David Frabotta

While progress toward provider status has been relegated largely to individual states, the opioid crisis could provide a path for movement at the federal level.

All but nine states have granted some sort of provider status for pharmacists, but the scope of services permitted by this state-by-state patchwork vary widely. More restrictive provider-status states permit the administration of influenza vaccines, while some have extended prescription authority for some classes of drugs. 

While the scope of approved practices is widening, challenges remain in integrating pharmacist-delivered services into the healthcare system and establishing a codified framework to work with payers, including CMS, for reimbursement of services. Currently, reimbursement is limited generally to vaccinations, MTM, and chronic care management in most states. More progressive states have created reimbursement mechanisms for Medicaid patients for broader immunizations, birth control services, and initiating and dispensing naloxone, travel medications, and nicotine replacement therapies. 

Lucinda Maine Recieves APhA Remington Honor Medal

While reimbursement remains a challenge, scope of services is expanding. Some states allow pharmacists to perform patient assessments and wellness visits; order and interpret drug therapy-related tests; refer to other healthcare providers; and initiate, adjust and discontinue therapy. Idaho pharmacists, for example, can prescribe medications in 20 classes after several years of expansion that now allows the Idaho State Board of Pharmacy to determine drugs or devices that pharmacists may prescribe for certain conditions.

At press time, there were 109 active pieces of legislation in statehouses around the country that will either establish or expand provider status roles for pharmacists. 

Lobbyists and industry advocates have been forced to make some hard choices during the last several years, the most consequential of which has been sacrificing direct reimbursement in order to establish new services for the profession. 

In most current systems, pharmacists are not eligible to receive direct payment from Medicare, Medicaid, or other government payers, but they can partner with provider networks, employers, or with private insurers to provide care for a set population. If pharmacists are going to be part of a healthcare team, then they need to join a team that is eligible to get paid. This clearly puts the responsibility of reimbursement squarely on pharmacists if they want to monetize the services they provide, and the one-off contract strategy is not ideal nor very likely to become widespread. 

However, expanded scope of services is widely considered a stepping stone to direct reimbursement. At the federal level, the Patient Access to Pharmacists’ Care Coalition is working to authorize reimbursement under Medicare Part B in medically underserved communities, which would reimburse pharmacists for approved services at 85% of the physician fee-for-service rate, similar to nurse practitioners and physician assistants. 

A version of the bill was first introduced in 2014 and was reintroduced in 2017 Advocates are discussing a path forward under the new leadership, according to Ann Burns, RPh, vice president of professional affairs for APhA. 

“We’ve had good bipartisan support of the bills that we have in Congress, but unfortunately they have not moved to legislation,” Burns says. “However, there is a lot of movement and interest in the opioid crisis, so that could be the pathway for a national framework.” 

As opioid use disorder continues to permeate the current political environment and public health debate, there is significant political will at the state and federal level to offer more access to care and interventions. 

Drug overdose is the leading cause of death for persons under the age of 50, and prescription opioids are responsible for 40% of opioid overdoses, or about 46 per day. More than 51,000 people died of drug overdoses in the United States in 2015, according to the World Health Organization. England and Wales ranked No. 2 with 3,323 deaths. More than 70,000 drug overdoses occurred in 2017, and a whopping 47,600 were opioid related, outpacing suicides (47,173) and traffic accidents (40,100) for the first time. 

“This is a uniquely American problem, and this is important to understand for society if we are going to make a difference because it really says something about our culture,” says Ron Friedman, an attorney who represents pharmaceutical firms and personnel in compliance matters. He discussed office-based addition treatment options. 

Fatalities continue to grow, and while prescription overdoses ebbed for the first time in 2017, prescriptions still contributed to more than 17,000 overdose fatalities. 

In the current political climate and crisis surrounding the opioid use disorder could motivate legislators to authorize pharmacist intervention programs that would qualify for reimbursement.  

Pharmacists Planning Services Inc. and the American College of Apothecaries Foundation highlighted public health initiatives that expand the scope of practice for pharmacists during its annual breakfast at APhA.  

Ryan Oftebro, PharmD, FACA, CEO of Kelley-Ross Pharmacy Group in Seattle, has embraced Washington’s expansive provider status authority to provide his community with access to two critical public health therapies: naloxone and PreP, pre-exposure prophylaxis that uses a combination of HIV medicines tenofovir and emtricitabine (Truvada). 

“We are the most accessible healthcare provider, and that gives us the opportunity to participate in important public health campaigns,” he said while discussing his Take Home Naloxone program. “Anyone who is at risk of witnessing an overdose-which is essentially everyone-can carry a kit, with some quick training and no questions asked.”

