Senate introduces bill to expand pharmacists’ ability to provide telehealth services

On August 4th, U.S. Senators Chris Murphy (D-CT) and Roy Blunt (R-MO) introduced Senate Bill 4421: the Temporary Reciprocity to Ensure Access to Treatment (TREAT) Act. As stated by Murphy’s and Blunt’s press releases, this bill “allows any health care practitioner or professional in good standing with a valid practitioners’ license to render services—including telehealth—anywhere for the duration of the COVID-19 pandemic.” This is the latest example of how the pandemic is going to have lasting permanent changes to the U.S. healthcare system.

Where is the current gap in care?

Prior to the pandemic, the provision of telehealth services across the healthcare continuum was limited. This was likely a result of telehealth services being reimbursed lower than the same service provided face-to-face as well as confusing rules and regulations. Some large medical centers had begun to support expansion of telehealth programs, however, there remained gaps in optimizing the use of telehealth. A big gap was in the rules and regulations that limited access to telehealth services, such as the fact that providers must be licensed in every state a patient is receiving telehealth services in, regardless of where that provider is practicing from.

Then the pandemic hit and we saw our healthcare system upended as we began to prepare for potential surges and spikes in cases. In the first months, primary care offices were unable to practice in the way that they always had. They were canceling appointments and patients did the same out of fear of risking themselves to an exposure. 98% of primary care offices saw a decrease in revenue and there was concern that many would close, further limiting access to care, especially for those that live in rural or medically underserved communities. 

Recognizing the potential long-term negative therapeutic consequences as a result of lapses in care, which could have further economic ramifications, CMS passed emergency rules and waivers to better compensate providers for telehealth services. This resulted in a boom in the utilization of telehealth by patients across the country. Some larger practices reported that their weekly percentage of telehealth visits before and during the pandemic went from 0% to 8.2%. Experts have predicted that telehealth will remain a more substantial piece of the healthcare marketplace in a post-COVID world. We have already begun to see this becoming a reality with the signing of executive orders and proposed rules from CMS to make expansions allowed during the public health emergency (PHE) permanent (read more about these expansions and how they apply to pharmacists here).

Despite these expansions, there remain issues with the provision of telehealth services. One of the biggest issues identified is that it matters where the patient and professionals are physically located when providing services. 

How will this bill fill this gap?

The TREAT Act does a few things that are notable and need to be discussed. Of course, the biggest is that it will allow for healthcare professionals to provide telehealth services to any patient as long as both of them are physically in the U.S. It specifically clarified that services can be provided regardless of if there is a prior relationship between the patient and the healthcare professional. 

From the perspective that this will be able to increase access to care, there are a lot of positives to this bill. Instead of being limited to your geographical area, healthcare professionals would have the ability to provide care to patients across the country. This would be incredibly important, especially for those that live in rural or medically underserved areas that previously may have had to travel a long distance to receive healthcare and may have been limited to utilizing telehealth services only if there was a previously established relationship. 

Another huge positive to this bill is not in what the bill does but in how the bill is written. Any health policy geek out there knows that when bills are typically written regarding what healthcare professionals can do, the term “healthcare professional” is often defined as referring back to the Social Security Act. We have already discussed that national provider status efforts essentially aim to add the pharmacist to this list of healthcare providers. What is different about the TREAT Act is that healthcare professional is broadly defined as an individual who “has a valid and unrestricted license or certification from, or is otherwise authorized by, a State, the District of Columbia, or a territory or possession of the United States, for any health profession, including mental health”. The all-encompassing language of how “healthcare professional” is defined means that this bill applies to pharmacists as well!

Where does this bill miss the mark?

Although there are positives to this bill, we have some logistical questions and are concerned with what is missing from the language. Despite the positives regarding access issues, what are the long-term hopes for the types of provider-patient relationships that may result from a completely virtual care experience? Will only acute services be offered that do not require an in-person physical examination? What if labs need to be drawn? A provider in Maine caring for a patient in Texas may not be familiar with local labs and the burden of those logistics may fall on the patient. If the patient is unable to solve such questions by themselves, this could result in providers making medical decisions without all the information they need. What if a referral is needed to be placed to a specialist? Providers often utilize their professional networks with local practitioners that they have referred to previously. This may be another logistical concern. Although these are some gaps, there would be plenty of opportunities for the private sector to step in to solve these issues through a lab/specialist referral interface. Although his bill would only be applicable during the current PHE,  we have seen so many rules and laws planned to be expanded beyond the PHE and this could have the potential of doing the same if it ends up being signed into law. Long term solutions to these concerns should be addressed from the beginning of implementation. 

Where else this bill misses the mark is in how it could impact the setting in which healthcare professionals practice. If bills such as the TREAT Act pass and telehealth continues to expand, some healthcare professionals may worry that their practice setting may resemble more of a call center rather than what they are traditionally used to. Although some healthcare professionals may not prefer this setting, healthcare businesses such as SinfoniaRx have embraced this model and use it to provide patient care to thousands across the country. Some healthcare professionals may not like the idea of practicing in a call center, but we should recognize that at the end of the day, we need to do what is in the best interest of the patient. If evidence supports that it means where we practice begins to change, then we should embrace what better helps our patients, not fight it because of personal preferences.

An obvious exclusion from this bill is any discussion on payment. This is likely because payment rules and executive orders for telehealth services are already in place and will likely remain in place following the lifting of the PHE. A gap remains for healthcare professionals that are included in the TREAT Act but are not listed under the Social Security Act (such as pharmacists), and thus still will not be able to directly bill for their services.

How can you advocate for or against this bill?

The TREAT Act has been referred to the Senate Committee on Health, Education, Labor, and Pensions. Currently the bill only has two cosponsors, but given the bipartisanship of those cosponsors, it has the potential to get some attention from other Senate members. At the time of the writing of this post, no pharmacy associations had come out in support or opposition of the bill, however, many other healthcare organizations had spoken out in support of it. Below is a selected list of supporters:

You can track the progress of the bill here. Click here to identify who your elected leaders are and here for communication templates to help let your legislators know your perspective on this bill.

Also, if you feel that the profession of pharmacy should take a stance on this bill, contact the elected leaders of the associations you are members of and ask for them to review the TREAT Act.

