Keith Loria is a contributing writer to Medical Economics.

Keith Loria

Despite decades of research, there is still no vaccine against HIV. As a result, pre-exposure prophylaxis (PrEP) has emerged as the most promising preventive strategy against the virus that causes AIDS. PrEP is the use of antiretroviral medications by HIV-negative individuals who are at risk of contracting the disease to reduce that risk.

But the PrEP regimens have involved taking a pill on a daily basis, which makes them ripe for nonadherence.

But in on Dec. 20, 2021, the FDA approved Apretude (cabotegravir extended-release injectable suspension), the first injectable formulation of PrEP. Instead of daily pills, Apretude will involve getting an injection in the muscle of the buttock by a healthcare professional once every two months, although the first two shots are given a month apart.

“It will not be for everyone; some people may want to continue with a daily oral pill,” notes Carl Schmid, executive director of the HIV+Hepatitis Policy Institute, an advocacy organization funded by several pharmaceutical companies. “They are fairly easy to take and there are limited side effects. People will continue to have to visit their provider for recommended periodic follow up labs and tests.”

 (tenofovir disoproxil fumarate and emtricitabine) was approved in 2012. Generic versions have come on the market since, particularly in the past year, and prices have dropped. The GoodRx’s lowest price today a 30-day supply of the most common version of generic Truvada is $35.96. What’s more, most people with private insurance do not have to pay cost sharing since it is a preventive drug approved by the United States Preventive Services Task Force.

Still, Schmid note some people may find it easier to get the injectable every two months.

“They will have to make their own decision, based on discussions with their provider, as to what is best for them,” he says. “Whatever option they choose, it is important for them to adhere to their medication as prescribed and have the periodic HIV, STI (sexually transmitted infection) and other lab tests. While PrEP protects against HIV, it does not protect against other STIs.”

The CDC says that in 2020, about 25% of the 1.2 million people for whom PrEP is recommended were prescribed it in 2020, compared with about 3% in 2015. The agency credits PrEP and other factors with reducing the new HIV infections: They fell from 37,800 in 2015 to 34,800 in 2019, a decrease of 8%.

This article was originally published on 

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Administered as an injection every other month, Apretude gives people at risk of contracting HIV a PrEP alternative to taking daily pills.

Injection Now Available to Help Prevent HIV

As an industry, virtual reality (VR) has moved far beyond a tool for gaming and entertainment: Over the last decade, VR—a market with a global value of $17.25 billion in 2020 and an anticipated growth to $184.66 billion by 20261—has gained a foothold within the larger health care industry. VR simulation is being used for everything from medical education to pain management to rehabilitation.

Pharmacists—and the pharmaceutical industry—are also learning just how VR can make a difference, as well as the significant role it can play in patient care.

Mary Youssef, PharmD, RPh, a mobile IV infusion therapist for HealthIV, noted that pharmacies and pharmacists have been exploring the possibility of better workplace accuracy and efficiency for years. This has slowly led to the study of VR in the burgeoning pharmacy field.

VR technology in health care grew from the desire to create immersive sensory experiences in virtual environments. This sensory delivery produces different stimuli in several ways to replicate the physical world. The experience is almost indistinguishable to that provided by natural stimuli and affects all 5 senses.

“With regards to pharmacy, VR can potentially be applied as follows: added to or as a replacement for some drug therapies; in patient counseling and behavior modification; in drug design and discovery; and in pharmacist education,” Youssef said.

“There is still ongoing research with VR systems in these fields.” In a 2019 study

 published in Pharmacy and Therapeutics, investigators explored many of these applications.

“The majority of studies conducted during the past decade have found VR to be safe and e.ective, and to promote a high degree of user satisfaction,” the authors wrote, adding that “VR technology has become increasingly affordable, flexible, and portable, enabling its use for therapeutic purposes in both inpatient and outpatient environments.”

Ani Rostomyan, PharmD, has been practicing as a clinical pharmacist in Los Angeles for 7 years. An avid user of and educator about VR, she recently founded SheAni, Inc, a concierge consulting company that teaches patients and health care practitioners about drug metabolism, drug mechanisms of action, and pharmacogenomics utilizing VR.

She explained how VR provides a multisensorial experience, which enhances therapy and elicits true emotional and physiological responses that are nearly identical to the responses in real-life situations.

