Contributing Editor Fred Gebhart works all over the world as a freelance writer and editor, but his home base is in San Francisco.

Fred Gebhart, Contributing Editor

The past year has been a busy one for vaccines. The Advisory Committee on Immunization Practices (ACIP) met more than 20 times, said ACIP committee member and independent pharmacy consultant Steve Foster, PharmD, FAPhA, retired Captain in the United States Public Health Service Commissioned Corps. This year’s annual immunization update from the CDC includes important changes for herpes zoster, pneumococcal, hepatitis B, and dengue vaccines.

“Pharmacists delivered more than 77% of all the COVID-19 vaccines administered in the US,” said Foster. “The ACIP is expecting pharmacists to give newly approved vaccines just as they have with COVID-19. Vaccines may be a major change in our practices going forward.”

Foster and Jeffrey Goad, PharmD, MPH, Associate Dean of Academic Affairs at Chapman University School of Pharmacy shared the latest vaccine recommendations during their presentation, “Know the Facts: Annual Immunization Update” at the APhA 2022 Annual Meeting & Exposition held in San Antonio, Texas.

“There was a huge pandemic dip for our routine common pediatric vaccines,” Goad said. “Vaccination is starting to come back, but we have a huge catch up to do.”

Vaccination rates for adults took a similar hit during the pandemic, but adult vaccinations have been slower to recover. Routine pediatric vaccination is driven largely by school requirements and pediatricians, but there are fewer drivers for adult vaccines.

The good news, though, is that the pandemic focused attention on the pharmacy as a safe, easy, reliable place to get vaccines. There is growing pressure at both federal and state levels to make permanent many of the pharmacy practice waivers put in place during the COVID-19 public health emergency to maintain and increase vaccine access.

The prevalence of influenza is significantly higher this year than during the 2020-2021 season, Foster noted, though hospitalization and mortality rates remain below prepandemic levels. All currently recommended flu vaccines are quadrivalent, with some egg-based and some not egg-based.

There are no preferences by brand, he added, which gives pharmacies more flexibility to administer whatever product is easiest to obtain based on age. FluMist, for example, is not approved for those younger than 2 or older than 49, while Afluria, Fluarix, FluLaval, and Fluzone are approved for those 6 months and older. Fluad and Fluzone High-Dose are approved for adults 65 and older.

With approximately 100 distinct serotypes of pneumococcal disease, pneumococcal vaccine development has been an exercise in adding more and more serotypes to each successive product, Goad said. The newest vaccine covers 23 serotypes.

The latest pneumococcal vaccine recommendations are relatively straightforward: Adults 65 ad older who are pneumococcal vaccine-naïve 

 whose pneumococcal vaccine history is unknown should receive a single dose of either the pneumococcal 20-valent conjugate vaccine (PCV 20; Prevanr 20) or the pneumococcal 15-valent conjugate vaccine (PCV 15; Vacneuvance). If PCV 15 is used, it should be followed by a dose of the pneumococcal polysaccharide vaccine (PPSV23; Pneumovax23).

Similarly, adults aged 19 to 64 with underlying medical conditions or with other risk factors who are pneumococcal vaccine-naïve or whose pneumococcal vaccine history is unknown should receive a single dose of either PCV 20 or PCV 15. If PCV 15 is used, it should be followed by a dose of PPSV23.

Currently, there are no comparative studies on efficacy of PCV 20 vs PCV15 plus PPSV23. “If you’re going to give 1 dose, use PCV20 and you’re done,” Foster said.

New for this year is a tacit recommendation for universal adult vaccination against Hepatitis B, said Foster.

Recommendations approved in November 2021 say that all adults aged 19 to 50 and those 60 and older with risk factors for hepatitis B infection should receive hepatitis B vaccine. Adults 60 and older without known risk factors for hepatitis infection may receive the vaccine.

