote, which has been associated with internalized racism and subsequently increased metabolic risk, cortisol secretion, and mental health illnesses, including depression. 

Many, including The Grassroots Pharmacist team, argue that health is influenced by many policies, outside of those that have a traditional direct tie to health (for example, access to housing and environmental policies). Although the relationship between voter suppression and health is not proven, evidence shows strong associations and as noted above, it is clear how voter suppression can exacerbate racial health disparities and vice versa. One of the overarching goals of Healthy People 2030 is to eliminate health disparities and achieve health equity. The report states “Achieving health equity requires valuing everyone equally with focused and ongoing societal efforts to address avoidable inequalities, historical and contemporary injustices, and the elimination of health and health care disparities.” As such, eliminating barriers to vote and allowing all people to become involved in civic engagement is essential to ensuring health of our communities in the coming years. 

A Call to Action: Ensuring All Voices are Heard

This is a critical time for us to advocate for the removal of barriers to voter accessibility and encourage our legislators to pass laws that protect all individual’s rights to vote. The For The People Act of 2021, which passed in the House of Representatives and was introduced in the Senate in March 2021, expands voter registration, including online, automatic, and same-day registration, and voting access, by allowing for vote-by-mail and early voting. Additionally, it limits removing voters from voter rolls and requires states to establish independent redistricting commissions to carry out congressional redistricting. This bill also addresses election security, campaign finance, and ethics in all three branches of government. The John R. Lewis Voting Rights Act, which was originally passed in the 116th House of Representatives but made no progress in the Senate, is also expected to be reintroduced during this Congress. This Act would restore the components of the Voting Rights Act which were invalidated in the Supreme Court Shelby vs. Holder case, thereby requiring pre-approval from the Department of Justice or the US District Court before making legal changes that would affect voting rights. 

As healthcare providers, it is our duty to advocate in the best interest of the health and well-being of all of our patients. We the people means all the people, and voting should remain a fundamental right, not a privilege, for all of the people.

What Pharmacist Advocates Need to Know – March 2021

Another month has gone by, which means it’s time for an edition of the Monthly Roundup. This has been an incredibly busy month in health policy, and we have done our best to compile the highlights for you. From a new COVID-19 relief bill to the approval of a new vaccine, there is a lot changing that’s important for pharmacists to understand.

And with that, here is what you need to know from March 2021

COVID-19

The American Rescue Plan Act

On March 12, 2021, President Biden signed the American Rescue Plan (ARP), the first signature piece of legislation of his presidency. The $1.9 trillion package provides significant relief to individuals and businesses to help combat the COVID-19 pandemic and subsequent economic crisis. While most people may be more familiar with provision providing $1,400 stimulus checks, the ARP will have enormous effects on the U.S. healthcare system and is set to be the single largest expansion of health care coverage since the passage of the Affordable Care Act (ACA). A summary of health care provisions are included below: 

  • Funding to set up a national vaccination program in order to reach communities across the country as quickly as possible, including communities of color and rural areas 
  • Funding for disease surveillance, including testing, contact tracing, PPE, and genomic sequencing
  • Investments in the health care workforce, including funding for public health workers, community health centers, and mental health providers 
  • Providing 100 percent subsidies for COBRA coverage for people who have lost their jobs or who have seen their hours reduced 
  • Increased funding for Medicaid expansion incentives and for ACA Marketplaces
  • Expanded subsidies for ACA Marketplace insurance plans and elimination of the 400 percent subsidy cliff, which will drastically expand affordable coverage for millions of people

Read More: Impact of Key Provisions of the American Rescue Plan Act of 2021 COVID-19 Relief on Marketplace Premiums

Approval of the Johnson & Johnson Vaccine

At the end of February, the Food and Drug Administration (FDA) voted to issue an Emergency Use Authorization (EUA) to the Johnson & Johnson vaccine. This vaccine is a single-shot vaccine and is largely seen as a cost-effective alternative to the Pfizer and Moderna vaccines. It does not have some of the same storage challenges that the Pfizer and Moderna vaccines have, and therefore can easily be used in more rural communities. In preventing serious disease, the Johnson & Johnson vaccine is just as effective as the Pfizer and Moderna vaccines. 