“As VR has advanced in pharmacy, I have noticed the storytelling format playing a bigger role,” Rostomyan said. “By making these complex and highly intricate biochemical processes more accessible and easier to understand, it helps patients get a better grasp of the information [that is] given to them, creating a much better environment for patient medication [adherence], disease state understanding, and patient outcomes.”

Kimberly Garza, PharmD, PhD, MBA, an associate professor and graduate program o.cer at Auburn University Harrison School of Pharmacy in Alabama, has been working with VR for some time.

“I first came to VR in the context of entertainment. It’s such a powerful experience and embodies the avatar that you are taking a perspective of, and it can really change people’s perception,” she said. “Once I started looking into how VR was being used in health care, I wanted to…learn how it could help with treatments.”

Using Auburn University’s dedicated VR space in their Innovation & Research Commons facility, Garza discovered how she could help patients with rheumatoid arthritis, utilizing VR to show them what disease progression would look like across differing treatment options.

Her pharmacy students are combining VR and haptic devices—mechanical devices that mediate communication between a user and computer—to learn about various physical limitations that patients may experience. Garza noted that the empathy-building learning activities are critical to the successful development of professional identity among her pharmacy students.

“Virtual reality creates a feeling of actually being there, a feeling that events are actually happening and… that you are actually inhabiting the virtual body,” Garza said.

The availability of VR systems in pharmacies can promote medication adherence and medication therapy management, as well as facilitate the development of a therapeutic action plan, according to Youssef.

“This can be done by providing short visual and auditory instructions regarding [the] medication and demonstrating techniques or administration practices,” she said. “Patients could then use the system to perform these behaviors virtually, allowing them to practice without harming themselves or wasting medication. Most patients are too shy or too anxious in the pharmacy to ask for advice or help, therefore with the introduction of self-serve VR, patients can step to the side and immerse themselves at ease.”

Study findings have also shown that a combination of VR and medical pain management can reduce severe pain experienced by people receiving wound care for burn injuries. VR helps control pain as it captures the mind’s attention and blocks pain signals from reaching the brain. It is akin to active hypnosis as it provides tactile and sensory feedback and enables the rallying of the neurotransmitter mechanisms that decrease pain. It can also be used to make injections and other painful or potentially frightening procedures less distressing to children.

VR has also proved effective for acute or chronic pain caused by injuries, and by cancer, neuropathy, migraine headaches, fibromyalgia, and pruritus, among other conditions.

“Perhaps the most highlighted implication regarding its efficacy is its potential to reduce the use of opioids, presenting a beacon of light in the current opioid crisis,” Youssef said. VR has also been studied as a treatment for anxiety and other mental health disorders.

“The current drug remedies available for such disease states work to influence physiological systems, easing the mind,” Youssef said, “whereas VR treats cognitive systems, immersing all senses in real-time use. This may be used to target treatment options not addressed by current drug models.”

 whose results were published in JMIR Mental Health in 2017, described how patients who used VR programs were able to dramatically decrease pain scores without any adverse effects or abnormal vital signs.

“VR is not meant to be a sole treatment or modality for pain management,” Rostomyan said. “However, VR amplifies the effectiveness of other traditional approaches such as medications, physical therapy, and exercise.”

In a landmark decision, the FDA recently approved the first VR system for chronic lower back pain,

 providing an opioid-free alternative to many current pain management regimens. AppliedVR is behind the EaseVRx device, which utilizes cognitive behavioral therapy and other therapeutic techniques to guide patients through games, lessons, and exercises to reduce their chronic back pain. The immersive software experience comes about through a VR headset.

Patients are required to use the device for 2 to 16 minutes every day for 8 weeks. Through this treatment, the VR therapeutic offerings stand in for traditional treatment options.

“We worked tirelessly over the past few years to build an unmatched body of clinical evidence that demonstrates the power of VR for the treatment of pain and couldn’t be more thrilled to achieve this important milestone,”Josh Sackman, cofounder and president of AppliedVR, said in a company statement.

“But our mission does not stop with this one approval. We’re committed to continuing research that validates our efficacy and cost-effectiveness for treating chronic pain and other indications.”