“[The] hepatitis [B] vaccine is more effective when given at a younger age, but you can now say that everybody gets vaccinated,” Foster said. “We have multiple vaccine options on the market, including a new one, PreHevbrio [hepatitis B vaccine (recombinant)], approved in November 2021.”

The latest recommendations call for 2 doses of the recombinant zoster vaccine (Shingrix) for all adults aged 19 and older who are, or who will be, immunodeficient or immunosuppressed due to disease or therapy.

The dengue vaccine (dengue tetravalent vaccine, live; Dengvaxia) is now recommended for individuals who are seropositive from a prior infection to reduce the risk of severe disease if infected again. Vaccination is not recommended for those without prior infection.

“You have to know the patient has an active antibody response before you vaccinate, which makes it very difficult to operationalize,” Goad said. “But if you give dengue vaccine without a prior infection, it puts the patient is at high risk for severe disease.”

Foster SL, Goad J. Know the facts: Annual immunization update. Presented at: American Pharmacists Association 2022 Annual Meeting & Exposition; March 18-21, 2022; San Antonio, TX

Articles

There’s more to vaccines than just COVID-19.

APhA: Annual Pediatric, Adult Immunization Update

Best Value Pharmacies is under attack. Every week, the 13 Dallas-Fort Worth area stores stop multiple online attacks every week. Some cyberattacks are as obvious as a receipt of invoices from vendors the company has never used, sent from online accounts outside the United States—and sometimes not even in English. Some of these attacks look like legitimate emails but carry hidden malware designed to open the company up to ransom and theft.

“Some of those cyberattacks have gotten through our outer defenses, firewalls, antivirus programs, and other protections,” said Jason Carter, chief technology officer at Best Value Pharmacies. “Luckily, we train all our employees to think before they click. Knock on wood—our staff have stopped the intruders.”

Best Value isn’t alone: Every pharmacy, large and small, as well as every health care provider and organization, is in the crosshairs.

“Hackers see pharmacy and health care as low-hanging fruit,” Carter said. “Any organization that has protected health information (PHI) is a rich target. Independent pharmacies don’t always have the advanced firewalls and security that larger organizations have.”

“It’s all about value,” said Jeff Hedges, president and CEO of R.J. Hedges & Associates, a pharmacy compliance consultant group in New Florence, Pennsylvania. “The black-market value of a Social Security number is under $1, [and] a credit card [is] maybe $5,” he explained. Patient health records, on the other hand, are valued at $250. “It’s not a matter of if you will be attacked—it’s when and how you protect yourself.”

The Health Insurance Portability and Accountability Act (HIPAA) of 1996 defines PHI as inclusive of any information within an individual’s health record that can identify them. Unlike a credit card that can be cancelled, PHI can’t easily be cancelled or changed.

PHI typically contains multiple types of health, financial, personal, social security, and insurance information, among others. Stealing multiple types of data fuels multiple criminal uses, from accessing bank accounts and other financial assets to fake prescriptions, receiving treatment, filing false claims, and beyond. Because PHI is difficult to cancel or change, misuse can generate illicit income for years after a breach has been identified and plugged.

Pharmacies offer other targets for cyber criminals as well, including employee data and financial assets. Ransomware programs can be introduced into any computer system, often by opening an infected email attachment. These nefarious programs encrypt system data and hold it for ransom. Ransomware is widely available online and is often employed by groups with a global reach.

“These gangs carefully vet their targets before attacking,” said Nick Dorazio, president of LVTech LLC, a health care cybersecurity provider in Greensburg, Pennsylvania. “I’ve seen pharmacies hit for $10,000 ransom, and the same program used against larger pharmacies to collect millions. It’s a massive, organized operation run by people who go into the office every day, and their only job is to break into you.”

Six Steps to Protect Your Pharmacy From Cyberattack

More than one-third of health care organizations in the United States were hit by ransomware attacks in 2020, Hedges said. Approximately 65% of these attacks were successful, and approximately one-third of the organizations that had data stolen paid up. However, only 69% of organizations that paid ransom actually got their data back.