Pharmacist-prescribed birth control is another service greenlighted in a handful of states. In California, Sally Rafie, PharmD, BCPS, assistant clinical professor at UC San Diego Health, is working with 1,100 pharmacies to conduct screening and deploy better education and access to birth control options.  

While pharmacist-driven public health initiatives are becoming more widespread, payment remains a challenge. California, known for its favorable provider status authority, is still looking for ways to pay those 1,100 pharmacies for their services.

Articles

Key updates from the Seattle, WA, conference in March.

APhA Conference Coverage: Provider Status Widens, Reimbursements Stall

Forty pharmacists in 26 states won elections in November, including four in statewide or federal races.

In California, State Sen. Jeff Stone, PharmD, won reelection to his second term in the 28th District, which stretches from southwest Riverside County across the Coachella Valley to the Arizona border.

Stone opened the Temecula (CA) Pharmacy in 1983 and became involved in local politics as a small business owner and a champion of the business community.

During his rise through positions in Temecula’s government, county board positions, and eventually the state senate, he has supported legislation to reduce regulations imposed on large and small businesses, which he says are the backbone of California’s economy. He has been an outspoken supporter for the pharmacy profession and a public health advocate throughout his career.

For his advancement of the profession and public health in California, Stone will be recognized as the Pharmacist Planning Services Inc. (PPSI) Distinguished Person of the Year in March. He will receive the award at the annual meeting of the California Pharmacists Association.
	PPSI is a nonprofit public health advocate that has helped organize The Great American Smoke Out, National Condom Week, and programs on birth control, hepatitis C, and medicinal cannabis.

Stone continues to own and operate a local business, Innovative Compounding Pharmacy, in La Quinta, CA.

DT: Community pharmacists are often driven by the people they serve. Was this mentality part of what drove you to public service?

: When I opened my first pharmacy in 1983 in Temecula, I never imagined running for public office. It was only when I saw the impact that graffiti was having on my community that I decided to get involved in 1992.

I ran for City Council because I wanted our city to crack down on vandals who were responsible for graffiti, and the voters in that election agreed. I’m proud to say I won handily and the City of Temecula still has the strongest anti-graffiti ordinance in the country. I quickly realized the common denominator between being a pharmacist and an elected official is helping people.

DT: What are some of the hallmarks of pharmacy practice that helped prepare you for public service?

: Being a pharmacist comes with many attributes, including the ability to study and retain complex health-related issues. What does that have to do with being an elected official? In order to be an effective elected official, one must have the discipline to study and understand new issues in order to then mitigate the problems or improve situations. As an independent pharmacy owner, I know firsthand the impacts of government regulations that can help or hurt my business. As the owner of the pharmacy, I need to understand accounting, workers compensation, insurance, employee laws, etc., hence making me more sensitive to the governmental mandates and unneeded bureaucracy.

Understanding these laws helps make me a better elected official. Having a medical background gave me a strong foundation as a county supervisor with a county hospital and helps me now as a state senator serving as vice chairman of the Senate Health Committee.

DT: As small business owners, how important is it for independent pharmacists to engage with state and local governments?

: If members of our profession do not get elected to state legislatures or federal office, then we succumb to bad laws authored by people that do not fully understand what we do and the challenges we face. As one of the most educated, but underutilized healthcare professionals, we need people in office who can help expand our scope of practice in accordance with our exceptional educational attributes.

DT: What advice would you give pharmacists who are considering public service? Is there a process for preparing yourself or methods that you’ve identified as essential to be successful?

: Public service comes in many forms. It isn’t just running for public office. I would encourage those with a passion to serve to become involved in their local Chambers of Commerce, their local Rotary Club, and to serve on various city boards and commissions. It is truly amazing how much a person can get done to change the way things are run if they just step up and get involved in a meaningful way.

My best advice can be summed up easily-get interested, get involved, show up, and work to change the things you believe need changing. You would be surprised how effective you can be if you just do these few simple things.

DT: What are your top priorities for this term?

: I will be once again attempting to pass legislation that expands the scope of pharmacists to independently treat disease in cooperation with a physician, as a way to ease the burden on our healthcare system. Additionally, I will be working with several of my colleagues to enact strong regulations over how pharmacy benefit managers operate in California.

PBMs are the least regulated part of the healthcare delivery system, and they should not be allowed to force pharmacies to lose money when filling prescriptions or to automatically claw back payments previously authorized. In addition to pharmacy-related legislation, I will also focus on economic development, public safety, and issues affecting taxpayers across the State of California.