Read More: Got Questions About Johnson & Johnson’s COVID-19 Vaccine? We Have Answers

New Guidelines for Vaccinated Individuals 

On March 8, the Centers for Disease Control and Prevention (CDC) issued the first set of public health recommendations for fully vaccinated people. According to the guidance, fully vaccinated people can now visit each other without wearing masks or social distancing. They can also visit with unvaccinated people from a single household, if they are at low risk of getting severe disease. The CDC has also said that fully vaccinated individuals no longer need to quarantine if they come in contact with someone who has tested positive for COVID-19 and are not symptomatic.

Read More: Interim Public Health Recommendations for Fully Vaccinated People

Increased Medicare Payment for COVID-19 Vaccine

On March 15, Andy Slavitt, a senior advisor for the federal COVID-19 response, said that the Medicare reimbursement rate for vaccines would be nearly doubled. Prior to the announcement, the Medicare reimbursement rate was about $23. Now the reimbursement rate is $40 per shot, giving providers $80 for a two dose regimen. This change was done as a result of a provision in the American Rescue Plan, requiring no out-of-pocket costs for beneficiaries. The move is likely to make it easier for providers to go into communities to provide vaccinations, and will improve access for the elderly and low-income communities. 

Read More: Biden-Harris Administration Increases Medicare Payment for Life-Saving COVID-19 Vaccine

The White House 

Senate Confirmation of Key individuals to Lead the Department of Health and Human Services 

This past month, the Senate also confirmed three individuals who will lead massive health care initiatives at the Department of Health and Human Services (HHS). The Senate voted  to confirm Xavier Becerra as the Secretary of HHS. The Senate also voted afterwards to confirm Dr. Vivek Murthy to his previous role as Surgeon General under the Obama Administration, and Rachel Levine as Assistant Secretary of Health, making her the first trangender individual approved by the U.S. Senate. These individuals have an incredible challenge ahead as they try to navigate the country out of the pandemic and tackle the rest of President Biden’s health care agenda. 

Read More: 2 More HHS picks hit the Hill

Access to Health Care for Newly Arriving Immigrants

As there often is around presidential administration changes, there has been a recent dramatic increase in the number of migrants seeking to enter the U.S. During times of processing, migrants may be held in immigration detention centers. We have previously written about how there has been limited access to healthcare in these detention centers and even reports of inappropriate care being provided. Due to the large number of migrants currently at the U.S.-Mexico Border there has been reports of children being held in detention centers longer than legally allowed. There have not been recent reports of limits to health care access or inappropriate administration of care in detention centers, however, there is risk that without widespread structural changes to the immigration detention center system that issues have remained. 

Read More: On Mexico’s Border With U.S., Desperation as Migrant Traffic Piles Up

Here’s what else you need to know: 

Legislation We Are Tracking: 

Articles/Papers We Are Reading:

Advocating for the mental health of pharmacists and their patients – Guest Writer Amy Reese

Mental health concerns are a lurking crisis in America that have only been increased by the COVID-19 pandemic. According to the Centers for Disease Control and Prevention (CDC), 19% of adults in the United States struggled with a mental illness as of 2018. As of 2019, of the 19.2% of adults who received treatment for a mental illness 15.8% of them received a prescription. Compliance for psychiatric medications are known to be dismally low ranging around 50% of adherence for depression, 50-60% for schizophrenia, and 35% for bipolar affective disorder. The COVID pandemic has brought difficult times on many people: mental health concerns have escalated since the beginning of this unprecedented time.  Since the COVID-19 pandemic, 40% of adults reported increased conditions associated with mental health issues. We are living in extraordinary times which have greatly impacted people’s mental well-being and this elevated mental health crisis since the COVID-19 pandemic has increased the number of prescriptions for mental illness. 

A community pharmacists experience

As a community pharmacist, I see how pervasive mental health concerns are. Mental health does not only involve the patients who pick up prescriptions for SSRIs or antipsychotics, but it also has to do with the patients who have diabetes and the patients with osteoarthritis. Mental health issues do not only affect the psychiatric patient who picks up her risperidone and divalproex every month. It can also mean the patient with diabetes who gets too depressed from her life situation and doesn’t take her insulin or the patient with hypertension who struggles with anxiety, leading to difficulties taking his lisinopril regularly.