“Don’t think that just because you are a small independent pharmacy that you are safe,” said Dallas Moore, PharmD, MS, director of pharmacy informatics and technology at the University of Utah Health Hospitals and Clinics in Salt Lake City. “We are all targets, all the time. The problem is only going to get worse.”

ECRI, a global health care quality and safety group, identified cybersecurity attacks as the top health technology hazard for 2022.

 Health care is a popular target, along with accommodation, the public sector, retail, and finance, according to digital security specialists at Ekran System. IBM Security reports health care has had the most expensive cyber breach costs for the past 11 years and an average of $9.23 million per breach in 2021.

Insurance policies rarely cover the entire financial cost of a cyber breach, Hedges cautioned. Any HIPAA breaches can lead to massive fines that are not discharged in bankruptcy, and no insurance policy can restore patient trust lost in a cyber breach.

“Protecting yourself starts with pharmacy leaders and staff educating themselves about the risks and the impact cyberattacks can have on your organization and your patients,” said Melissa Skelton Duke, PharmD, MS, BCPS, FAPhA, executive director of population health pharmacy solutions at Banner Health in Phoenix, Arizona. “The second thing is to minimize the risk of cybersecurity attacks in day-to-day operations. It’s a cat-and-mouse game that is always evolving.”

Solid cybersecurity takes a layered approach. The first layer is a private domain—something like fredspharmacy.com, Dorazio said. A private domain enables company email, which is easier to secure than multiple employee email addresses. “We still see pharmacists using AOL for their email, which is anything but secure,” said Dalton Fabian, PharmD, data scientist at UnityPoint Health in Des Moines, Iowa. “Not using a company email for your pharmacy, or allowing employees to log in using their personal email, is inviting attack.”

Just as physical security starts with an alarmed wall, cybersecurity starts with a firewall that can be tuned to stop threats from the outside, block outgoing connections to unsafe locations, and prevent downloads of content, such as online games that may harbor malware. A virtual private network encrypts traffic, which is a key safeguard when staffers log into the pharmacy system remotely.

“Work with your IT [information technology] vendor to design your protection, first by finding an IT security vendor who knows health care—preferably pharmacy,” Fabian said. “We have specific cybersecurity needs and vulnerabilities.”

The next layer of security is antivirus. Dorazio recommended active EDR/XDR (end point detection and response/extended detection and response) antivirus. With cyber crooks using artificial intelligence (AI) to create malware, pharmacies need AI protection. “EDR/XDR is AI-based to detect [emerging] threats,” he said. “Having these active protections on each device is one of the best ways to stop intruders.”

The final layer is staff training. Phishing—emails designed to trick users into disclosing information, opening infected attachments, or visiting infected websites—is the source of most ransomware and other malware, Dorazio explained. Every person with any access to any part of the pharmacy system—from the owner to the newest part-timer—should be trained to recognize phishing.

“The most effective approach is a short training session with a surprise phishing test from you or a security firm like ours,” he said. “That [instantly] tells you who got the message and who needs to pay more attention.”

The key is to look at where the email came from and where any active links lead, Dorazio explained. Before visiting any links, right-click to see the true source of an email and the true destination of a link. “Think before you click,” he said. “If there is one-half of 1% of doubt, don’t click on it. If you’re not expecting something, chances are it’s not real.”