DT: How is California dealing with the opioid crisis? Are there new initiatives being discussed or implemented? What is the role of pharmacists in what many are calling a public health emergency?

: We have a statewide and national crisis over opioid addiction and overdoses. Fentanyl has burst onto the scene as a major killer of people who have become addicted to these dangerous drugs, and I am working with my colleagues on both sides of the political aisle to come up with a solution to stop the illicit importation of drugs like fentanyl.

One solution we are looking at involves improving the CURES database in California, to make it accessible to pharmacists on a real-time basis so pharmacists will know if patients are filling prescriptions at multiple locations. If we can bring this database into the 21st Century and make it accessible to physicians and pharmacists, we can save lives.

DT: Drug prices, gag clauses, direct-to-consumer advertising, and pharmacy reimbursements have been thrust into the national debate. What role should pharmacists play as these discussion progress? How should we articulate the balance between price and innovation? How will this debate play out at the national level?

: This is an issue that is particularly troubling to me as both a pharmacist and a state senator. The issue over gag clauses and reimbursement rates prompted me to successfully request a legislative audit of a local health system in California that has been slashing reimbursement rates to below acquisition costs to local independent pharmacies, presumably as a way to force patients to begin using the preferred PBM’s mail order services.

This issue was raised by a local pharmacist, and legislators and public policy leaders need to hear more from individual pharmacists to teach decision makers about the ramifications of so-called “cost cutting” measures that ultimately put patients at risk by reducing access to quality care.

DT: California Governor Gavin Newsom’s first executive order directed the state’s health department to negotiate drug prices directly with pharmaceutical companies, and he took steps to enable states to manage a single-payer system. How would these initiatives affect pharmacists in the California? Do these changes have the potential to deliver on their intent?

: I am looking closely at the governor’s order, but I am greatly concerned that having the state involved in drug price negotiations will severely reduce patient access to quality pharmacy services. Having the state be in charge of purchasing drugs directly poses many challenges to physicians, pharmacists, and patients by potentially limiting the availability of necessary medications in many special circumstances.

Also, having the State of California function as a “super PBM” would likely force hundreds of pharmacies to close because it will certainly result in a rapid growth of mail-order pharmacy services, which might be fine in many circumstances, but these services do not necessarily work for patients needing specialized individual care and treatment.

State Senator Jeff Stone tackles PBM reform, reimbursement rates. 

PPSI Honors Distinguished Person  of the Year

Walgreens pharmacists could be part of a healthcare delivery revolution as the chain rethinks its stores and services for its patients. As new delivery models emerge to make healthcare more personalized, accessible, and affordable, Walgreens is banking on Microsoft’s cloud-based computing and artificial intelligence (AI) to help it evolve and remain competitive, particularly with newcomer Amazon

Walgreens Boots Alliance (WBA)-Walgreens’ parent company that includes Duane Reade stores, Boots and other international retailers, and 400 distribution centers that include Alliance Healthcare-and Microsoft Corp. announced a strategic partnership intended to develop new healthcare models, technology, and retail operations to improve the future of healthcare.

The alliance combines Microsoft Azure, it’s cloud and AI platform, with Walgreens’ customer reach, retail locations, outpatient healthcare services, and industry expertise to provide an integrated care-management model that incorporates digital innovations such as access to virtual care with its more than 9,500 physical locations. WBA replaced General Electric last year as one of the 30 companies that constitute the Dow Jones Industrial Average.

The seven-year deal includes research and development investment to build healthcare solutions, improve health outcomes, and lower the cost of care. This investment will include funding, subject-matter experts, technology, and tools, according to Walgreens. The companies will also explore the potential to establish joint innovation centers in key markets. Additionally, in 2019 WBA will pilot up to 12 store-in-store “digital health corners” aimed at the merchandising and sale of select health care-related hardware and devices.

“Our strategic partnership with Microsoft demonstrates our strong commitment to creating integrated, next-generation, digitally enabled health care delivery solutions for our customers, transforming our stores into modern neighborhood health destinations and expanding customer offerings,” Stefano Pessina, executive vice chairman and CEO of WBA said in a statement. “WBA will work with Microsoft to harness the information that exists between payors and health care providers to leverage, in the interest of patients and with their consent, our extraordinary network of accessible and convenient locations to deliver new innovations, greater value and better health outcomes in health care systems across the world.”

The partnership will also focus on enabling more personalized health care experiences from preventative self-care to chronic disease management. WBA will pursue lifestyle management solutions in areas such as nutrition and wellness via customers’ delivery method of choice, including digital devices and digital applications or in-store expert advice. Additionally, the companies will work to build a seamless ecosystem of participating organizations to better connect consumers, providers-including Walgreens and Boots pharmacists-pharmaceutical manufacturers and payors.