During this pandemic, many people have struggled with isolation and loneliness; some of these people turn to the pharmacist for an ear to hear their worries and sorrows. Community pharmacists are the most accessible healthcare provider available to serve the community. Many patients have opened up to me about their anxiety, their hopelessness, and their sadness. I have seen an uptick in prescriptions for anxiety since the pandemic. I know many other pharmacists have seen this burgeoning of prescriptions for anxiety medications. Personally, I have noticed more younger females receiving medications due to their struggle with anxiety than other groups but that may just be because of the population I serve. When counseling on a new prescription for anxiety, I talk to my patients about breathing exercises, walking outside to ease anxiety, and the importance of therapy in conjunction to medication such as Cognitive Behavioral Therapy (CBT). When I counsel on a new antidepressant, I ingrain the importance of taking the medication every day to ensure the medication is effective; I discuss self-care and the importance of therapy also. My goal is to convey a message that there is no stigma of mental illness when they talk to me. 

I want to address the deeper issues of mental health during a counseling session and be able to have resources to refer patients. As a pharmacist, I am not able to do everything the patient needs but I want to be the first line of defense for hope and resources as the most accessible healthcare provider. People need connection, especially during this unprecedented time. Pharmacists have truly showed up fully to this national crisis, but we can do more to serve our patients. 

The role of community pharmacists

Community Pharmacists ought to be trained to deal with mental health issues in all types of patients deeper than just counseling a patient on his/her/their medication or making pharmacotherapeutic recommendations. We may not be therapists, but we need to be able to know how to navigate the key issues of mental health conditions. I have the ability to talk to patients about some mental health concerns such as anxiety and depression from seeing friends and family struggle with these burdens, but I lack the training to make a deeper connection with these patients. Making connections with patients in a deep meaningful manner can enhance their lives significantly. David Woods Bartley gave a TEDx Talk about how connection saved his life. He opened up about how clinical depression had taken a hold of him and convinced him to commit suicide. He was on a bridge about to jump to his death when an EMT made a connection with him which gave him hope. Mr. Woods Bartley stresses how connection gives each one of us hope and how hope saves lives. How many times do you think a pharmacist has saved a life of a patient through connecting with that person? We cannot always tell who suffers from clinical depression; it could even be the happy nationally-recognized achiever such as David Woods Bartley. Martin Rubin, MD, a psychiatrist at Kaiser Permanente in Sacramento, California recently gave a talk about the mental health crisis in this country. He stated that pharmacists are in a unique position to connect with patients: pharmacists know what ailments the patients has due to their medication indications and pharmacists may be the only human interaction that a patient has in a day.

In creating deeper connections with patients, pharmacists should also have the knowledge of resources to refer patients. Pharmacists can refer patients to organizations such as National Alliance for Mental Illness (NAMI) which connects people who are working to overcome mental illness to support groups and social workers who can better address each individual’s needs. NAMI has a hotline to talk to a person; the organization developed a hotline specifically for COVID-related mental illness because they realized the pandemic has been difficult for many people. One branch of NAMI is partnering with its local police department to connect all the patients who are held under an involuntary psychiatric hospitalization have resources to cope with their illness when they are released. If NAMI could be a resource for pharmacists as it is to police departments, maybe we can alleviate some of the mental health crisis occurring in this country one person at a time.

Advocating for change

Despite pharmacists’ obvious role in providing mental health services, there are barriers that limit patient access to these services. The most obvious of these barriers include restrictive state scope of practice laws that limit patient access to services provided by the pharmacist and lack of an ability to directly bill for the services provided (provider status). The latter disincentives the businesses pharmacists work for to allow them the time they need to provide these mental health services. Advocating for expanded scope of practice for pharmacists and provider status can be effective ways to increase access to these mental health services.  

In addition to increasing the prevalence of pharmacists in providing mental health services to our patients, it is imperative that mental health considerations for members of the profession be prioritized as well. Studies have shown that pharmacists experience a high degree of burnout, over 50% in health-systems and nearly 75% in community pharmacies! This high rate of burnout could contribute to higher rates of suicide and rates of substance use disorder within the profession. This is an unsustainable issue and needs to be addressed in order to ensure both pharmacist and patient safety. National pharmacy associations have taken up the cause of advocating for the mental health of pharmacists but more help is needed. In addition to advocating for policy changes to address the underlying system that contributes to these mental health effects, advocating within organizations can be effective to raise concerns about both employee and patient safety.