Racial Differences in COVID-19 and the Potential for Pharmacists

At the end of July, CMS published updated data on COVID-19 impacts on the Medicare population, including details on the American Indian/Alaskan Native Medicare beneficiaries for the first time. The new data indicated that this population has the second highest rate of hospitalization for COVID-19 among racial and ethnic groups after Blacks. The updated information further confirms the disproportionate effect the pandemic is having on vulnerable populations.  

It is not enough to note the differences, but to address why they occur. According to the CDC, there are several inequities in social determinants of health that put racial and ethnic minority groups at an increased risk of morbidity and mortality associated with COVID-19: discrimination; healthcare access and utilization; occupations; educational, income, and wealth gaps; and housing. With many Americans facing eviction and limited ongoing support for the unemployed, we will continue to see how these disparities are magnified during emergencies. 

While the press release did report that the CMS Office of Minority Health was hosting sessions to receive insight into ways in which CMS can address health disparities, no action has been taken. Regardless, it is crucial that all health care providers, including pharmacists, continue to address inequities in social determinants of health. Afterall, the first vow of the Oath of a Pharmacist is to “consider the welfare of humanity and relief of suffering my primary concern.”

In order to ensure fair access to health, specifically during the current pandemic, the CDC made recommendations for various groups, including the healthcare delivery system:

  • Ensure that chronic disease management and services to prevent illnesses are maintained and accessible
  • Increase availability and accessibility of COVID-19 testing for racial and ethnic minority populations and other populations that are disproportionately affected
  • Work with community health workers/promoters, healthcare providers, and patient navigators to connect community members with health resources
  • Increase engagement with trusted community and faith-based organizations and institutions that have relationships with local communities
  • Provide telehealth options that are tailored to the needs of patients
  • Ensure providers show awareness of and respect for culture when providing COVID-19 testing and care
  • Train employees at all levels of the organization to identify and interrupt all forms of discrimination; provide them with training in implicit bias
  • Increase language access and help adapt public health guidance to local circumstances so that health information and recommendations reach the people who need it the most

Pharmacists role in increasing access to testing

In a previous post, we discussed the gaps in testing for communities of color, namely Black and Latinx, and how pharmacists have the potential to significantly impact the rates of testing. Although pharmacists in every state can provide COVID-19 tests, unfortunately, implementation has stalled for various reasons, including access to testing kits, lack of information on where to send the kits for processing, and guidelines for reimbursement. There is enthusiasm for pharmacists to expand their role, as seen with significantly more pharmacies obtaining CLIA certificates. However, if the proper infrastructure is not in place for processing and payment, these barriers will inhibit pharmacists from being utilized as key players in improving access to testing. 

On the horizon: pharmacists to provide COVID-19 vaccines

Although a vaccine is not yet available, there is already concern that communities of color, who have historically been underrepresented in clinical trials and have deeper distrust for healthcare systems, may face greater barriers to obtaining the COVID-19 vaccination once it is available.  We do not need to tell you how important pharmacists are in increasing access to vaccinations for the general public, but the relationships pharmacists have with their patients will be even more critical to ensure widespread vaccination against COVID-19. Pharmacists may also consider partnering with other organizations in the communities, such as places of worship, to increase access to testing and vaccinations for these populations. 

Many questions still remain as vaccine development continues. Innovative models, such as pharmacy technician administration of vaccines, will need to be considered to ensure access to COVID-19 vaccines, while maintaining vaccination rates for other key illnesses, such as influenza. We suspect there will be more to come on this topic in future blogs (*insert shameless plug about subscribing to our emails here*). 

Pharmacist-led disease state management and addressing social determinants of health

Beyond testing and vaccinations, there is a significant opportunity for all pharmacists to improve chronic disease state management and provide patient-centered, prevention-based care, which incorporates recognition and addresses social determinants of health. 

Population health initiatives that target patients at highest risk for medication non-adherence or poor outcomes may be employed within local pharmacies and health-systems. Additionally, regular screenings for chronic diseases and education on the importance of preventing and appropriately managing these chronic diseases should be available within pharmacies and other easily accessible locations within our communities.

Outreach activities may include phone calls to patients with uncontrolled blood pressure or diabetes, or to patients prescribed multiple medications for a specific indication. At touch points between patients and pharmacy staff, specific questions can be asked to identify barriers to medication adherence, as well as addressing the factors that may impact a patient’s overall health and well-being. Acutely, unemployment and unstable housing may lead to limited medication and healthcare access. Although pharmacists may not be able to solve these problems directly on their own, screening tools may help identify the problems and help triage or refer patients to other resources in the community, such as Community Health Workers or mental health clinicians, for further assistance. Additional considerations, such as abbreviated public transportation schedules, may make it difficult for patients to get to the pharmacy to pick up medications. Medication synchronization programs or coordination of delivery of medications may help improve access. When applicable, pharmacists should continue to find ways to reduce pill burden and cost, and improve overall access to care. These recommendations may include optimization of medications, recommendations to improve disease control, and monitoring and health maintenance follow-up.  Pharmacists have an opportunity, or perhaps rather an obligation, to connect with their patients during this time in order to gain an understanding of their needs and help improve outcomes.

Unfortunately, policy change, including development and implementation of payment models (see our past blog post on the “why” behind provider status), are needed in order to ensure access to these pharmacist’s services for all people, especially our most vulnerable populations. Additionally, funding to support CDC and state and local public health agencies to provide public health infrastructure are crucial to combating the inequities of social determinants of health that impact many of our patients.

Pharmacist Medicare incident-to telehealth services here to stay?

It is no news that pharmacists are able to bill incident to a physician when providing patient care services. This has been widely discussed since the American Academy of Family Physicians (AAFP) requested clarification on this from CMS back in 2014. Despite this clarification, some pharmacists have still faced pushback on billing incident to the physician and there have been additional restrictions placed on the types of codes and level of service that pharmacists can bill incident to. 

An additional gap in pharmacists’ ability to bill incident to has been through the provision of telehealth services. However, with the pandemic we have seen an explosion in demand of telehealth services and quick rule changes allowing for non-physician practitioners (NPP) to bill incident to the physician through telehealth services. We saw Medicare provide further clarification around this during the pandemic detailing out that pharmacists can bill incident to for their telehealth services as well. While encouraging, these rule changes all had the provision that they would continue in effect through the public health emergency (PHE). Many pharmacists have been understandably concerned that once the PHE is lifted, they will no longer be able to bill for telehealth services, and patients will consequently lose access to care they have come to expect.