. Published January 25, 2022. Accessed February 10, 2022. 

https://www.accountablehq.com/post/why-is-phi-valuable-to-hackers

Hedges J. Dreaded reality of ransomware in pharmacies part 1 [podcast]. R.J. Hedges and Associates blog. Published January 6, 2022. Accessed February 10, 2022. 

https://www.rjhedges.com/blog/how-to-protect-your-pharmacy-against-ransomware

Top 10 health technology hazards for 2022. ECRI. Accessed February 10, 2022. 

https://assets.ecri.org/PDF/White-Papers-and-Reports/ECRI_Top10Hazards_2022_ExecutiveBrief.pdf

Tunggal AT. What is the cost of a data breach in 2021? UpGuard blog. Updated January 14, 2022. Accessed February 10, 2022. 

https://www.upguard.com/blog/cost-of-data-breach

How to be a healthcare BA and not lose 25 million PHI records. Agio blog. Published November 29, 2021. Accessed February 10, 2022. 

https://healthcare.agio.com/newsroom/how-to-be-a-healthcare-ba-and-not-lose-25-million-phi-records/

Personal health information is among the most valuable black-market data for cybercriminals to collect and sell.

Black Market Boom: Protecting Pharmacy Data from Cybercrime

An emerging body of evidence is changing perceptions and approaches to rheumatic diseases in children. Pharmacists can expect more demand for biologic agents for children with lupus, polyarticular juvenile idiopathic arthritis (pJIA), and other pediatric autoimmune conditions and less reliance on conventional disease-modifying antirheumatic drugs (DMARDs).

Growing recognition that similar exposure to biologics in children and adults produces similar results could bolster the use of pharmacokinetic matching to extrapolate efficacy from adult to pediatric populations. Pharmacokinetic-based approvals could ease the path to more pediatric approvals and broader off-label pediatric use of agents approved for adults.

“Pediatric rheumatologists are well aware that children with JIA do respond well to biologics and that biologics have dramatically changed outcomes for children with JIA,” said Yukiko Kimura, MD, professor of pediatrics at Hackensack Meridian School of Medicine and chief of the Division of Pediatric Rheumatology at Hackensack Meridian Health in New Jersey.

But, Kimura said, “clinical inertia and insurers requiring step therapy––failing DMARDs before you can use biologics––are common barriers to starting biologics early in children.” For these patients, the question becomes, “How we can personalize treatments to get the best outcomes?”

Kimura was the principal investigator for the STOP-JIA trial (NCT02593006),1,2 an observational cohort study comparing 3 initial therapeutic approaches to pJIA: DMARDs only, biologics only, and a combination of DMARDs plus biologics. Data came from the Childhood Arthritis and Rheumatology Research Alliance (CARRA), a nationwide registry of more than 12,000 children with lupus, JIA, and other rheumatic diseases.

Although all 3 patient groups showed improvement, 59.4% of the combination therapy group had clinically inactive disease after 24 months compared with 48% of the biologics-only group and 40.1% of the DMARDs-only group. When the investigators observed disease activity over time, patients in the trial fell into 1 of 3 groups: slow, moderate, or rapid improvers. The trajectory analysis of treatment response showed that the 3 groups began to diverge within 3 months, Kimura noted. The single most important predictor of rapid improvement was early initiation of biologic therapy after pJIA symptoms appeared.

“Regardless of which treatment plan a child was started on, if they started a biologic within 3 months of symptoms appearing, their chances of being in the best response group increased by 3.5 times, supporting the idea that starting biologics is superior,” she said.

However, she added, there were a few children in the rapid improver group who received only conventional, nonbiologic DMARDs. For this small group of children, early initiation of DMARDs was the significant predictor of rapid improvement.

“Understanding how to distinguish patients who aren’t going to respond to methotrexate versus the patients who will do very well on methotrexate is critical,” Kimura said. “We need to be able to tell which patients need to start biologics early and which patients may not need to be exposed to biologics at all.”

One of the enduring barriers to treating children is the paucity of pediatric clinical trials compared with adult trials. Adjusting adult dosing to child sized bodies doesn’t always work.

“Children aren’t just little adults,” said Aimee O. Hersh, MD, an associate professor and chief of the Division of Pediatric Rheumatology at the University of Utah in Salt Lake City. “Pediatric patients are still growing and developing their bodies and their immune systems, so their reactions to treatment aren’t always the same as adults. And their disease isn’t the same.”

