How did 2020 affect American Pharmacists Association members? “Profoundly” is an understatement. “Irrevocably” is appropriate. “Positively” may be hard to see right now, but I believe it’s the truth. Pharmacists emerged from last year — a year that few words can adequately describe — stronger, and they enter 2021 empowered like never before.

Scott Knoer

The way I see it, 2020’s pharmacists faced four remarkable moments in time, each with repercussions that will influence our world for decades to come: the COVID-19 pandemic and its countless challenges; a racial injustice reckoning; a showdown with pharmacy benefit managers; and a clearer association between broken payment models and patient safety. Each one strikes at the soul of who, how and why we serve. And each one represents opportunities limited only by our imaginations.

COVID-19’s curses and blessings

For years, the pharmacy community has worked to build pharmacists into pandemic and emergency preparedness plans, and our partners in public health have seen the value of what they can offer: curtailing of preventable diseases; education; and triage that saves hospital visits for only the most at-risk patients, the ones who can’t be treated in community settings. Plans didn’t mean much in 2020.

Unfortunately, pharmacists’ roles were not sufficiently formalized or defined at the federal level when the unimaginable became reality. We can only speculate on how much more effectual the nation’s response to COVID-19 would have been if Congress had heeded years of urging to include pharmacists as providers in Medicare Part B or had not failed to include Part B coverage for pharmacists’ coronavirus-related services in stimulus legislation.

But things did get better as they went along.

The Department of Health and Human Services (HHS) teed up state-licensed pharmacists to order and administer Food and Drug Administration-approved COVID-19 tests, including serology tests, by adding them as “covered persons” to the Public Readiness and Emergency Preparedness Act. The agency later clarified that its guidance applied to every state, regardless of restrictive laws limiting access to pharmacists’ evidence-based care.

HHS-granted authorities have expanded to include testing and immunizing for strep, flu and COVID-19. Most dramatically, pharmacists gained the authority to administer routine childhood vaccines for patients ages 3 through 18. Qualified pharmacy technicians and state-authorized pharmacy interns can now administer childhood, flu and COVID-19 vaccines if they meet certain requirements. Most recently, HHS created a pathway for pharmacists who enroll with Medicare as mass immunizers to roster bill for COVID-19 vaccines. It’s very possible these authorities will survive the end of the public health emergency.

Big changes like the ones HHS enacted take time to fully manifest. While lots of pharmacists have already put the rubber to the road, others are still working out the details. But we know where this is going: to pharmacists serving a massive role in protecting Americans’ health and safety in 2021 and beyond.

APhA members are resilient. They’ve masterfully leveraged technology and, moving forward, pharmacists will provide more telehealth services and care for patients they previously could not reach. They’ve created and helped patients adapt to new paradigms, like curbside pickup, medication delivery and controlled store traffic. And they’ve proven that there are better, smarter more efficient ways to do things.

Fairness, dignity, equality

Black lives matter. That’s a fact, not a political statement. Black lives matter.

It is everyone’s responsibility to confront racial injustice and COVID-19’s outsize impact on communities of color. All pharmacists took an oath to “consider the welfare of humanity and relief of suffering my primary concerns,” and we have a powerful platform right where we stand — in our pharmacies.

We cannot ignore the connection between historic oppression and poorer health outcomes, and these are far from limited to COVID-19. Dismal disparities in maternal and infant health and management of chronic conditions are a disgrace to our nation. Worse, these disparities persist even when controlling for socioeconomic status. Pharmacists and pharmacy staff must disrupt that cycle by enacting measures that eliminate inequities resulting from racism and discrimination in all pharmacy spaces: patient care, pharmacist and pharmacy technician continuing education, student pharmacist education, workplace practices, pharmacy school admissions, leadership opportunities, and organizational policies.

APhA owns our role in this. In 2020, the APhA board of trustees set in motion an action plan to influence personal, professional and societal change. The board approved the formation of a task force to guide APhA and the profession on policy, communications and activities geared at dismantling racial injustice. That task force is now at work determining our way forward; that work that will be ongoing in 2021 and likely many years to follow. APhA will also host forums, including town halls, for members to share their thoughts on fighting racism.

What about pharmacists as individuals? Begin with a personal inventory of one’s own implicit biases. The Harvard University Implicit Association Test or Harro’s Cycle of Socialization can get the ball rolling.

And understanding social determinants of health is a must. APhA offers tools to help members learn about nonclinical barriers to care — lack of access to resources, financial obstacles, uninsurance and underinsurance, challenges in transportation, medical mistrust, difficulties obtaining healthy food, the toxic stress of being treated unequally, and more — and become resourceful patient advocates.

APhA takes pride in the diversity of our members and the patients they serve, and we stand with communities of color in rejecting hate, racism, unequal treatment and all forms of discrimination.

The highest court in the land

After decades of pharmacy advocacy at the federal and state levels to gain better control of drug pricing and protect the viability of community pharmacies, finally the most critical grievances of our profession have been heard in the highest court of the land. In fall 2020, the Supreme Court of the United States heard oral arguments in Rutledge v Pharmaceutical Care Management Association that may determine whether states can restrain PBMs’ opaque, predatory business practices and unchecked greed.

PBMs reimburse some pharmacies less than others. Often reimbursement is so low that pharmacies lose money on prescriptions, go under water and drown. PBMs also retroactively steal reimbursement dollars on the basis of muddled “quality standards” over which pharmacists have no control. This leads to pharmacy deserts and robs patients of the accessible, reliable care that pharmacists provide.

Although we feel pharmacy has the righteous position, it’s hard to speculate with confidence what the outcome of Rutledge will be. We don’t expect a decision from the Supreme Court until later this year, possibly as late as June.

APhA isn’t standing still while we wait. We support state PBM-reform legislation that has passed or is pending across the country. APhA will continue to advocate and educate about the damage PBMs do. Our members’ livelihood and ability to serve patients depend on change.

Patients over profit

Pharmacist well-being and their overwork in the community setting entered the public consciousness when The New York Times ran a story highlighting how a broken payment system leads to chaos and medication errors, particularly at high-volume pharmacies. This is a huge issue for APhA members, many of whom are judged on speed and volume rather than the quality of their patient care.

Pharmacies are businesses, and they exist to make money, and if pharmacists could get paid for patient care, all pharmacies would change their business model to take advantage of that. We fight for reimbursement of pharmacist-provided patient-care services under Medicare Part B to move beyond volume over value and profits over patients. Pharmacy and its allies must overcome congressional inertia in 2021.

Perverse payment incentives affect more than patient safety. They pose an existential threat to the profession. Burnout and overwork have reached unacceptably high levels, and pharmacists report lost sleep and even despair. Our pharmacists in high-volume chains crave the ability to use their education and not just count, pour, lick and stick.

It is a positive sign that the public has woken up to the ways pharmacy’s current model jeopardizes the nation’s health.

The outlook

2020 was a year like no other, but I’m excited for what we have planned in 2021. APhA will be taking huge steps to support all pharmacists and all of pharmacy.

Team Pharmacy is strong. We have emerged from 2020’s challenges with new life, clear vision and a renewed sense of purpose. A bright future lies at the end of this dark tunnel. We will get there together.

Scott Knoer is the executive vice president and chief executive officer at the American Pharmacists Association.