On August 3rd, President Trump signed an Executive Order (EO) that requests the Secretary of HHS to evaluate within 60 days the additional telehealth services offered for Medicare beneficiaries during the PHE, and propose a regulation to extend these measures beyond the PHE. In response to the EO, CMS specifically mentioned pharmacists being able to bill incident to a physician or other NPP as a service that it would recommend for continuation after the PHE. This is encouraging as we hope this means pharmacists will be able to continue to bill incident to for the telehealth services they are providing. CMS included similar language in its Proposed Policy, Payment, and Quality Provisions Changes to the Medicare Physician Fee Schedule for Calendar Year 2021 as well, providing further confidence of the center’s prioritization of this in future plans. 

Although encouraging, we have discussed the need by our patients for pharmacists to directly bill for our services through recognition as healthcare providers under Medicare Part B. Billing incident to the physician and NPP with further expansion to the telehealth space is a step in the right direction, but still far off from where we need to be. There remains an opportunity to advocate for provider status language in the next COVID-19 legislative package. Check out our post here where we discuss ways you can take a few minutes to make a positive impact for patient access to care.

More will come soon as the Secretary of HHS releases their plan in the coming two months and we will likely see more health and pharmacy policy changes that will impact the practice of pharmacy.

Board of Pharmacy Restricts Hydroxychloroquine, then Caves to Ohio Governor

We didn’t think it would be useful to cover the proven inefficacious use of hydroxychloroquine and chloroquine on this blog. By the time we had launched, studies had already begun to question speculations circulating on social media of its efficacy for the treatment of COVID-19. The American Medical Association, along with national pharmacy organizations, published a joint statement condemning inappropriate self-prescribing by physicians, and it seemed as if its use was no longer commonplace as it fell out of the headlines of mainstream media. However, its utility in the pandemic has continued to be promulgated, as we can see from the recent erroneous viral video promoted by “America’s Frontline Doctors.” 

With hydroxychloroquine back in the spotlight, we have seen new policy implications around its use that need to be unpacked for members of the profession of pharmacy. The Ohio State Board of Pharmacy was the first to take such a drastic step as the emergency rule that will be discussed in this post, but it could have national implications if other states take similar actions.

The State of Ohio Board of Pharmacy

Starting in March, the State of Ohio Board of Pharmacy was taking action to ensure the appropriate prescribing and dispensing of hydroxychloroquine. Fearful of medical decision making based on social media rather than evidence and the potential for shortages of the medication, which is used chronically for lupus and arthritis, emergency rules were approved on March 22nd. These emergency rules required that hydroxychloroquine prescriptions bear a written diagnosis code, and if written for COVID-19, a confirmed positive test was required, along with a limit of no more than a 14-day supply, with no refills allowed.

On March 26th additional emergency rules required that prescriptions for hydroxychloroquine in the outpatient setting must contain documentation that therapy is continuing from the inpatient setting after discharge, and that the patients are enrolled in a clinical trial to test hydroxychloroquine’s safety and efficacy. These rules were updated in mid-April, further limiting the hydroxychloroquine prescriptions to no more than a 7-day supply. 

Following these emergency rules, no further action was taken for three months, until the “America’s Frontline Doctors” erroneous viral video began circulating. In July, the State of Ohio Board of Pharmacy took an unprecedented step of issuing an emergency rule that prohibited the prescribing of hydroxychloroquine and chloroquine for prophylaxis and treatment of COVID-19. This rule was quickly met with pushback by Ohio Governor Mike DeWine, who referenced Food and Drug Administration (FDA) Commissioner Dr. Stephen Hahn, appointed by President Trump in 2019, that the decision to use hydroxychloroquine should be between a physician and a patient. 

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With this feedback, the State of Ohio Board of Pharmacy quickly reversed action, withdrawing this emergency rule. Although after a few days’ time nothing ended up changing, this (almost) policy change was unique in how Boards function, and could have implications for pharmacists and future rules in other states. 

The Cons to the Board’s Emergency Rule

The purpose of a board of pharmacy is to protect the public. That is their primary mission, and the reason that they frequently oversee such responsibilities (depending on the state) such as licensure of members of the pharmacy personnel, oversight of prescription drug monitoring programs, and adoption and management of rules to best protect the public. You can even see the tie back to this purpose when the Ohio Board of Pharmacy explained the reason for their most recent emergency rule as being a patient safety issue. However, this rule is starkly different from other regulations created by boards. Boards are not the regulatory body that approves or disapproves of medications for different therapeutic indications. We all know that responsibility is with the FDA. Boards also don’t declare which medications are controlled substances or scheduled; that is in the purview of the Drug Enforcement Agency and FDA. It is important to note, though, that some states may place more stringent restrictions on medications than the federal government, and boards of pharmacy may be engaged with this process.

Off-label prescribing is a frequent practice in medicine that is utilized when there is sufficient evidence to support the use of a medication, but it has not been blessed with an FDA approval for that indication (just to be clear: we are in no way making the argument that there is evidence to support the use of hydroxychloroquine for COVID-19). The lack of an FDA approval for an indication could be for a variety of reasons, but oftentimes it is because the manufacturer of the medication decides there is not enough of a financial incentive in order to go through the expensive FDA approval process. 

This emergency (almost) rule by the State of Ohio Board of Pharmacy appears more aligned with actions commonly taken by federal agencies like the FDA or DEA, and not necessarily by a board of pharmacy. A big con to such a rule would be the fact that it could set the precedent that another regulatory body that does not have the traditional expertise or procedures like the FDA could further limit access to medications that it deems create a “patient safety issue.”

In an era where healthcare professional decision making is often dependent more on insurance formularies rather than what the provider’s expertise believes is in the best interest to the patient, we should not be in support of a rule that could further limit access to medications that could benefit patients from off-label prescribing. Again, this concern does not apply to hydroxychloroquine or chloroquine, which is not effective or safe for the prophylaxis or treatment of COVID-19, but is more of a fear of the liberty a board may take in the future once this precedent is set.