Up to 20% of all patients with lupus have childhood onset, Hersh said. This is a total of approximately 10,000 children and adolescents in North America alone. Children with lupus have higher rates of organ disease, including lupus nephritis; premature atherosclerosis with increased risk of myocardial infarction; multiple skeletal deficits; and multiple psychosocial impairments that extend into adulthood.

“Most of the treatment approvals in childhood lupus have been extrapolated from adult studies,” she continued. “Patient-reported outcomes could be very different for pediatric patients versus adult patients, as well as medication, disease, and [adverse] effects. Seeing more trials and outcomes through the lens of the child, and the adult managing their long term development is crucial.”

One way to learn more is to follow children over time. Hersh is the current chair of CARRA, which follows children for at least 10 years to glean longer-term data on the natural history and treatment outcomes of pediatric rheumatic diseases. CARRA and other pediatric rheumatology groups are also pushing the FDA to require pediatric arms of adult studies for new and extended approvals.

An FDA comparison of treatment response between those with pJIA and adults with rheumatoid arthritis (RA) suggests another approach to pediatric approvals. Pharmacy investigator and study author Renu Singh, PhD, reported on a response-and-exposure comparison of registration trial data for infliximab, tocilizumab, golimumab, and adalimumab in pJIA and adult RA.

Results of the exposure comparison showed that exposure in pJIA trials was similar to or higher than exposure in adult RA trials across all 4 biologics. The sole exception was lower pediatric exposures to infliximab in patients weighing 70 kg or less. The pJIA response was similar to or higher than responses in adult RA trials, suggesting that children may be more like little adults than we currently believe—at least when assessed by exposure to di. erent biologics.

“These analyses provide support for the use of pharmacokinetic exposure matching for extrapolation of efficacy from adults with RA to children with JIA for products with an established mechanism of action,” said Mara L. Becker, MD, MSCE, a professor of pediatrics at Duke University School of Medicine in Durham, North Carolina. “This bridges a huge gap in clinical pharmacology and may allow for therapeutic approvals with an adequate pharmacokinetic study that matches a pediatric dose with an exposure associated with e. Cacy in adults. This is a big step forward in therapeutic approvals.”

Treatment adherence is a problem in most diseases and most patient populations—pediatric, adolescent, or adult. Community pharmacists have long shown that refill reminders can boost adherence for a variety of medications and on the hardware side, multiple companies have developed pill vials and other devices to remind patients when a dose is due. The iPersonal trial (NCT04358302)4 is bringing automated reminders to a home-based adherence and exposure response trial of hydroxychloroquine in children and teenagers with lupus.

The trial uses an automated pill vial cap, Pillsy, that provides audio, visual, and electronic medication reminders. If the vial is not opened within 10 minutes of a scheduled dose, it flashes visual and audible signals.

The patient or caregiver can also opt in to receive additional text and telephone reminders. The vials record all openings, including scheduled pill counts, erroneous openings, or refills, which allows the study team to reconcile pill counts and doses dispensed as reported by the electronic pill vial.

Patients were recruited from the CARRA registry. “If you have any doubts about the design of this trial, they met their enrollment goal within 10 days, during COVID-19,” Becker said. “And they have a waiting list of people who are interested in participating.” The trial was completed in mid-2021 and final results are pending.

Emerging evidence is changing health care providers’ approach to treating pediatric rheumatic diseases.

Update on Childhood Rheumatic Disorders

 bring a broad network of business experts who can help with everything from buying your first pharmacy through selling your final pharmacy before retirement and maximizing profits during the decades between. 

 supports the entire life cycle of pharmacy ownership and profitability.

“Pharmacy is evolving and pharmacy owners have to evolve with the profession,” says Jennifer Zilka, 

 group vice president of Field Programs and Services.

