Keeping Up With Pharmacists’ Changing Scope of Practice Amid COVID-19

A panel discussion at the Academy of Managed Care Pharmacy Nexus 2020 meeting examined the changes in the health care landscape occurring due to the coronavirus disease 2019 (COVID-19) pandemic, particularly around pharmacists’ scope of practice, and which changes are likely to persist after the pandemic.

Margaret Scott, MS, MPH, RPh, associate principal at Avalere Health, began by saying that COVID-19 is a topic that needs no introduction, as it has affected everyone in some way. She outlined the myriad of changes that the health care industry has witnessed in the months since the pandemic, including an influx of Medicaid enrollment due to unemployment, disruptions to both new and ongoing health care treatment, a shift in policy focus away from drug pricing, and the increased awareness of social determinants of health.

Especially relevant to pharmacists are the changes in drug utilization, with more drugs moving from the medical to the pharmacy benefit as fewer are administered by providers; regulations that alleviate prior authorization and step therapy requirements; expansion of the scope of practice for pharmacists, as preparations begin for a COVID-19 vaccine; and a reorganization of the provider landscape, as there have been stronger pushes to grant provider status to pharmacists in the hope that reimbursement will follow.

Data show that patient use of prescription drugs has declined drastically, with billing frequencies down 50% for oncology products and 44% for autoimmune products in May 2020 compared with May 2019. “New brand prescriptions are lower this year than last year, and also new brand prescriptions are more likely to be prescribed in an office visit than in a telehealth visit,” Scott noted.

The disruptions to access stemming from the pandemic are widespread, particularly because patients may find their usual providers are not covered by a new network if they lose their employer-sponsored insurance and because providers prefer to see new patients in the office instead of via telehealth. Scott mentioned that the combination of barriers to care, such as transportation, reduces the feasibility of more straightforward solutions to access that may have worked in a pre–COVID-19 world.

According to Nick Diamond, a consultant at Avalere, one of the most important changes seen amid the pandemic has been the emergence of telehealth as a modality to maintain a touchpoint between patients and providers. In Medicare, Congress and CMS have implemented more flexible policies to increase access to telehealth, leading to an increase in utilization; all 50 states and DC have expanded telehealth services in Medicaid through a variety of legislation, executive orders, and waivers; meanwhile, many large commercial plans have voluntarily expanded their members’ access to telehealth.

Diamond highlighted which telehealth-related changes are most likely to remain after the pandemic, including the coverage of initial visits for certain specialties, expansion of provider types other than physicians who can deliver telemedicine, recognition of provider licensure across state lines, the use of telehealth tools to remotely supervise the delivery of care or treatment, which can be done by pharmacists. Some changes he deemed unlikely to stick around are reimbursement parity equal to in-person visits and the selective enforcement of the Health Information Portability and Accountability Act, as some telehealth visits have used noncompliant apps like FaceTime during the public health emergency.

Drug utilization management has also become more flexible amid the pandemic, Scott explained. In Medicare Part D, some of these changes are optional, such as waiving prior authorization requirements, whereas changes like suspending quantity and days’ supply limits are mandated under the Coronavirus Aid, Relief, and Economic Security Act. States are also directing their Medicaid programs to make similar changes and to override the preferred drug list requirements in case of shortages.

Speaking more about the scope of practice, Diamond discussed how “professional scope of practice for pharmacists, what pharmacists’ training enables them to do and the services they’re able to provide, doesn’t always perfectly align with legal scope of practice, so what a state law says a pharmacist can and cannot do.”

Reform in this area first began in 2009 when laws were expanded to allow pharmacists to deliver the H1N1 influenza vaccine, and some states have continued expanding these laws in the years since, leading to a patchwork of state laws, Diamond said. In 2020, there has been a 2-pronged effort by federal and state governments to expand the scope further. HHS has now issued guidance that pharmacists may administer COVID-19 testing, deliver recommended routine vaccinations to children aged 3 to 18 years, and order and deliver a future COVID-19 vaccine to patients over the age of 3. This is an example of the tone that HHS is setting around the scope of practice that pharmacists should have in the context of the pandemic, Diamond explained.

Challenges around reimbursement are another important issue in the context of the pandemic, according to Daniel J. Nam, RPh, Esq, associate principal of pharmacy policy at Avalere Health. Even when laws allow for an expanded scope of practice for pharmacists, an adequate level of reimbursement is still a concern, especially because pharmacists do not have provider status in Medicare and as such cannot bill Part B, except via the workaround of being considered “mass immunizers” for Part B vaccinations.

Nam spoke about the opportunity for reimbursement in the commercial space, where it is up to pharmacists and pharmacies to demonstrate through innovative contracts that they can lower costs and improve outcomes in a short amount of time. In the context of COVID-19, the ability of pharmacists to provide services and receive reimbursement is related to 2 trends: the expansion of leveraging pharmacists for diagnostic testing and the refocusing on prevention of chronic and communicable diseases.

The array of HIV preventive products currently being studied is a great example of how pharmacists can learn about a pipeline of emerging drug classes and be ready to deliver value, Nam said.

“Within prevention, there’s a real opportunity for pharmacists to set themselves up, not as just valuable professionals, but as public health partners in dealing with these large public health crises,” he concluded.