The Pros to the Board’s Emergency Rule

These are not normal times, and we are seeing the traditional checks and balances of our healthcare system break down, such as the inappropriate self-prescribing of hydroxychloroquine by physicians. Is there a role for boards of pharmacy to step in during states of emergency and ensure evidence-based decision making is being adhered to? This is not a question that we can answer, but we believe that although there are potential long-term consequences to such a rule, the original intent of the regulation was positive. In a time where science and politics are so dramatically colliding, one is left to question the intent of the stark rebuke of the rule by the Republican Governor of Ohio. 

Governor DeWine has made national headlines and received praise throughout the pandemic for his dedication to listening to public health officials and not resorting to the propagation of pseudoscience. However, this request to rescind a rule that would promote evidence-based decision making by healthcare professionals for the treatment and prophylaxis of COVID-19 seems uncharacteristic. The request is aligned with the narrative that has been widely distributed by the Trump Administration.

Health policy is incredibly important, as it dictates how our healthcare professionals practice and how accessible their care is. One can only hope that the policies that govern healthcare workers are themselves evidence-based, but we should not be blind to the influence that politicization of issues has on health policy. We should scrutinize health policy with the same level of vigor as we do any peer-reviewed literature. This emergency rule has pros and cons, and although it is rescinded, we must remain vigilant as you can be sure further emergency rules will be adopted by our Boards of Pharmacy before we overcome this pandemic.

Advocacy Advice: How to advocate through print media

As a result of a world where policies are constantly changing because of the pandemic, we at The Grassroots Pharmacist have been largely focused so far on providing updates on all of these changes. However, a key piece of our purpose is not only to provide educational content on the ties between health policy and the profession of pharmacy, but also to provide individuals with the necessary tools to be an advocate for enhanced patient care.

In the coming weeks, we will be adding to our resource center to provide advocates with the tools they need to be effective change-makers. As we add to the resource center, we will also be posting about these resources and how they can be best used. This week, we review ways to advocate to your community through the use of print media.

Why is community advocacy necessary?

Before we get into the nitty gritty, it may be important to discuss why advocating to your community is even important. Some have taken the stance that when thinking about health policy and advocacy, it’s only worth communicating with elected leaders. However, helping your community understand the value of the pharmacist is another important piece of advocacy. Unfortunately, there are currently plenty of gaps in our communities’ understanding of this value. Any community pharmacist who has worked the drive-thru and feels as though patients treat them more like fast food workers than healthcare providers has felt this gap. It has also been described in the literature. Bastianelli et al found in a 2017 study on pharmacists providing point of care (POC) testing that, although many patients believed the pharmacist was a good source of health information, many did not understand that pharmacists could provide services such as POC tests. This is just one example of the many gaps in this understanding.

Advocacy at its core is about education. When you’re advocating to your legislator, you’re educating them on a topic that matters to you in a hope that the education will result in them joining in your perspective. As a republic democracy, there is an incentive for members of our state legislature and congress to listen to their constituency as they formulate opinions on legislation, as these are the individuals that vote for them. Think about how many times we’ve seen large pieces of legislation pass when societal opinion on an issue shifts (for example civil rights and gay marriage). 

Educating your community on important issues such as those discussed on this blog and how they impact your ability to provide patient care services are vital pieces of the advocacy puzzle. Grassroots activism should not be limited to the statehouse or congress; the public needs to learn about these issues too. Where there are pros to advocating to the legislator, there are also pros to advocating to the public, as this can in turn result in additional constituent activists ready to advocate for your cause.

Ways to advocate to the community through print media

There are many ways to advocate to members of your community. One of the best ways to reach a wide audience is through online and print media. Sometimes you may be able to pitch topics for articles to reporters, especially if you have built up a relationship with them either personally or through a social media platform such as Twitter. However, a way to ensure that your message is entirely your own and consistent with what you are advocating for is by utilizing opportunities to express your opinions through the microphone of their medium. Editorials and letters to the editor are perfect ways to accomplish this. 

Editorials, Op-Eds, or commentaries are a great way to make your case on an issue with more room to explain why it matters to you. Many newspapers have editorial staff for reviewing and publishing important public perspectives on relevant issues. Some may have a process on their website to submit editorials for consideration, but oftentimes only a staff member’s email address is listed. If there is an important message that needs to get out to the community, consider submitting it to the member of the editorial staff for their consideration. Worst case scenario they say no, best case scenario you make a huge impact on your community! An example of an editorial written by a member of The Grassroots Pharmacist team can be found here.

Letters to the editor are another great way to educate your community. Overall, they tend to be shorter than editorials, often limited to a few hundred words, but they may have a higher chance of being published, especially as you look to larger papers, as compared to editorials. Consider what the most impactful parts of your message are and prioritize including those in your letter. We adapted our recent blog post about the census and have included it below as an example letter:

New York Times Article: Trump Seeks to Stop Counting Unauthorized Immigrants in Drawing House Districts 

Healthcare professionals should voice concern over the recent executive order that removes undocumented immigrants from census counts. Jeopardizing the integrity of census data by excluding millions of U.S. residents could have dramatic effects on access to healthcare.

Misinformed data can result in inappropriate allocation of billions of federal funds and misinformed data used by the private sector. Census counts are used to allocate funds for public health insurance programs and informs the designation of medically underserved areas. Healthcare organizations and businesses use census data to understand health demographics and rates of social determinants of health for populations they serve. A misinformed count could further amplify disparities in our country caused by systemic racism.

Census data has also been used to assist in the response to public health emergencies. The U.S. should not jeopardize data needed to respond to current or future pandemics.

This executive order will compromise information key to the critical infrastructure of the U.S. healthcare system and should not be accepted by members of the healthcare community.

Advocacy takes time

Regardless of how you are advocating to your community, it is important to recognize that advocacy takes time. We can’t expect our community’s perspective on the value of the pharmacist to shift after one op-ed, but we can recognize the significance of the education that we are providing. At the end of the day, perseverance and resilience are important traits to be able to fall back on. As you look to begin advocating through print media, you may face rejection of an article or idea, or no response at all. Don’t give up. Reevaluate. Reflect on why you’re advocating (to improve patient care) and step back up to the plate. Every effort in grassroots advocacy to our community leads to another individual we’ve helped educate on the value and potential of the pharmacist.