“Pharmacists go to pharmacy school because they want to help patients. The running of the business side is often secondary in terms of their own priorities. That is why it is so important to have partners who can help them identify what kind of opportunities will make the most impact for what they want to do in pharmacy. Our goal is to give our pharmacists more time with their patients.”

 Pharmacy Ownership Program matches pharmacists who want to sell with pharmacists who want to buy. And because sellers are most often existing 

 members, the prospective buyer has access to detailed sales and operations data that a typical buyer can only dream about.

 banking partners are ready to offer the best terms. They know the new pharmacist-owner will be in good hands with 

 business partners, consultants, and coaches. 

 business support network gives pharmacy owners important business and financial advantages.

AmerisourceBergen’s Pharmacy Services Administrative Organization (PSAO), Elevate Provider Network, doesn’t just negotiate contracts, it constantly monitors and reevaluates contract performance and changing market conditions. Detailed data from every 

“We know the insurance cards patients at each of our stores are using,” says Chuck Reed, AmerisourceBergen’s vice president for Pharmacy Innovation and Solutions. “We see every claim, we know the patient population, and we can see details like patient sensitivity to copay changes that aren’t always obvious at the store level. We have the data that prompts us to make some tough calls and the gumption to stay with those calls.”

In 2017, for example, AmerisourceBergen recommended that pharmacies not join a preferred provider network offered by one of the largest health plans in the nation. Data showed that the plan population was loyal and had a large proportion of low-income-subsidy Medicare patients. Pharmacies could maximize reimbursement by staying out of the preferred network and focusing on Medicare scripts.

“Not only have we not lost patients by not joining the preferred network, in this case, we are up double digits in that plan this year,” Reed says.

Elevate’s proprietary pharmacy analytics system, InSite, help pharmacies track and review every claim. Other programs help pharmacies correct rejected claims to move toward 100% reimbursement.

Inventory management is another vital issue.

“Independent pharmacists have a tendency to want to have every product all the time,” Zilka explains. “It goes back to wanting to help their patients. We can help pharmacists tailor their inventory to have the right products on the shelf at the right time so they aren’t carrying excess inventory and cutting into their own earnings.”

Other coaching programs help owners focus on specific areas such as employee training and motivation, front end operations, attracting the next generation of patients, and keeping one step ahead of the competition.

Advocacy is another vital area. AmerisourceBergen’s OurIndependentVoice.com gives independent pharmacists a voice by providing a centralized place to access tools and resources to join advocacy movements that impact care in their community setting, research policies supporting independent pharmacy, access letter templates, write to legislators and connect with other pharmacists and pharmacy organizations.

And when it’s time to sell, the Pharmacy Ownership Program can help once again.

“We like sales three to five years out where we can use business coaching to maximize the value of the business and find the ideal buyer,” Zilka says. “We are not reimbursed for our matchmaking services by our pharmacies, so a deal has to make sense for both buyer and seller or we don’t pursue it. Our goal is to keep independent pharmacies independent. That’s good for our owners and good for AmerisourceBergen.”

How the right partner can help protect the independence of community pharmacy.

AmerisourceBergen and Good Neighbor Pharmacy Work to Keep Independent Pharmacy Healthy, Profitable

Pharmacists in almost every setting are pushing for provider status. While provider status is the most direct and transparent way to get paid for clinical services, it’s not the only way. Pharmacists who learned how to navigate the reimbursement system have been getting paid for clinical services for years.

“We started our first pharmacist-managed ambulatory care clinic in 1996 and have been getting paid for our services from day one,” says Dean T. Parry, RPh, assistant vice president for clinical informatics at 

. “Today we have about 60 pharmacists working full time in ambulatory disease and medication management. Getting paid is a matter of figuring out where in your specific administrative and financial system you can fit in. Provider status would be nice, but it is not a prerequisite to getting reimbursed for clinical services,” says Parry.

Like many other integrated networks, Geisinger covers only about 40% of members through its own insurance program. The remaining 60% are covered by standard commercial payers. The key to convincing commercial payers to reimburse clinical pharmacy services is to provide a reasonable return on the payer’s investment, says Parry.

