COVID-19 might have accelerated changes for retail pharmacists and pharmacies

by George Van Antwerp, managing director, and Greg Myers, manager, Deloitte Consulting LLP

Think back to the last time you visited a retail pharmacy. If you wanted to talk to the pharmacist, you likely stood near the counter and patiently waited for her or him to finish up a phone call. The pharmacist might have been trying to get a prior authorization approved or was on hold after suggesting an alternate drug because a patient’s copayment was too high.

While those are critical tasks, retail pharmacists are highly trained and trusted medical professionals who typically spend a disproportionate amount of time counting pills and addressing clinical edits rather than operating at the top of their license. For years, we have been talking about the need for pharmacists to assume a bigger role on the care team by ordering and analyzing lab results, counseling patients, supporting transitions in care, and by working directly with physicians to close gaps in care (e.g., missing vaccinations or a diabetic without a statin prescription). However, the breadth of services retail pharmacists can provide varies by state and is often limited. Moreover, reimbursement (and billing) for the additional services they can provide remains largely undefined.  

Early this year, we outlined the changing role of retail pharmacies and pharmacists in our paper on the Future of Pharmacy. We believe the COVID-19 pandemic has accelerated this transformation and moved us closer to that future. Pharmacists are typically seen as trusted sources of information, according to an annual survey of professionals.¹ Once a vaccine becomes available, pharmacists will be needed to play a critical role in convincing people to be vaccinated—in addition to administering the vaccine—the National Association of Chain Drug Stores (NACDS) recently noted. The pandemic has also fueled substantial changes around the delivery of prescriptions as many consumers seek touchless shopping experiences or avoid going to stores altogether. This has led to a jump in 90-day prescriptions, new drive-thru options at retail pharmacies, and more home deliveries by courier.

The role of the pharmacist is expanding

While US pharmacists are trained in the safe and effective use of medicines, state licensing rules typically prevent them from writing prescriptions or ordering lab tests. That, however, appears to be changing. For example, 11 states and the District of Columbia now allow pharmacists to prescribe and dispense birth control, and three states let pharmacists prescribe certain drug therapies. In May, the administration issued guidance that gave pharmacists provider status to bill Medicare for diagnostic COVID-19 tests.² Additionally, several hospital systems have told us they are embedding pharmacists in their practices (especially around oncology) and are using collaborative practice agreements. We expect future care models will include pharmacists in both physical encounters and virtual health destinations.

An anticipated shortage of physicians, increasingly complex therapies, and people living longer with chronic conditions, could create more opportunities for pharmacists to engage in care delivery. Moreover, as the dispensing of medications becomes more automated—and as artificial intelligence takes on more administrative processes like prior authorization and formulary management—retail pharmacists could have time to engage more directly with patients and clinicians. Pharmacists could become the next generation of primary care providers (PCPs) who treat patients for acute illnesses and help manage chronic conditions. It seems plausible to imagine a pre-defined pharmacist formulary that could be prescribed against and clinical pathways that could be used to determine therapeutic substitutions tied to specific clinical values and benefit designs. 

We are likely to see pharmacists take on an expanded role beginning in underserved populations. This would be similar to the way physician assistants (PAs) saw their role expand. At one point, PAs were only allowed to write certain types of prescriptions in underserved areas. Once that model proved valuable, PAs gained more prescription-writing authority.³

While expanding the role of the pharmacist will likely require regulatory and reimbursement changes, health plans, employers, and the US Centers for Medicare and Medicaid Services (CMS) appear to be recognizing the value these medical professionals bring to the table. For example, a pharmacist who can effectively monitor a patient and adjust medications could help keep that patient out of the hospital. Some examples of this include:

• Buckeye Health: The Medicaid managed care organization recently launched the first phase of a program that pays pharmacists as medical consultants. Through the program, which was launched at two federally qualified health centers in Ohio, pharmacists work collaboratively with physicians to manage chronic conditions such as diabetes, depression, and cardiovascular disease.⁴
• Troy Medicare: In 2019, the North Carolina-based Medicare Advantage (MA) company began paying pharmacists directly for enhanced care management services. Troy Medicare’s model is based on paying pharmacists $30 to $50 per-member-per-month for those services.⁵
• Aspen RxHealth: This company bridges the gap between pharmacists who want an opportunity to practice at the top of their license (as part of a gig economy) and patients who need medication management services. When members require clinical services, a pharmacist is matched to them based on key social and clinical markers such as disease state, medication regimen, language, and geographic relevance.⁶
• CPESN USA: This is a clinically integrated, nationwide organization of local networks whose participating pharmacies are accountable for the care they provide to patients.

An evolution for brick-and-mortar pharmacies

The pharmacist is typically a trusted resource in the community. We don’t see that changing. In reality, many patients interact with their pharmacist more often than they interact with their physician. Combine that with the health inequities that the pandemic has highlighted and it’s clear that a trusted, easily accessible resource is needed. Additionally, being able to respond to the needs of the community is becoming increasingly important as we gain a better recognition of the drivers of health (e.g., access to healthy food, transportation, housing) and their impact on health outcomes. 

The question is, how does the physical pharmacy evolve? We’ve been seeing the expansion of health services (e.g., medical, lab, vision, hearing, dental) into the pharmacy as a physical destination. It is also increasingly common to hear people use the term digital front door when describing how virtual health and digital tools (e.g., symptom checker) are used by consumers to engage with the health care system (i.e., telehealth visit, clinic, physician, hospital).

Additionally, while historical results around central-fill models have been mixed, the ability to work virtually, use technology to predict refills and automation processes, and rely on home delivery (not necessarily mail order) could lead to a new model that helps to free up the local pharmacy to be more focused on cognitive services (e.g., closing gaps in care).  That could create new career paths for pharmacists which might include:

• Digital pharmacists who provide tele-pharmacy services or virtual support
• Embedded pharmacists who work with providers on complex care (e.g., cell and gene therapy)
• Community pharmacists who work both in retail and in the home, and have increased training in behavioral health and consumer engagement

What are the next steps?

There will likely be some challenges in transforming the nation’s 88,000 retail pharmacies, and the pharmacists who work there, into a core part of the care team. The role of pharmacists for COVID-19 testing and future vaccinations has highlighted some of the challenges. Identifying and assigning value to gaps in care, which can show clear causality tied to pharmacist interventions, is a next step that could help payers quantify value. All of this will likely depend on the ability to integrate electronic medical record (EMR) systems and retail point-of-sale systems along with the integration of digital tools. As this happens, the overall consumer experience will likely improve as these integrated care teams work together to lower costs and improve health outcomes.

Endnotes

^{1. Nurses Again Outpace Other Professions for Honesty, Ethics, Gallup, December 20, 2018}

^{2. Advisory opinion, US Department of Health and Human Services, May 19, 2020}

^{3. PA prescribing, American Academy of PAs, April 2019}

^{4. Program expanding role of pharmacists launches in Cincinnati, Cincinnati Business Courier, June 25, 2020}

^{5. Troy Medicare is launching a North Carolina MA plan with pharmacists at its center, MedCity News, May 12, 2019}

^{6.  Humana, Aspen RxHealth collaborating to offer app connecting patients with pharmacists, Fierce Healthcare, June 25, 2019}

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