Why pharmacists need to count on the census

The census, the decennial count of our nation, is important for a variety of reasons. As a vehicle for how our democracy functions, the primary purpose of the census is to determine the number of congressional representatives each state has. The basis of our government is on balance between the three branches of government that (ideally) have equal power to ensure an appropriate level of checks and balances is possible. Ensuring validity in the number of individuals each representative serves is important to ensure equal representation by our elected leaders. Arguably as important as the function of determining the number of representatives each state has is the fact that the count of the census is used to appropriate billions of federal funds.

The appropriation of federal funds and ensuring our democracy is balanced and functioning is why it is so concerning to see the current concerted efforts to undermine the integrity of the census. Earlier this week, the Trump Administration signed an executive order that instructed that undocumented immigrants would be removed from census counts. This has been described as unconstitutional, as traditional interpretation of the constitution mandates the census count of all individuals living in the U.S.

It should matter to all citizens that there is currently an effort to undermine our democracy and constitution, but why is this particularly unsettling for healthcare professionals and pharmacists? It all comes back to the money.

What are census dollars used for?

Federal funds allocated by the census are used for many different purposes to help communities, and it is very important that all persons are counted to ensure appropriate appropriations of funds. As described by the Census Bureau on its website, “Your community benefits the most when the census counts everyone.” These funds are spent on education, critical infrastructure, vital public programs, and healthcare infrastructure and services.

Digging in to how census dollars are used for healthcare services is important to understand why this issue is relevant to patients that pharmacists care for. An accurate census count is used as the foundation of allocating funds for public health and insurance programs, such as Medicaid, Medicare Part B, Children’s Health Insurance Program (CHIP), Supplemental Nutrition Program for Women, Infants, and Children (WIC), and reproductive health programs. Without these programs, many of the patients pharmacists care for would not have access to vital healthcare services.

Census data is also used to identify medically underserved areas in our communities. Recent efforts to pass legislation that would recognize pharmacists as healthcare providers under Medicare Part B are focused on pharmacists providing care to patients in these medically underserved areas. I mean, our bill in the 114th and 115th Congress was even called the Pharmacy and Medically Underserved Areas Enhancement Act! Jeopardizing the integrity of the way that we identify these areas by excluding millions of individuals that live in our country could have dramatic effects on access to healthcare in areas that are already underserved.

Misinformed data

In addition to direct issues that a misinformed count could have on representation in our democracy and allocation of federal funds, there are many indirect consequences due to the numerous sectors that use census data. Census data is used to understand population health demographics, supports the decision making of businesses that assist with social determinants of health, and are used for various other public health programs. A misinformed count could further disparities that we are already seeing in our country as a result of systemic racism.

Relevant to our current pandemic, census data is frequently used to respond to public health threats and natural emergencies. In their 2019 article, Cohen et al lays out how census data was vital during an emergence of the Zika virus in New York. While we live in this current pandemic, and fear for future occurrences, we should not be jeopardizing the data we need to appropriately respond.

The integrity of our census is so important for our democracy and the allocation of vital healthcare resources. Access to health insurance programs and healthcare centers funded by federal dollars are vital to millions of patients having access to pharmacist provided care. Hopefully, this executive order will be ruled unconstitutional in the courts, but we should never assume justice will prevail without concerted effort. Pharmacists, students, and professional pharmacy associations cannot stand by as the patients pharmacists care for and their access to healthcare is put in jeopardy. We must act. Reach out to your elected leaders. Talk about this in your communities and on social media. Help our government realize how this will harm and not help.

Resources to read more

Georgetown Laws Center on Poverty and Inequality

American Public Health Association

Cohen GH, Ross CS, Cozier YC, et al. Census 2020—A Preventable Public Health Catastrophe. Am J Pub Health. 2019;109(8):1077-1078. doi: 10.2105/AJPH.2019.305074.U.S.

Census Bureau: Responding to the Census Will Help Plan Health Care Programs for the Next Decade

Why pharmacists should care about access to COVID-19 data

Data is vitally important to members of the profession of pharmacy and is essential in how we develop evidence-based methodologies that guide how we care for patients. Ensuring veracity of data is important in giving us the right foundation to develop long-term strategies to improve patient outcomes. That’s why it was particularly concerning to see the Trump administration issue new guidance on how COVID-19 data is reported. 

Earlier this week, the Trump administration ordered hospitals to bypass the Centers for Disease Control and Prevention (CDC) and send all COVID-19 information to the Department of Health and Human Services (HHS). The new guidance requires hospitals to submit certain pieces of information on a daily basis. This data includes important information like daily reports on capacity and utilization, testing, and the availability of resources (e.g. hospital beds and ventilators). The administration says that this information “will be used to inform decisions at the federal level, such as allocation of supplies, treatments, and other resources.” 

The Trump administration says that all public health agencies are on the same team, and that the new rule will help streamline data to assist public health officials in allocating resources. However, the decision to change data reporting has significant implications to the overall healthcare system and pharmacy in particular. 

Changing Data Collection Makes It Harder To Make Decisions

Despite being months into a public health emergency that has claimed the lives of over 135,000, the national strategy of the federal government has been called into question. Decisions, such as how to safely reopen, are being left to the states. We’ve seen over the past few weeks that many states have struggled – many of them that opened up early are now imposing policies such as lock downs and mask mandates. Since these decisions are being made by local officials, it is important that local officials are able to access the data needed to guide these decisions. The major thing to note here is that local health officials did have access to CDC data. The new HHS database, however, is not open to the public, making it significantly harder for local officials to make important decisions. By taking this data away from the CDC, states and hospitals will not be able to frequently assess the impact of the virus on their communities and take the necessary steps to prepare. Bruce Meyer, president of Jefferson Health in Philadelphia, said the CDC’s data collection and analyses have been “highly reliable and efficient. Sidestepping these established tracking systems creates deep concerns that we will be unable to obtain appropriate and reliable information to perform research and manage our response to the virus.”

This Rule Adversely Impacts Rural Hospitals 

Many state health leaders and hospital officials are ringing the alarms saying that this change will increase the burden on facilities that are already stretched thin by the pandemic. Smaller hospitals, in particular, are not well prepared to adopt new methods, especially given the fact that they have fewer resources. The COVID-19 pandemic has already threatened the ability for rural hospitals to remain financially viable. An analysis from Health Affairs shows that rural hospitals already operate on razor thin margins and rely on high margin services, such as elective surgeries, to keep them afloat. Since many of these hospitals have had to cancel these services, rural hospitals are in more danger than they’ve ever been. In order to keep overhead costs down, rural hospitals don’t have access to the same personnel resources to focus on data reporting. Changes in reporting requirements, especially the stipulation for daily reporting, will have severe implications on rural hospitals creating issues in medication distribution, health access, and patient-outcomes associated with COVID-19. 