Payers have seen all the data on the health and financial outcomes of clinical services. Parry says that they know just as well as pharmacists that the appropriate pharmacy interventions can improve health outcomes and reduce overall costs of care-over time.

“Payoff time is the obstacle for payers,” he explains. “They need to see a payoff in reduced total cost of care in less than one year. That might be possible in some disease states, but the return on investment for anticoagulation, asthma, COPD, cardiovascular disease, and most chronic diseases is too long term for most payers to work with.”

The current wave of consolidation among payers, 

s, pharmacies, wholesalers, and providers may ease the ROI problem. With far fewer payers in the system, each payer is more likely to retain patients for a longer period of time, Parry suggests. The longer patients remain with a single payer organization, the longer that payer’s time horizon for a return on its clinical pharmacy investment.

Integrated networks like Geisinger seldom worry about whether their pharmacists can bill payers directly, Parry said. Clinical pharmacists are part of the overall patient care team working to control costs, reduce admissions, improve adherence and provide more effective care. When pharmacists are part of the patient care team, the health system looks to the total cost of care versus the total reimbursement for care. Whether services are reimbursed directly or through some other provider becomes an accounting exercise for the integrated health network. The key to convincing commercial payers to reimburse clinical pharmacy services is to provide a reasonable return.

Getting Reimbursed for Services Rendered: It’s no Magic Trick

For now, closed systems like Kaiser, where a network is exposed to patients’ entire cost of care over multiple years, have an easier time justifying the financial investment in clinical pharmacy services. Pharmacists in other settings must find an appropriate work-around. Closed system pharmacists don't get reimbursed individually because the system is responsible for everything: insurance coverage, cost of care, quality of care, patient and provider satisfaction. If a third party payer is involved-Medicare, Medicaid, or some other public system-the system gets reimbursed, not the provider.

Up next: Collaborative agreements and how to get started

A work-around usually means teaming up with another provider who has the necessary reimbursement status, most often a physician or nurse practitioner. Many states have collaborative practice agreements that make it relatively straightforward for pharmacists to provide clinical services under protocol with another provider and bill for services through that provider. The billing provider shares reimbursement under terms agreed to by both provider and pharmacist. If pharmacy is part of an SSP, reimbursement is simply part of health plan revenues that go to pay all providers.

Geisinger started with a single pharmacist, Parry, and a collaborative practice agreement with a single neurologist to handle anticoagulation. Today, Geisinger pharmacists are covered by a network of overlapping collaborative agreements with multiple providers to ensure that clinical pharmacy services are eligible for reimbursement.

These agreements may not be the ideal reimbursement solution, but it’s a workaround that can work for an entire career.

“I’ve been prescribing and adjusting drug therapy almost since the day I got out of pharmacy school,” says pharmacy consultant Fred Pane, RPh, former hospital pharmacy director. “Granted, I worked mostly in hospital pharmacy, but there is always a way to work around not having provider status. You do it by solving clinical problems for providers who do have the right reimbursement status.  When you become an indispensable member of the patient care team, there are always ways to get paid for your services,” says Pane.

The key to building collaborative practice and reimbursement is creating a concrete plan that solves provider pain points, says Parry.

The first step is to evaluate published outcomes and cost data against your own practice and project returns locally. Once the program has local buy-in, pharmacy creates standardized work flows for interventions, data collection, and data reporting on patient and financial outcomes. Standardized clinical procedures and data collection makes it easier to document both interventions and outcomes.

“One of our programs worked with difficult-to-manage diabetes patients with elevated hemoglobin A1c levels,” Parry says. “Clinical pharmacists brought more than half of them to A1c goal in less than one year. That kind of data sells itself.”

Pharmacists are finding ways to get reimbursed for clinical services. See what you can do to get paid.