Most pharmacists advocating for VR believe it o.ers several advantages due to its creating an artificial environment so similar to the real world. “This implementation can even [be applied in] the educational sector to better understand drug binding and efficacy in the body with future pharmacokinetic use,” Youssef said.

“The enveloping effect of the virtual world has significant potential. With further research, more data will become available regarding its efficacy, and as the technology improves, costs and other obstacles will be reduced. Having another world in the pharmacy may begin to bridge the dissonance we see with patients and medication.”

A look at how virtual reality is making an impact on pharmacists and
patient care.

Rx for VR: The Role of Virtual Reality in the Pharmacy

In 2019, opioid overdoses were responsible for the death of nearly 50,000 Americans, according to the National Institute on Drug Abuse.1 These opioids- which include prescription pain relievers prescribed after surgical procedures—are part of a “serious national crisis” that has impacted everything from public health to social and economic well-being.

Data show that both opioid-naïve and non–opioid-naïve surgical patients are at high risk for chronic opioid use following surgery, but it can be challenging to minimize these risks while appropriately managing postoperative pain. In fact, according to a recent report presented at the American Society of Anesthesiologists annual meeting, 1 in 5 opioid-naïve patients continue to use opioids 3 months after surgery,

 a statistic that many pharmacists are trying to change. 

Joe Moose, PharmD, co-owner of Moose Pharmacy in Concord, North Carolina, and director of strategy and luminary development for CPESN USA, said that starting a patient on opioids comes with the responsibility of setting realistic expectations on what pain management should be and how it should be controlled.

“A patient should be continuously educated on their pain medicine instructions to ensure that they are only taking [the medication] for the necessary amount of time,” he said. “Education...is rarely provided to patients [in a comprehensive way].” 

Another significant problem is the irregular, inconsistent enforcement of prescriber limits. Although policies are in place, for both providers and pharmacies, factors like auto-renewals and too-high-of-volume fills both contribute to prolonged, inappropriate use.

Anna Legreid Dopp, PharmD, senior director of clinical guidelines and quality improvement for the American Society of Health-System Pharmacists (ASHP), said that recognized risk factors for opioid misuse or opioid-use disorder (OUD) include a family or personal history of substance abuse, untreated psychiatric conditions, younger age, and social environments that encourage misuse.

“Thanks to our ability to track trends in opioid-use data, we have learned that early prescribing patterns of opioids, especially for those who are opioid naïve, [have] significant influence on the potential for long-term use,” Dopp said. “[The] risk of chronic opioid use...increases with each additional day of medication prescribed—

starting with the third day. This has led to numerous evidence-based policies that limit opioid prescribing to a certain amount of days, often required by institutional, state, or payer policies.”

According to Jim Lichauer, PharmD, BCPS, FASHP, performance improvement program director of pharmacy for Vizient, Inc, prescribed quantities and refills should be limited to 7 to 15 days, or up to 30 days with no refills. “[CDC data] show that the use of prescription refills after a patient’s initial opioid prescription is associated with an increased incidence of persistent opioid use at 1 year,” he said.

Hospital pharmacists can make a difference by conducting a prescription drug–monitoring program (PDMP) search prior to admission, and retail pharmacists can help by assessing current home supply and understanding patient habits by viewing their history of prescribers and early refills, as well as determining the stability of the current regimen.

“Pharmacists need to start setting short term and long-term goals for pain management, opioid use, and pain expectation,” Moose said. “It is also important to discuss what signs of addiction might look like. Pharmacists should also stress the importance of not leaving medications around the house.” Proper disposal prevents children, pets, and others from getting ahold of these medications.

If a patient is still in pain 5 days after their procedure with their current medication, a deeper dive should be conducted into why this might be, including the possibility that opioids might not be the best course of action. Pharmacists should engage with the interprofessional care team across the spectrum of pain management, including when opioids are indicated, in the screening for and prevention of opioid misuse, the management of opioid-exposed patients, and the management of patients with OUD.

Pharmacists can manage this collaboration by screening patients for risk factors, educating patients, monitoring PDMPs, building prescribing alerts into electronic health records, and developing policies and protocols to be on alert for potentially risky opioid-prescribing behaviors.

Taylor Fortson, PharmD, of Carolina Pharmacy, a Charlotte, North Carolina–based independent group with locations across the Carolinas, noted that pharmacists should provide both medication reconciliation and counseling to assess patient pain and help develop an action plan with physicians to explain to patients how to control postoperative pain safely and effectively.