The pharmacist has a definite role in providing mental health services to our patients. By advocating for policy to expand these efforts, our patients can receive greater access to the care we provide while we fight for a system that appropriately cares for the practitioners wellbeing as well.

Guest writer profile

Amy Reese currently works as a community pharmacist at Wal-Mart Pharmacy in Southern California and a mass COVID vaccination clinic at Loma Linda University. She graduated from Loma Linda University School of Pharmacy in 2019. She completed a Masters degree in Bioethics through Loma Linda University School of Religion while she was in pharmacy school and graduated with her MBe in 2018. After pharmacy school, she went on to do a fellowship at Sherwin B. Nuland Summer Institute in Bioethics at Yale Interdisciplinary Center for Bioethics, Yale University. Dr. Reese started working in community pharmacy in 2019 and is passionate about the intersection of bioethics and pharmacy practice.

Monthly Roundup – February 2021

It is hard to believe, but we at The Grassroots Pharmacist have been putting out content and resources for nearly a year. During the first year of the pandemic, we saw such dramatic health policy changes happening so frequently that it warranted continual blog posts on all that was changing. As we look forward, and less frequent health policy changes occur, we wanted to identify a more sustainable way to inform and empower pharmacists to be involved in grassroots advocacy efforts. That is why we will be publishing a monthly roundup of legislative and regulatory updates relevant to pharmacists moving forward. Many of the topics discussed on these monthly roundups should not only be viewed as us sharing information with our readers, but as calls to action to increase civic engagement and discourse on issues that directly and indirectly relate to pharmacists and the communities we serve. There is so much room for improvement in the healthcare system, and active civic engagement is necessary to ensure advancements in the delivery of quality, equitable, and accessible healthcare.

So with that, let’s get started. There is no time like the present to advocate for the change we hope to see in the world.

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There has been a lot of action in the new Congress with the reintroduction of bills that died at the conclusion of the last Congress and discussions on the next COVID package. Here are a few of the top bills we are tracking:

American Rescue Plan 

Of course, much of the focus of Congress and the new administration has been on President Biden’s American Rescue Plan. This $1.9 trillion stimulus package is planned to move forward in the coming weeks utilizing the budget reconciliation process in order for Democrats to pass the law without any Republican support. Key provisions of this bill that are relevant to pharmacists include:

  • The creation of a national vaccination program that would include the creation of community vaccination sites nationwide. Pharmacists have already been tapped by the administration in expanding COVID vaccine efforts, and would likely be a key piece of this national vaccination program
  • Increasing equitable access to the COVID vaccine by ensuring access to those in underserved communities
  • Expand access for employers of frontline workers to Occupational Safety and Health Administration (OSHA) grants to ensure workers are protected from unsafe working conditions
  • Expand the subsidization of COBRA health benefits through September for those that lost employment and thus health coverage during the pandemic

S. 298: Pharmacy Benefit Manager Accountability Study Act

Introduced by Senator Blackburn (R-TN), this bill would require the Government Accountability Office to study the role of pharmacy benefit managers (PBMs) in the drug supply chain and submit a report to Congress. This bill was introduced in the last Congress (S. 1532/H.R. 3223), though it did not make any progress and gained minimal cosponsors. If the language of S. 298 is consistent with the last version of the bill, the report that would be submitted to Congress would include 1) the state of competition in the PBM industry, 2) the use of rebates/fees by PBMs and who the rebates benefit (patients, payors, or PBMs), 3) if PBMs structure formularies to prioritize high-rebate drugs over lower-rebate drugs, 4) average prior authorization time, 5) analysis of step therapy, and 6) the extent of spread pricing.

The bill has been referred to the Senate Health, Education, Labor, and Pensions (HELP) Committee, which is chaired by Senator Patty Murray (D-WA). Although Senator Murray has supported legislation in the past that looked to reign in PBMs, S. 298 is currently only supported by Republicans, giving it a low likelihood of being prioritized for a committee hearing. If the profession of pharmacy would like such a bill to advance, grassroots efforts should be focused on drumming up bipartisan support for the bill, especially for constituents whose members serve on the Senate HELP Committee.

