Table of Contents
The pharmacy profession and patient care services delivered by the pharmacy team have evolved significantly over the past few years, bringing new opportunities and challenges. The pandemic has spotlighted the value of pharmacies as vital access points to care, leading policy makers and payers to explore new ways to engage pharmacists and the pharmacy team. There is a buzz of optimism that we are at a turning point and the change and disruption that has been churning for pharmacy sustainability, services, payment, workforce well-being and resilience, and other factors influencing the pharmacy ecosystem, will finally arise in 2023.
Ilisa Bernstein
A top priority is sustainability of our nation’s community pharmacies — keeping pharmacy doors open, with financial stability, predictability and growth. The current pharmacy reimbursement and payment model is ripe for change and disruption. We are seeing this with the emergence of cash-only pharmacies, which are filling gaps in health care access. Disruption also is needed to break the lopsided, unfair and deceptive business practices of PBMs who are puppeteering and ravishing the health care industry, particularly pharmacies. In 2022, the Federal Trade Commission began a study of PBM practices and announced the agency’s intent to exercise its full statutory authority against companies that use unfair tactics to gain an advantage instead of competing on the merits. All eyes are on the FTC in 2023 to see them use their enforcement powers on PBMs. In addition, more states are expected to pass laws and regulations this year as courts continue to stand by the Supreme Court’s two-year-old Rutledge v. PCMA decision allowing state oversight of PBMs. Among this, we are also seeing readiness on the federal level to pass legislation that provides fairness, equity and transparency in pharmacy payment.
In 2022, the Centers for Medicare and Medicaid Services (CMS) eliminated retrospective direct and indirect remuneration (DIR) fees starting in 2024, but DIR and the mischief around these fees and claw-backs still exists and is likely to continue. This must be fixed in 2023 for community pharmacies to maintain their ability to keep their doors open and serve as access points for medications and patient care services.
Pharmacists have been giving away free patient care services for too long. Enough is enough. We need to push long-standing legislative efforts over the finish line in 2023 and get recognized as providers under Medicare for our nation’s seniors. There is momentum to pass the Equitable Access to Pharmacy Services (ECAPS) Act, which would authorize pharmacists to provide care and receive direct reimbursement for test, treat and immunize services for certain respiratory illnesses. Importantly, this legislation codifies the temporary scope of practice authorities gained during the pandemic and provides a payment mechanism for the covered services. The Future of Pharmacy Care Coalition, which APhA co-leads with other pharmacy champions, is working diligently to get this legislation passed in 2023. Any pharmacy company not involved is encouraged to join. Find more information at pharmacycare.org.
Many advancements in payment for pharmacists’ patient care services are emerging in the states. An increasing number of states have passed laws that require payment for pharmacists’ patient care services “in parity” with other health care professionals, either for state Medicaid programs or commercial payers, and services are paid in the medical benefit. The types of services covered and billing codes that are used can vary, but these developments provide a revenue stream to support pharmacists’ time to provide clinical care, and a new opportunity for service growth in community pharmacies.
Commercial health plans are also independently seeing the benefits of pharmacists’ patient care services. There are pockets of arrangements around the country with plans paying pharmacists for patient care. Positive outcomes and efficiencies that are generated from these arrangements will support advocacy efforts to scale this up for multifaceted coverage, such as in fee-for-service or value-based payment, across payer types.
This care is premised on expanding state scope of practice through legislative directives, statewide protocols or enhancements to collaborative practice authority. There has been a lot of activity in the states to make authorities for COVID-19-related services permanent, in addition to advancements for Test and Treat, HIV PEP and PrEP, hormonal contraception, nicotine cessation, furnishing naloxone, and more. State legislators and public health officials see firsthand the level of care pharmacists provide and, with this recognition, we expect to see further advancement in scope of authorities aligned with pharmacists’ education and training.
Innovation in the profession is also abuzz and infectious. We cannot lose sight of innovative and entrepreneurial practice in the profession enabling top use of knowledge and skills. Technology continues to be employed in new ways across the health care system. Telehealth services exploded during the pandemic, supported by wide-ranging technology systems, and are expected to be prominent moving forward. Digital therapeutics are poised to impact treatment of conditions in new ways, and pharmacists are increasing their involvement with digital monitoring devices and corresponding assessment services. And we are seeing effective use of automation and artificial intelligence to free up pharmacists, allowing them to focus on clinical services. There is tremendous room for growth for this and more innovation to flourish in all practice settings in the coming year.
None of these great strides can happen without a strong pharmacy workforce. There is room for improvement to stabilize and maintain pharmacist and pharmacy technician well-being and resilience to effectively care for patients. And workplace conditions need to include dedicated time and support to provide patient care services and facilitate safe medication dispensing. Key stakeholders must continue to come together to address these issues head on in an open, honest, transparent and professional manner. Fixing the pharmacy payment and reimbursement model will help to ensure adequate staffing to break the cycle, but this is complex, and additional work must be done to support pharmacists and their teams in a meaningful, productive manner.
The latest findings from the Pharmacy Workplace and Well-being Reporting (PWWR) initiative, which was launched by APhA and the National Alliance of State Pharmacy Associations to collect pharmacy workplace experiences, show a continued theme of threatening or abusive behaviors leveled against pharmacy staff by customers and coworkers. This trend cannot continue. Improving pharmacy team well-being and workplace conditions will be a primary focus in 2023.
Enrollment in schools and colleges of pharmacies is dramatically down. There is a decreasing attractiveness of pharmacy as a career choice, partly because of the concerns raised by pharmacists about current conditions. Whether they see a “pharmacy closed due to pharmacist shortage” sign or toxic postings on social media, the external image of pharmacy is threatened. Not only must we change harmful conditions, but we need to take significant steps to elevate the perception and reputation of the profession. In the coming year, the pharmacy community must band together to develop a public relations campaign to market the profession, not just to prospective students, but to the public and to health plans, policy makers and other health care professionals.
Just when we thought we had turned the corner and put COVID-19 behind us, we are entering 2023 in the middle of a triple-demic, with drug shortages of vital medications to treat respiratory infections, including amoxicillin, albuterol, oseltamivir and O-T-C children’s fever reducers. In recent years, widespread shortages of essential medicines mostly impacted health systems. The current shortages are predicted to carry well into 2023. Pharmacists will be scrambling to stock these products or working with patients and prescribers for alternatives.
New tensions between federal and state authorities emerged in June 2022 with the Dobbs v. Jackson Supreme Court decision that placed the regulation of abortion services with the individual states. States have adopted a myriad of often confusing requirements related to medications that have multiple purposes but could cause the loss of a pregnancy. Pharmacists and pharmacies have been caught in the middle of this issue, and the quest for clarity is likely to continue into 2023.
Another disrupting event in 2023 will be implementation of the final phase of the Drug Supply Chain Security Act (DSCSA). DSCSA establishes an electronic, interoperable system that identifies and traces certain prescription drugs down to the package level as they move through the supply chain and requires pharmacies to have systems and processes to comply with the law’s requirements. The final phase of implementation is in November 2023. As of now, most independent and many small chain pharmacies are not ready and need more time. Significant work will be needed to implement the requirements or seek a delay in enforcement from FDA to have more time, will be a focus in 2023.
Change is ahead for pharmacy, along with many opportunities and challenges as we enter 2023. We have positive momentum for the changes and disruption needed for our profession. APhA stands ready, willing and able for the work ahead, alongside our pharmacy partners, using a solutions-oriented approach to move the pharmacy profession and the sustainability of community pharmacies forward.
Ilisa Bernstein the executive vice president, CEO American Pharmacists Association.