“Although medication counseling should always be done upon either discharge from the hospital or after surgery, never assume,” she said. “Ask the patient if they have ever taken opioids and review their goals, [adverse] effects, and how to ensure safe use.”

Explain to the patient prescription opioids help relieve short-term pain, but carry a serious risk of addiction and overdose. Fortson typically recommends to patients that they take opioids only for severe pain and use ibuprofen for less severe pain. Fortson generally counsels patients to switch after a few days to alternating between acetaminophen and ibuprofen every 3 to 4 hours.

At Moose Pharmacy, patients are encouraged to read and sign a policy of procedure, which is a key step in opioid counseling. After going over the document and expectations, if a patient is not comfortable, then pharmacists provide counsel on other options and consider a secondary conversation with the prescriber. Pain management must also be patient centered, said Dopp.

“Including the patient in determining functional pain management goals, identifying therapy options, and setting realistic expectations for treatment will result in buy-in from the patient and their caregiver,” she said.

“Something we have been advocating for is to make pain management plans interoperable and accessible to everyone on the interprofessional care team. Doing so enables adherence to the plan throughout transitions of care from the postoperative setting to the patient’s home.” Simona Dorf, PharmD, BCMAS, clinical

pharmacist and editorial manager at First Databank, Inc, which publishes and maintains drug databases for health care professionals, said that some of the most difficult conversations she has had with patients have been on this topic.

“It was never on the first fill,” she said. “It typically occurred down the line with the third filll or later.” Dorf recalled a conversation she had with a patient taking 2 different opioids from different prescribers: 1 for leg pain and 1 for back pain.

Although the patient was adamant that each opioid worked on only that specific pain area, after counseling the patient, Dorf and the patient agreed to discuss the situation with each physician and let them consolidate the pain management regimen.

Although a physician has to write the prescription, the pharmacist is the gatekeeper. They see their patients more frequently, which provides more opportunity to reinforce the correct medication habits and identify negative adverse effects.

“Pharmacists overall have a closer and more accessible relationship with their patients and the ability to spend time with them,” Moose said. “They also can look into details like where they last received [or] purchased medications to make an assessment on if it might be an escalating situation. ”


Robert Alesiani, PharmD, BCGP, chief pharmacotherapy officer at Tabula Rasa HealthCare, once had a patient who underwent a total hip replacement secondary to osteoarthritis and also experienced chronic, episodic lower back pain. The oxycodone prescribed after surgery also helped manage the patient’s back pain, so he continued using it long after the hip healed.

“While he originally self-medicated to improve his function, over time he found himself overmedicated and less functional,” Alesiani explained. “He always seemed to come in for a new fill a couple days early, but not so early that the prescription card didn’t pay.”


When the patient came in for a refill, Alesiani pulled him aside and in a nonconfrontational tone asked, “What are you expecting from these medications, and are they working for you?” The response was tearful and surprising: The patient just wanted to get back to normal—and no, the medications weren’t helping.

“After obtaining permission from the patient, I contacted his primary care physician and together, [we] came up with a plan that included an orthopedic consult,” followed by steroid injections and physical therapy. “After 6 weeks, the patient was taking much less of the opioid and utilizing a COX-2 [inhibitor]. He was more alert, cheerful, and positive. He was still experiencing some pain, but it was manageable.”

Opioid overdose crisis. National Institute on Drug Abuse. Updated March 11, 2021. Accessed November 3, 2021. 

https://www.drugabuse.gov/drug-topics/opioids/opioid-overdose-crisis

More than one in five opioid-naïve patients still use opioid three months after surgery. News release. American Society of Anesthesiologists. October 9, 2021. Accessed November 3, 2021. 

https://www.asahq.org/about-asa/newsroom/news-releases/2021/10/more-than-one-in-five-opioid-naive-patients-still-use-opioids-three-months-after-surgery

Pharmacists discuss the best methods for postoperative opioid
prescription management.

Pharmacist Intervention Helps Combat Chronic Opioid Use, Misuse 

A successful pharmacy is one that doesn’t rest on its laurels and continues to be innovative and opportunistic. After all, even though things may be going well now, that can always change, and a pharmacy owner should have alternative revenue streams coming in to combat any challenges.