H.R. 153: Protecting Consumer Access to Generic Drugs Act

Introduced by Representative Bobby Rush (D-IL-1), this bill would prohibit brand name drug manufacturers from paying generic drug manufacturers to delay bringing generic drugs to market. This is one of those bills that leaves you scratching your head and thinking, “Wow…we need a bill for this? This isn’t already illegal?” Well, unfortunately it’s not, and the Federal Trade Commission estimates it’s resulting in $3.5 billion in higher drug costs per year. H.R. 153 would prohibit drug manufacturers from agreeing not to compete with each other in what is referred to as “pay-for-delay.” Banning these anticompetitive deals would benefit patients by ensuring that they have greater access to generic medications.

Versions of this bill have been introduced since 2007. The current bill has been referred to the House Energy and Commerce Committee and the Judiciary Committee. It has gained 15 cosponsors so far, and according to GovTrack and Skopos Labs has a 46% chance of being enacted, which is one of highest rated probabilities of any health-related bill in Congress right now. However, a companion bill has not yet been introduced into the Senate, which means there are still many steps ahead for this bill if it has any hopes of passing into law. 

H.R. 280: PDMPs Help Patients Act of 2021

Introduced by Representative David McKinley (R-WV-1), this bill would create a pilot program in five states to integrate a substance use disorder (SUD) and behavioral health treatment locator tool into their prescription drug monitoring programs (PDMP). This tool could then be utilized by health care providers if they suspect misuse or abuse to refer patients for treatment or an assessment. The language of this bill does not specify which health care providers this would apply to. However, with more than half of states requiring pharmacists to register with their PDMP, it would not be surprising if additional expectations may be placed on the pharmacist as a result of H.R. 280. Assuming the implementation of such a policy is done in a way that does not result in significant more burden on the pharmacist, the profession would be in a key and accessible position to provide counseling to patients for SUD assessment and treatment.

This bill does have bipartisan support, but has gained minimal cosponsors and may not make much progress in the current Congress. 

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Things have slowed down a bit on the regulatory side as the new administration works to get its legs under itself. Below are some of the big updates over this past month:

Chiquita Brooks-LaSure to be nominated CMS Administrator

A past Obama Administration official, Ms. Brooks-LaSure brings with her decades of experiences including roles in the Centers for Medicare and Medicaid Services (CMS) and the U.S. Department of Health & Human Services (HHS). She previously played a large role in the crafting and implementation of the Affordable Care Act (ACA). Ms. Brooks-LaSure has not spoken publicly in the past regarding pharmacy/pharmacist policy, so it is too early to say where she will align herself on some of the policy priorities of pharmacists. Given her past work on the ACA and the resulting increase in access to healthcare for millions across the country, one could make the argument that she could be supportive of further leveraging health care professionals, such as pharmacists, to further increase access to care.

Delays in effective dates of regulations

A normal course of action for new presidential administrations is to place a regulatory freeze on the work that agencies were completing under the direction of the past administration. There are two regulations that have been delayed in being implemented that are relevant to pharmacists. The first is a program that would have required the use of an electronic prior authorization program for Medicare Part-D covered medications. This rule was set to go into effect on February 1, 2021, but has been delayed to March 30, 2021 in order for the new administration to further review the rule.

The second rule is related to pharmaceutical rebates, point-of-sale of medications reductions, and PBM fees. This rule makes three changes under safe harbor regulations within the anti-kickback statute in the Social Security Act. First, protections will be removed that allow PBMs to reduce the price of medications in connection with the sale or purchase of the medication from manufacturers or plan sponsors under Medicare Part D. Second, protections are set in place for certain point-of-sale reductions in prices. And finally, new protections were added for fixed fees that manufacturers pay to PBMs for the services they provide. This rule has been delayed until March 22, 2021, but may be delayed further due to pending litigation from the Pharmaceutical Care Management Association.

Now is the time to take action

Civic engagement should not be limited to voting at the ballot box. Engaging in grassroots advocacy can happen throughout the year and as legislation and regulation advance. As healthcare professionals, our viewpoints and passion for our communities are important perspectives to our elected leaders. Take this moment to reach out to your elected leaders regarding the issues above, or any issue you are passionate about. Our collective voice and vision for a better healthcare system is exactly what needs to be shared during these times of great potential.