Allocation of Vital Resources Including Medication 

By far the biggest impact this rule change will have in the short term is how the federal government distributes current and future COVID-19 treatments, such as remdesivir. The distribution of this critical medication had already been off to a rough start in May, with hospitals unsure about how doses were being distributed. Late last month, HHS put out a statement saying that they had reached a deal to distribute 500,000 additional doses of the medication. However, many state officials are now upset that changing data reporting during the middle of the allocation process could pose an unnecessary barrier in ensuring patients receive access to this life-saving medication. If hospitals, particularly rural hospitals, aren’t able to accurately report their data due to financial considerations, the lives of patients requiring medications could be in jeopardy. HHS Secretary Alex Azar has already said that data that hospitals report this week will be the basis by which the federal government distributes remdesivir and other therapeutic supplies. 

What Data Needs to Change

Data is vital in ensuring that all stakeholders have access to the necessary information to make decisions. Beyond just that, it’s important that these stakeholders have access to the right information. We’ve seen cases over the past few months of state officials firing public health officials for refusing to manipulate data. This change in the flow of data by the Trump administration seems to be similarly motivated. However, that being said, there is still a need for specific types of data. 

Over the past few weeks, we’ve seen more and more attention being placed on racial disparities in all areas of our society. Specifically as it relates to healthcare, we’ve seen minority communities face the overwhelming burden from the COVID-19 pandemic. In a past post we discussed how individuals that live in primarily minority populated neighborhoods have less access to COVID-19 testing. However, despite this awareness, there is still no comprehensive demographic data on people who are being tested or treated for the virus. It is critical that data be accessible in order to better understand how COVID-19 is affecting communities of color, and empowering local and state organizations to develop programs to respond to those communities. 

Access to data to guide the decision making of our policymakers is vital. As members of the profession of pharmacy, we can see how interruptions in this access can result in gaps in patient care and financial consequences for our healthcare infrastructure, such as for rural hospitals. By advocating for increased access to this data across the healthcare continuum we can expect positive patient outcomes, more evidence-based decisions, and (hopefully) an end to this new normal.

Advocacy Alert: How to ask for provider status inclusion in the next COVID-19 bill

The next COVID-19 legislative package

In this “new normal” of the pandemic we have seen giant pieces of legislation being crafted and passing through Congress. These packages are being used for a variety of different issues in order to help the country respond to the pandemic. We saw the results of the CARES Act as money went back into the hands of the public in order to stimulate the economy and assistance was given to the healthcare system to ensure access to care is maintained. Another massive piece of legislation, the HEROES Act (which we reviewed in the post here) was passed out of the House but has not made any progress in the Senate. As we are now seeing cases start to spike again, Congress is beginning conversations on what would need to be included in the next iteration of a COVID-19 legislative package. Media is reporting that Congress plans to have these conversations over the next two weeks with an initial draft of legislation coming together by the end of July.

Organizations and lobbying groups are already making the rounds to members of Congress asking for their priorities to be included in the next package. However, the involvement of this brainstorming process is not meant to be limited to lobbying groups. Citizens and healthcare professionals should be a part of this process. Your elected officials represent you, and a great way for pharmacists and students to get involved in grassroots advocacy initiatives is to bring forth considerations to your elected leaders for pieces of legislation and regulatory changes.

In past posts, we have reviewed the why behind the importance of provider status and the how behind the federal legislative strategy. We also have begun to discuss the need for incremental changes in order to reach our eventual goal: increased access for all patients to pharmacist-provided care as a result of sustainable reimbursement for pharmacist services. Now is the time for one of those incremental changes. As Congress takes steps on the next COVID-19 legislation, there is an opportunity for pharmacists and students to contact elected leaders and voice our recommendations to include reimbursement for pharmacists under Medicare Part B for COVID-19 and influenza services to patients during the state of emergency.

Which advocacy path will you take?

Now is go-time for all pharmacists, students and advocates for pharmacists’ provider status to take action by contacting their elected leaders. Given the restrictions due to the current pandemic and the abbreviated timeline, we have identified three pathways by which you can advocate for this issue, broken down by the amount of time you can invest.

It is also important to be mindful of the effectiveness of different advocacy strategies. Research has shown that the more unique/individual communication can be with your elected leaders, the more impactful it is. Any action is better than no action – but remember that taking the time to make your message personal will result in bigger gains for the effort you’re fighting for.

Quick impact – 60 seconds to 5 minutes to make a difference

The first advocacy pathway is for those looking to make a quick impact on this issue with minimal time to invest. Through the American Pharmacists Association (APhA) Action Center you can enter in your address and three auto-populated letters will be crafted for you to send to your two Senators and Congresswoman/man. This letter aligns with the ask members of the profession should be advocating for. However, it is important to take a few moments to make this message personal. This can be accomplished by including information about where you currently practice and/or go to school. Include a personal anecdote that showcases the positive therapeutic or economic value of pharmacist-provided care. Making this message personal will increase the impact of the letter sent to your elected leaders. Press send, and in just a few minutes, you have already made a positive impact for future patients and the profession.

Every pharmacist, student, and advocate for pharmacists’ provider status should at a minimum send a letter.

Establishing a relationship – 5 minutes to 15 minutes to make an impact

What about those that may have a few more minutes to spare to advocate for the profession? Well, if you do, consider calling your member of Congress’s office and leaving a brief voicemail expressing your thoughts about what should be included in future COVID-19 legislative packages. This can be a great way to express your thoughts in a more personal way than sending a letter. If you are worried about what you will say on the voicemail, consider pulling the language from the automated letter from APhA’s Action Center into a document and adapting it with any personal anecdotes you would like to share. Having these talking points in front of you is helpful to ensure you are communicating a concise and consistent message to your elected leaders about what your asks are.

If you want to ensure your call goes to voicemail, call the office outside of business hours.