Today’s pharmacies must install diverse or alternative revenue opportunities to boost profits. This can mean revamping their front end, expanding on services such as specialty pharmacy medications, or partnering with health care providers or hospitals in the area. It can even entail offering tailored services to their patients such as smoking cessation, weight-loss counseling, or nutrition guidance.

“In the changing landscape accentuated by pharmacy benefit managers, the profit margins that have previously supported pharmacists’ salaries and the cost of running independent retail pharmacies have been borne on the spread of the product,” says Paige Clark, RPh, vice president of pharmacy programs and policy at Prescryptive Health. “That reimbursement model, in many cases, can no longer support independent pharmacies.”

Therefore building a robust and significant clinical services provision is essential to the success of all community pharmacies. Jennifer Donovan, PharmD, vice president of clinical services at Shields Health Solutions in Stoughton, Massachusetts, notes there is a need to balance how to deliver high-quality care while offsetting the costs of caring for patients who are underinsured or not insured.

“Finding alternative ways to generate revenue is necessary to ensure all patients, regardless of ability to pay, have access to high-quality health care,” she says.

JoAnn Sanborn, BSPharm, owner and vice president of operations for Hudson Pharmacy in Hudson, Michigan, notes that due to decreasing profits for prescription drugs, which are the main source of business, she often looks to outside sources to help stay in business. These include point-of-care testing, immunizations, hormone replacement therapy consultations, medication therapy management, and complimentary medicine consultations.

Shelley Roberts, PharmD, owner of Grassroots Pharmacy in Lexington, Kentucky, shares that during the first part of the COVID-19 pandemic, the pharmacy’s front-end sales were severely depressed, although prescription sales went up.

“The reduction in cash flow that resulted really drove home the point of how important those sales truly are,” Roberts says. “We have a thriving smoothie business and gift shop that bring in cash daily versus waiting on insurance reimbursement checks. It is so important to diversify all aspects of your business to account for when one piece is affected.”

In Kentucky, there are numerous board-approved protocols that the pharmacy is beginning to delve into to create multiple revenue streams. 

“From the beginning, we have looked for ways to be different—the look of our store, the offerings, the atmosphere,” Roberts says. “To be successful, you either have to be unique or do the same thing better than everyone else. With the big boxes’ hold on the market, it is hard to beat them on price, so we don’t try to.”

In many states, public health departments are highlighting the fact that community pharmacists are trusted and highly accessible resources.

Under the crisis of COVID-19 and the Public Readiness and Emergency Preparedness Act, all pharmacists can provide testing services to detect COVID-19. Additionally, as of September, pharmacists are empowered to provide monoclonal antibody treatment to patients who are positive for or have been exposed to the disease.

"Finding alternative ways to generate revenue is necessary to ensure all patients...have access to high-quality care."

“So we now truly have…testing, treatment, and immunization services that are comprehensive for serving our communities in the fight against COVID-19,” Clark says. “This is a great revenue opportunity to look into right now.”

“The state of Oregon was among the early adopters of the concept of pharmacists being enabled to provide subcutaneous injections of REGEN-COV [casirivimab and imdevimab] to COVID-19–positive patients,” Clark continues. “As such, the Oregon Board of Pharmacy with leading subject matter experts built a comprehensive clinical protocol to guide pharmacists through patient care. We have incorporated that resource into our turnkey solution at Prescryptive. Not only is the protocol available for utilization, Prescryptive has then built the model policies and procedures needed for independent retail pharmacies to operationalize this clinical service.”

Among other revenue opportunities, 15 states have extended pharmacists’ ability to provide birth control services to patients in some form. Other states have allowed pharmacists to provide services for tobacco cessation and postexposure and pre-exposure prophylaxis for HIV prevention.

“In all cases, expanding clinical services and pharmacist scope of practice relate to meeting unmet public health needs,” Clark says. “My tendency is to advise pharmacists to move into areas that are directly reimbursable at a state level by Medicaid, such as birth control prescribing.”

Trieu Bao, PharmD, of Soleil Pharmacy in Glen Burnie, Maryland, notes that pharmacists have excellent training that goes far beyond their ability to fill prescriptions.

