The more than 20,000 community pharmacies in the United States serve as a patient safety net for their communities during normal times and during times of emergencies. Hurricanes Sandy, Michael and Katrina. Tornadoes. Floods in the South and Midwest. Wildfires in California. The coronavirus we’re currently facing has been a bit different from some of these other disasters, because the entire country is directly affected by it. But whether it’s a crisis situation or normal times, community pharmacies are there making sure citizens land safely.
Not surprisingly, pharmacies have been named essential businesses during the ongoing pandemic, businesses that can and must stay open while most of the rest of the country was advised to shelter in place in their homes. Brave teams of pharmacists and their staff have reconfigured pharmacies to serve their communities well and as safely as possible. They’re at work every day, regardless of the risk, potentially exposed to COVID-19 even as they are expanding home deliveries, utilizing drive-thru and curbside service, and compounding hand sanitizer for first responders and their patients.
Unfortunately, this vital safety net is getting smaller. Health care consumers have fewer options, as the number of community pharmacies and chain drug stores has shrunk by more than 2,000 pharmacies, leaving an estimated 10 million patients without the pharmacy of their choice. The primary reason for these closures is an unsustainable payment model that commoditizes the product and offers little recognition for those pharmacies excelling at non-dispensing services that cradle patients when they fall through the health system gaps. Changing the pharmacy payment model was the focus of my comments in this space last year. That focus continues for the National Community Pharmacists Association, and the pandemic has opened up new avenues for pharmacists to shine through the coronavirus darkness.
As the voice of the community pharmacist, NCPA has been telling policy makers what pharmacies need to help do our vital work. Some of these needs are in response to the pandemic, such as patient signature log waivers, relief from pharmacy benefit manager audits, and forgivable federal loans for community pharmacies and other small businesses as part of coronavirus relief legislation. Other needs have been longer-term challenges for community pharmacy such as pharmacy direct and indirect remuneration (DIR) fee reform.
Ironically, the pandemic has elevated the profile of community pharmacists; we are seen as part of the solution to combat the pandemic. NCPA surveyed its members about what they think pharmacy practice will look like post-pandemic and found that 61% of community pharmacists anticipate that more pharmacies will be offering point-of-care testing for various illnesses, including COVID-19 when that becomes available. Widespread testing will be key, perhaps in particular for the possible protective presence of COVID-19 antibodies. The faster testing can be expanded, the sooner the country can get back on its feet economically. With neighborhood pharmacists being the most accessible health care providers, they are well positioned to safely and rapidly expand testing, a point we are repeatedly emphasizing to federal and state policy makers. We have seen some progress in this area, but more must be done so pharmacists can serve their patients in this way.
When a coronavirus vaccine becomes available, it’s not unreasonable to imagine hundreds of millions of Americans lining up to be immunized. And as with testing, pharmacists will play a tremendous part in the education and administration of the vaccine. An NCPA analysis of pharmacies shows that 20.5% of ZIP codes in the United States don’t have a big chain drug store. They’re served by locally owned, small business, independent pharmacies, mostly in rural areas and some urban centers where big chains don’t have a presence and physicians may be difficult to access. In order for health care consumers to fully benefit from the skills of the pharmacist, though — in many cases their most accessible provider — we are advocating loudly for federal provider status.
While working to fight the coronavirus, community pharmacies are also still struggling with PBM clawbacks and below-cost reimbursements. For their efforts to help through this pandemic, they will get a big bill as PBMs soon come calling for pharmacy DIR fees. Fixing these fees and reining in PBMs has never been more vital if pharmacies are to continue operating now and when this emergency passes.
Eliminating DIR fees and changing the pharmacy payment model has been NCPA’s broken-record message for years. The current payment model is confusing, complex and convoluted for consumers and pharmacies alike, benefiting only the PBMs that thrive on the opaqueness. Changing the pharmacy payment model is not just about the need to change how prescriptions are reimbursed. It is also about ensuring pharmacies are paid for the services that are improving health care outcomes.
The number of Americans covered by Medicaid has grown from 13% in 2008 to 20% in 2018, and many experts believe that the economic impact of the coronavirus will force even more people onto the Medicaid rolls. A disproportionate share of Medicaid and Medicare patients choose community pharmacies (when they have the freedom to choose), making community pharmacies especially sensitive to changes to Medicaid reimbursement and making it a top priority for NCPA’s state advocacy efforts. A number of states have discovered that the pharmacy benefit in their Medicaid managed care program is needlessly costing their state tens of millions of dollars. In fact, in the last two years, nine states have conducted investigations, issued reports or filed lawsuits related to the pharmacy benefit of their MMC program. Following West Virginia’s successful conversion back to the state overseeing its Medicaid pharmacy benefit, which saved the state over $50 million in the first year, two states have carved or are in the process of carving out pharmacy from Medicaid managed care, and at least eight others introduced legislation or pursued administrative action to do so. Medicaid managed care reform, whether through an appropriately crafted NADAC-plus model or other innovative approaches, is a high priority to NCPA to ensure that the community pharmacy safety net can be there for this especially vulnerable population.
CPESN USA is also key to a new payment model that puts pharmacist services at the center. CPESN’s mission is to help the financial sustainability of community pharmacies by providing high-quality patient-centered services. This clinically integrated network of pharmacies is helping transform the system into one that allows pharmacists to be recognized for practicing at their full scope. This is something especially relevant today as CPESN marshals the clinical skills and talent of its network of pharmacies in responding to the COVID-19 pandemic. There are now over 2,600 pharmacies in 49 networks across 45 states, a number that continues to grow.
The economy has been knocked off balance by the pandemic, and the American people are walking a health care tightrope, looking for balance between protecting their health and returning to daily life. At a time like this, it’s only natural that patients and policy makers would turn to community pharmacists. Community pharmacists really are that safety net that helps keep communities safe, offering a path to help return the country to a more normal rhythm of life. In return, we ask that policy makers change the pharmacy payment model, unshackling pharmacists from current economic obstacles and allowing them to fully serve their communities.
Douglas Hoey is chief executive officer of the National Community Pharmacists Association.