How to Get Paid for Pharmacy Services

 state to adopt telepharmacy legislation. The legislation is expected to be signed into law this year with the first outlets scheduled to open in early 2019.

	Six other states have authorized pilot programs that could apply to telepharmacy and five states permit waivers of legislative or administrative requirements that could allow for telepharmacy, according to the Rural Policy Research Institute at the 

University of Iowa College of Public Health

Telepharmacy: New Jobs, Expanded Opportunities

	As more states adopt telepharmacy legislation, some pharmacists are raising concerns over what it could mean for patients and the pharmacist job outlook. To help address those concerns and others, the 

, which supports the legislation, negotiated a series of protections for pharmacists and patients.

	“The big issue that came up from some of our members and other stakeholders is to ensure that this is a safe practice,” says association CEO Kelly Fine, RPh. “We are equipping and training both technicians and pharmacists, making sure that security and surveillance are sufficient, and requiring HIPAA-compliant high-definition video conferencing for face-to-face interaction with the remote pharmacist.”

	Most telepharmacy locations will likely be in rural areas, at least to start, she says. But community health centers and hospitals have also expressed interest. "So have independent pharmacists who want to expand into pharmacy deserts, areas with few or no pharmacies and severely limited local access to pharmacy care."

	The potential for urban expansion has raised objections among some pharmacists. “This bill can and will likely be used to lay off hundreds of pharmacists and convert hundreds of ‘underperforming’ pharmacies in urban areas, effectively reducing pharmacist jobs by over 75%,” says P. Charles Zaffrey, RPh, pharmacist at 

, a supermarket chain pharmacy in Tempe, AZ, who opposed the legislation.

Kmart Opens First Telepharmacy with Plans for More

	The Arizona Pharmacy Association insisted on including language in the telepharmacy legislation that may help prevent such problems from occurring. The legislation limits pharmacists to overseeing one remote location in addition to managing operations in their own physical location. Pharmacists who do not have oversight responsibilities for a physical pharmacy will be allowed to oversee two remote locations. 

	Adam Chesler, PharmD, director of regulatory affairs for 

, which is backing the legislation, says many providers who fear job loss due to telepharmacy may have misconceptions about state-level legislation.  

	“One of the lessons we have learned is the need for provider education,” he says. “Anything and everything a pharmacist has to do in a physical pharmacy today still has to be done in a telepharmacy. None of the steps of pharmacist involvement in oversight, counseling, and clinical responsibilities is gone with telepharmacy. If anything, you see increasing clinical involvement by pharmacists because they are able to see more patients as telepharmacy expands access.”

	Mark J. Hardy, PharmD, executive director of the 

, says pharmacist employment hasn’t fallen since North Dakota became the first state to authorize telepharmacy in 2002.

Genoa MMS: Medication Management for its Community Pharmacies

	“If anything, telepharmacy has expanded the hiring of pharmacists across the state,” he says. “It has allowed them to focus on clinical duties and interact with more patients than ever before by expanding pharmacy access. If there have been job losses, they are attributable more to economics than to telepharmacy.” 

	Beyond jobs, telepharmacy is also creating opportunities for patients.

	“The big pro for telepharmacy is better access to medications and to pharmacists,” says Mohamed A. Jalloh, PharmD, assistant professor at 

Touro University California College of Pharmacy

, community pharmacist, and a spokesperson for the APhA. “The reality is there are places in every state where access to pharmacy is difficult to impossible. Telepharmacy can increase access.”

	Telepharmacy seems to be expanding steadily, if not quickly.

	“Pharmacists are learning about it and state boards are taking deliberate approaches to be sure it will work in their state,” says Lisa Schwartz, PharmD, senior director of professional affairs for the NCPA. “And thanks to software advances, you no longer have to come up with technology solutions by yourself. When you have a turnkey package, the business case makes more sense.”

Arizona joins a growing list of states to adopt telepharmacy legislation. Here’s how it could affect pharmacists. 