A recent survey of 500 healthcare executives revealed that 94% of respondents see investments in technologies, such as AI, as the clearest route to affordable, accessible, and equitable healthcare in the future.

But in order to realize those future possibilities, a culture shift needs to happen in healthcare today, says Tom Lawry, director of worldwide health for Microsoft. The future of healthcare technology relies more on the culture and framework being created by clinical and business leaders today, Lowry tells Drug Topics.

“What really is going to be needed in the future is not just the breakthroughs in technology, but breakthroughs in creative thinking and the ability of leaders to think differently when redeveloping their processes to leverage the power of the technologies rather than trying to insert these new technologies into a framework,” Lawry says.

Editor’s note: Subscribe to Drug Topics to read more about how Microsoft, AI, and other technologies are shaping the future of pharmacy in our February issue.

Walgreens locations, Duane Reade stores, and Walgreens Boots Alliance distribution centers will move workflows to Microsoft’s Azure cloud and AI tool.

Walgreens, Microsoft Knit Strategic Partnership to Deliver New Care Models

As pharmacists continue to battle professional challenges that include low payments, hidden fees, higher volumes, insufficient support , and a healthcare system that relegates them to a service department, it appears as though no amount of money could offset systemic frustrations. Pharmacist compensation continues to rise, but modest financial increases aren’t making pharmacists any more satisfied in their jobs, according to the annual Drug Topics Salary and Job Satisfaction Study (see Methodology). For the third year in a row, pharmacists report higher workloads, more stress, and less overall job satisfaction despite individual incomes that are twice the national average than those of entire households.

More than 70% of pharmacists earn at least $120,000 per year with significant bonuses and benefits, yet more than a quarter of pharmacists are dissatisfied in their current position, and 41% say they are not adequately compensated for the work they do. The reasons for their disillusion are primarily caused by the mix of workload expectations, insufficient support, and variable reimbursements that many consider arbitrary.

Half of pharmacists are paid salaries while half work on an hourly basis. In 2016, 57% of pharmacists were salaried employees; 52% were salaried last year, and this year’s even split continues the trend toward hourly employment. More than two-thirds of respondents work between 30 hours and 44 hours per week; 12% work fewer than 30 hours, and 19% work at least 45 hours per week. Few (2%) reported working more than 60 hours per week.

Salaries remained strong in 2018: 71% of respondents made more than $120,000 this year, on par with last year but up significantly from 2016, when just 61% made at least $120,000. Another positive trend: 18% of respondents made more than $150,000 this year, up from 15% last year and up from 7% in 2016 (Chart 1). The more salaries at the top of the range show that despite the glut of graduating pharmacists, there is still room at the top for those with management experience and those willing to work in high-volume locations in big cities.

Hospital pharmacists tend to make more money: 82% of hospital workers make more than $120,000 per year; 25% make at least $150,000, and just 5% make less than $100,000 per year compared to 10% of all pharmacists who make less than $100,000. Similarly, managed care pharmacists and those who work in nursing home/long-term care pharmacy are more likely to earn salaries (66%) versus an hourly wage, and 32% earn more than $150,000 per year, making health system pharmacists almost twice as likely to earn salaries in the top range for the profession. Not surprisingly, health system pharmacists are more likely to receive regular raises (68%) but less likely to receive bonuses or additional incentives; 70% of health system pharmacists say they are adequately compensated for what they do, and just 15% say they are dissatisfied in their work compared to 27% of all pharmacists.

Does higher education mean more money? The short answer is yes, but there appears be a point of diminishing return. Only 14% of those who are board certified say their certification helped them draw a higher salary; 10% are unsure, and more than 75% say it has no impact on salary. The data

 confirms that sentiment: 74% of board-certified pharmacists make more than $120,000 per year, just a tick above overall respondents. They are no more likely to say they are adequately compensated, satisfied with their current positions, and receive regular raises or bonuses.

 generally correlate to salary. Health-system pharmacists earn more per hour than community pharmacists, and education level has a marginal effect on earnings. One troubling trend is a decline in regular raises: 47% of all respondents received a raise in 2018, down from 53% last year and 62% in 2016. For those who received raises, the lion’s share were 3% or less, similar to years past 

Additionally, the number of pharmacists receiving bonuses, incentive pay, or other profit-sharing rewards continues to decline. In 2016, 55% of pharmacists received a bonus; that number fell to 43% last year and 42% in 2018. Two-thirds of those who received additional bonuses say those earnings were $5,000 or less; 15% earned between $5,000 and $10,000, and 15% received bonuses of $15,000 or more, up from 7% in 2016.