Advocacy Achiever – 15 minutes to 60 minutes to make an impact

For those that want to go above and beyond, consider scheduling a meeting with your member of Congress or one of their legislative aides. Constituents meeting with elected leaders or their staff members has been shown to be the most effective way to advocate for issues. Search for your elected leaders on your preferred browser, and once you find their webpage, there are usually options to schedule a meeting. Enter in your information and a message around why you would like to meet (adaptable template available here).

When preparing for your meeting, list out your talking points, like we described above. Also, during these individual meetings is a great time to bring constituency connection to this issue. In addition to including personal anecdotes about why this issue is important, help the person you are meeting understand why it is vital to that elected leader’s district.

For this issue, consider going to www.census.gov/mycd and looking up the statistics of your district. You can quickly find the number of individuals over the age of 65 and get an estimate of the number of Medicare beneficiaries in the constituency. For District 12 in Ohio, this comes out to 123,476 people. All of a sudden, you’ve taken this abstract idea, and directly connected it to their district. This is just one example of many possible tools to use when advocating.

Regardless of how you are advocating, share your story, be concise, keep it positive, and be respectful. You can help to create the change you want to see in the healthcare world by taking any of the above pathways.

If there is anything we can do to support you, feel free to contact us at grassroots.rph@gmail.com. Now get out there and make a difference. If we each do our part, it may only take a few minutes to change the world.

Provider Status Explained: Understanding the how behind the federal legislative strategy

Provider status is essential to the future of the profession of pharmacy. We explained last week the reason why pharmacists need provider status now more than ever (if you missed it, check out the post here) and began to discuss some of the background around why this shift in the business model is so substantial. For all the Simon Sinek Golden Circle fans out there, now that we have dissected the why, the natural next step is to understand how we shift this business model in pharmacy. This week we will take a look at how this could happen at the federal level and will follow up with a look at states next.

Public Payors Influence the Private Sector

You may be thinking, “Okay, we need to shift our revenue stream. Why are legislative or regulatory changes even necessary? The role of the pharmacist has shifted, let’s charge for the patient care services we provide.” Although this “build it and they will come mentality may be applicable to other sectors of the economy, the business of healthcare is pretty unique. Because healthcare is so expensive, it is not realistic to expect to build a sustainable business model outside of the health insurance system.

The next challenge is to understand how to integrate the pharmacist into the health insurance system to be paid as providers. So, if we were to simplify the health insurance system to the extreme, we could say there are two paths you could choose to go down: public payors or private payors. Looking at other sectors of the economy, you can make an observation similar to Ellen Glasgow: “The government’s like a mule, it’s slow and it’s sure; it’s slow to turn, and it’s sure to turn the way you don’t want it.” So, you may think the private sector is the way we must go, and may set your sights on behemoths like UnitedHealth Group, Anthem, or Humana.

But, healthcare doesn’t work like other businesses. Despite the normal mantra that the private sector innovates, and the public sector adopts, healthcare tends to be the opposite. This may be because, as was discussed in the first installment of our series, business follows the money. Despite there being behemoths in the private health insurance industry, the single largest insurer of the most people in the United States is the public healthcare system (Medicare and Medicaid). With this significant share of the marketplace, the public payors have created a culture in which they shape change in the healthcare system.

So, a strategy is starting to take shape. An effective way to be recognized as healthcare providers is to create legislative or regulatory changes at the federal level specific to the public health insurance system.

The Social Security Act

What we are seeking is reimbursement for pharmacist-provided patient care services under Medicare Part B. This would align us with other comparable healthcare professionals that are reimbursed for their services under the medical insurance system. So, you may be asking yourself, how do you change who can be reimbursed for healthcare services under Medicare Part B? Well, it all comes back to the Social Security Act, and the influence this giant piece of legislation has had on our healthcare system.

The Social Security Act was signed into law in 1935 and established many of the social programs much of our country has come to depend on (e.g. Social Security Program, unemployment insurance, maternal & child welfare programs). Thirty years after originally signed into law, the 1965 Amendments were passed establishing the Medicare and Medicaid Systems. Included in Section 1861(s)(2) of the Social Security Act is a list of all healthcare providers other than physicians that can be reimbursed under Medicare. The healthcare professionals stretch across the gambit, from physical therapists and physician assistants to social workers and psychologists. Notably missing from this list, though, is the pharmacist.

Our mission is clear: to add pharmacists to this list. But is this even possible? How can we be sure this strategy can even be accomplished? If only we could test this strategy with a recent example from another healthcare (since 1997) provider.

The Nurse Practitioner Strategy

After more than 20 years of grassroots advocacy campaigns and systematic legislative victories in Congress, the 1997 Balanced Budget Act was signed recognizing nurse practitioners (NPs) as healthcare providers under Medicare Part B. Prior to this legislative victory, NP salaries were paid out of the health systems that they worked for, and the justification for their salaries was largely dependent on expected cost savings and an increase in health outcomes of patients that was associated with the care that they provided. Sound familiar?

Recognizing the unsustainability in an indirect ability to bill for patient care services and how this could negatively result in a lack of access to patient care services, nurse leaders began organizing and forming advocacy campaigns in the 1970s. They began with the introduction of a bill in 1974 that would recognize NPs as providers and it died. Recognizing the limited ability to make such a substantial change in one swoop, they reevaluated their strategy and instead began passing smaller, more realistic bills that began to create a culture shift within the healthcare team in our country. Over the course of these decades, NPs came together as a profession, completing numerous grassroots advocacy campaigns that resulted eventually in the signing of the bill in 1997 that finally got them to their goal.

From a historical perspective, we can see that legislative victories in this country often come down the path of incremental change. One may make the observation that by leaning into those incremental changes for 20 years, NPs were able to get to their final goal: provider status. If you’re interested in reading more about the nurse practitioner journey and how it relates to pharmacists, check out the great article here.

If we are to adopt a similar strategy, the profession of pharmacy should consider what the incremental changes are that we can adopt to get us to the finish line. There has never been a better time. The COVID-19 pandemic has highlighted the essential nature of pharmacists in our healthcare infrastructure, and has showcased to policy makers how vital pharmacists are in local communities. 

Incremental change, you say?

We’ve torn apart the why and the importance behind this issue. We’ve examined the how when it comes to our federal legislative strategy. But we can’t ignore the states and their (proportionally) greater nimbleness when it comes to implementing change. In the next installment of the Provider Status Explained series, we will be tackling the how behind the state strategy to reach provider status and postulate around the eventual tipping of a scale when a majority of states pass the finish line that may increase the chances of national success.