Men tend to receive larger bonuses than women, although this could be attributed to tenure, as 60% of men have at least 25 years of experience versus 45% of women. While men and women received bonuses at a similar rate, 44% and 40% respectively, men (20%) were more than twice as likely to receive a bonus of at least $15,000 versus women (9%); 57% of men received bonuses of less than $5,000, whereas 73% of women who earned bonuses received less than $5,000.

Job satisfaction metrics haven’t changed significantly in the past few years, which means they still aren’t good 

; 27% of respondents say that are dissatisfied in their work in some way, and almost one-third of respondents (29%) say that are considering a job change in the next 12 months, up slightly from 27% from last year and on par with 2016 numbers.

Two-thirds of respondents say they have more stress compared to last year, up from 60% in 2017 who said their stress had increased. Similarly, 72% said workload increased versus last year’s workloads, and just 4% say their stress and workload had decreased, although many who reported less work and stress had voluntarily reduced their responsibilities, for reasons like their run up to retirement.

The reasons why job stress is on the rise and job satisfaction is low is fairly predictable: Increased workload volume and inadequate support staff reign as the largest frustrations 

. With increased responsibilities for MTM, vaccinations, and patient-care services that are migrating to pharmacies, there is a critical need for better-paid and better-educated technicians, but this isn’t happening in the current environment driven by employee-per-volume metrics.

Paperwork, EMRs, and practice management software aren’t making work easier, either: 45% say documentation is a cause of stress, much of it a result of antiquated management/patient systems or inadequate training on new systems.

The DIR system, hidden fees, coercive negotiating practices by PBMs, and audits continue to be major frustrations for community pharmacists who own and/or manage purchasing for their outlet, driving many to look for greener pastures elsewhere. It’s unclear the extent to which the current healthcare system contributes to general sentiments about income (or revenue), job satisfaction, and poor workplace environment, which is also a major factor driving pharmacists to find new jobs. Professional advancement, job security, and income were cited by more than 1 in 4 as reasons for looking for new work 

Administering vaccinations is a growing reality for pharmacists, but the brunt of vaccinations happen at community chain pharmacies. Not surprisingly, 75% of chain pharmacists say they must deal with unrealistic vaccination quotas compared to one-third of overall respondents and other community pharmacists; 59% of chain pharmacists say it takes up too much of their time compared to 29% of all pharmacists and 33% of other community pharmacists. There isn’t much wondering why: 45% of all pharmacists do not administer any flu shots, whereas just 4% chain pharmacists skip the duty. One in three chain pharmacists administer more than 50 flu vaccines each week during peak season compared to 13% or all pharmacists and 12% of other community pharmacists 

The burden of vaccinations, corporate politics, workflow metrics, and the lack of time to give patients the information they need lead chain pharmacists to be the most disenfranchised sector of the profession. More than half (53%) of chain pharmacists say they are dissatisfied with their jobs, almost twice the proportion of the overall profession.

How does all this translate to the duty pharmacists have to their patients? In short, 71% say they are able to give patients the information and tools they need to be healthier; 17% are neutral, and 12% say they cannot give these services. For chain pharmacists, the workload toll is a concern for patient health. Double the number of chain pharmacists (24%) say they are unable to make patients healthier versus 58% that say they are able to deliver health information and tools.

The Drug Topics Annual Pharmacist Salary and Job Satisfaction survey was emailed to our newsletter audience on Sept. 13 and Sept. 20. The survey was in the field for 13 days and received 1,230 responses, which gives the survey a ±2.75% margin of error with a 95% confidence interval or a ±3.6% margin with a 99% confidence interval.
	For the first time, the gender of respondents was evenly split, and age is more or less evenly distributed: 20% are under 40 years old; 22% are age 40 to 49; 25% are 50 to 59, and 32% are 60 or older. More than half of respondents have 25+ years of experience. Just 8% of respondents have earned master’s degrees; 41% have earned PharmDs, and 14% are board certified. Almost half of respondents work in a retail setting, and 82% of respondents are employed full-time; 10% are employed part time, and 8% are independent consultants, contract employees, retired pharmacists, or unemployed. The mean number of pharmacists per location was 15, and the median number of pharmacists per location is 4. The charts below show the breakout of respondents by geography, title, and type of pharmacy.

David Frabotta is the Executive Editor of DrugTopics. Send him your feedback, ideas, or letters-to-the-editor at david.frabotta@ubm.com.

Results from DrugTopics' annual salary survey suggested that salaries, raises, and bonuses fail to improve pharmacists' professional satisfaction. 