Until next time, stay curious and passionate.

Provider Status Explained: Why do pharmacists need provider status?

Provider status has been such a focus of the pharmacy profession for decades. However, before we talk about how to advocate for provider status, it’s important to understand why something needs to change. 

It’s all about that product

My grandfather was a community pharmacist in the Cleveland, Ohio area for nearly 50 years. I remember hearing about how when he graduated pharmacy school in 1959, the practice of pharmacy was (shockingly) different. When a patient came into the pharmacy to fill a medication, the pharmacist was not allowed to tell the patient what the medicine was, or provide much counseling information at all. In the eyes of the patient, the value being provided by the pharmacist was in the compounding and dispensing of this tangible product – and that is exactly what the patient paid for. In the 1980s, for example, a majority (70%) of prescriptions were paid out-of-pocket by the patient. Over the years, as the cost of prescription medication increased, insurance companies began covering more of the costs.  

Despite this shift in who is paying for the product, the way the pharmacist brings in revenue to the healthcare businesses they work for has remained largely tied to the dispensing of medications. This is fundamentally different than how other healthcare professionals bring in revenue to their healthcare businesses. In business terminology, there is a spectrum of the types of products that customers will purchase, called the goods-service continuum which can be important for us to understand how important this difference is. 

At one end is goods. Goods are completely tangible products that have no level of service associated with them. They are something that can be put on a shelf that a customer will purchase. Take, for instance: table salt. It is a completely tangible good that requires no additional service to the customer. On the other side of the spectrum is services. These are completely intangible and more aligned with a business providing an action that their customer is paying for. Think of education. Education is an intangible service that is offered by a teacher. You can’t put education on a shelf – it is provided by a skilled teacher to their students. In the center of this continuum are things that have a bit of both goods and services. For example, take a tailored suit. Customers are paying for the clothes, but also paying for a level of service to make the clothes fit just for them. 

When it comes to the way pharmacists bring in revenue to their businesses, through dispensing medications, what the pharmacist is offering falls in the center of this spectrum: a tangible good that has a level of service associated with it. Now, there is a significant level of service happening behind and in front of the counter (i.e. drug utilization review, counseling, consultations, etc.), however, this is largely not the services that are being paid for by the patient or payor. This is different from how other healthcare professionals bring in revenue to the healthcare businesses that they work for. For example, let’s look at the physician. The physician offers many things to their patients, however, what the patient is often purchasing (through the help of insurance) is the expertise of the physician. This is aligned farther toward the service end of the spectrum. 

This is similar to other healthcare professionals (think physician assistants, nurse practitioners, dentists, etc.). They provide expertise, or a service, to their patients, and that is what is paid for and how these professions bring in revenue to the healthcare businesses that they work for. 

Why is pharmacy different?

Our profession has significantly changed in its roles and responsibilities in the past century. In the 1950s, a community pharmacist’s responsibility was focused on compounding a medication and dispensing this to the patient. As healthcare continued to grow in complexity, it became obvious that healthcare teams required a medication expert… i.e. they needed a pharmacist. This new demand, coupled with the publication of landmark studies and calls from professional organizations, established the doctoral education as the baseline for new practitioners. With this new baseline, pharmacists were now able to provide fundamentally different services for patients. However despite these monumental shifts, there was no change in the business model. 

The current landscape

Since the pharmacy business model continues to be driven by medications, the pharmacist’s main responsibility continues to be the product.  It is no surprise that businesses follow where the money is. Without the ability for the pharmacist to directly bill for most of the patient care services they provide, they are forced to fit them in between their other responsibilities. In the past this was an issue because the pharmacist was not allowed their full time to do what they are trained to do: provide patient care and serve as the medication expert. This resulted in a lack of access to patient care for many, especially those in rural communities. However, dispensing fees were not in jeopardy at the time and pharmacists were able to continue practicing in this non-ideal environment.

The current business model is no longer viable! Declines in dispensing fees and anticompetitive practices of some businesses have made pharmacy practice significantly more challenging.  As dispensing fees have fallen, the businesses that pharmacists work for are asking pharmacists to do more with less in an attempt to maintain a sustainable business. This has resulted in a system of unrealistic community metrics that is squeezing everything out of the pharmacist to dispense as many products as they can, and we have seen the effects of this system. The New York Times detailed these risks in the excellent article, How Chaos at Chain Pharmacies is Putting Patients at Risk.

Because pharmacy payment models have not evolved, pharmacists’ responsibilities continue to be largely aligned with dispensing products. Although this is not optimal for patient care, the pharmacist is able to continue to function and provide care while also dispensing. Small advances have been made with the ability to bill for Medication Therapy Management codes, but these codes alone are not enough to create a sustainable business around them. In other settings, such as ambulatory care or in health systems, pharmacists are often hired with the expectation that there will be indirect cost savings that can justify their salary. Other methods have been utilized for pharmacists to bill incident-to the physician, however, there remain barriers to creating widespread sustainable pharmacist care clinics through these alternative billing methods.

Why now?

Now that the foundation of the dispensing model is collapsing, we are seeing the results in news stories across the country. Independent pharmacies are closing at an alarming rate, grocery stores are closing their pharmacies as well, and big-box stores are closing and slowing the opening of new stores. Because the business model of pharmacy did not shift with the roles and responsibilities of the pharmacist, the profession of pharmacy is now in crisis. 

As noted above, business practices follow the money. With the ability to directly bill for the patient care services that they provide, the healthcare businesses that pharmacists work for would allow them more time in their responsibilities to focus on the provision of patient care, which aligns with their training and expertise. Provider status moves pharmacists further toward the service end of the goods-service continuum and would be more aligned with how comparable healthcare professionals bring in revenue to the healthcare businesses that they work for. This would increase patient access to care and have numerous positive therapeutic and economic benefits for our communities.

Okay, so we now understand a little about the history and importance of why provider status is so essential – but there is still a lot left to unpack! What is the Pharmacy and Medically Underserved Areas Enhancement Act, why has the advocacy strategy been largely focused on public health insurers, and are we the only healthcare professional that has had to go through such a dramatic shift in our business model? All these answers and more coming soon in the next installments of our Provider Status Explained series!