“As clinicians, we are driven to provide many other services for the overall health of our clients, thus improving patient outcomes,” he says. “As [many of us are] immigrants, we understand the unique needs of those from a multitude of cultures and provide culturally competent care. Then, we want to be sure they know where and how to get access to other elements of their health care.”

As a Clincal Laboratory Improvement Amendments–certified pharmacy, Soleil Pharmacy offers COVID-19 testing. They also provide international normalized ratio and A1c tests when appropriate for the patient and their care plan. 

“We offer and deliver in our pharmacy—or in other locations—many types of vaccines,” Bao says. “We are currently finalizing a plan to have primary care telehealth available in our pharmacy or in the homes of the uninsured population in our community.”

As recent recipients of the National Community Pharmacists Association Diabetes Prevention Program grant, the pharmacy is also expanding its diabetes services in 3 languages.

“We have found if you focus on the unmet needs in your community and the unique strengths of your staff, you can create something pertinent and of great value,” Bao says.Soleil Pharmacy focuses on vaccinations, common medications, and supplies that support hospital discharge and make the discharge process easier for patients and their caregivers.

“We have reconsidered the products we carry and removed the feeling of being crowded in the front of our store,” Bao says. “We are intentionally making it easier for the pharmacist or technician to acknowledge the patient upon entry and for patients to have access to items that will benefit their health journey.”

Clark adds that pharmacies that have not carved in private patient care spaces need to consider doing so, as soon as possible.

Making changes to the layout or design of the pharmacy could also attract new customers. This has been key to many older pharmacies bringing in people and getting them interested in new services.

Because Grassroots Pharmacy has been open for less than 5 years, Roberts feels fortunate to not need a facelift yet. However, the pharmacy does consistently change the merchandise and layout of the store.

“Keeping things fresh is important,” she says.

Partnering with Hospitals and Health care Facilities

In some cases where collaborative practice agreements (CPAs) are required, partnering with other providers or organizations can be helpful to a pharmacist in bringing in new revenue.

“Partnering with health care providers and health systems allows for the best patient care,” Donovan says. “The patient stays integrated within the health system and information is accessible by all health professionals in the multidisciplinary team. Integrating pharmacy services into care is necessary to drive meaningful changes in patient outcomes.”

One strategy Donovan has found to be successful is aligning specialty pharmacy programs with the health system’s accountable care organization and at-risk populations to further drive quality and value.

“Developing programs and strategies to help the at-risk population has [been] shown to improve patient care and lower total medical cost,” she says.

Hudson Pharmacy has a practice agreement and offers point-of-care testing with a local physician.

“Early on in the pandemic, before we were able to obtain product, both the local health department and hospitals offered vaccines for us to vaccinate the elderly in long-term care facilities [who had been] missed, as part of a federal initiative,” Sanborn says. “We have been partnering with the health departments in both counties to schedule and run clinics and obtain vaccines. We’re basically on call whenever they need help and it’s been very profitable; there’s administration money available from insurance companies to do this work.”

The pharmacy has also worked with hospitals to offer a continuum of care for when patients leave the hospital and transfer to long-term care facilities or back home.

“We’re there making sure there’s a proper coordination of care and to offer counseling,” Sanborn notes.

Pharmacists should also consider helping with things such as smoking cessation or weight-loss counseling.

“The pharmacist can play a crucial role in these conditions as there are tremendous short-term and long-term benefits to their health and the health care system,” Donovan says. “Even within our specialty pharmacy program, we stress the importance of smoking cessation, weight reduction, stress management, and nutrition as part of an overall care plan to ensure we are helping our patient today and in the future.”

Hudson Pharmacy once tried offering diabetes management but found that it was very difficult to get insurance companies to pay for the service. In addition, it was something that people weren’t as willing to pay for.

“Now we’ve been doing hormone replacement therapy consultations,” Sanborn says. “And that the patients are happy to pay for directly, so that’s been successful.”

According to Roberts, because the pharmacy is located in a city with multiple large hospital settings and a thriving health department, these services are available for free for most individuals so she hasn’t instituted any programs.

“This could definitely work in other locations though,” she says. “What has been more helpful than anything is doing compliance packaging for their patients. This is what we were trained to do, and what we can excel at.”

Alternative revenue opportunities that pharmacies can take on to boost profits

Diversifying Your Pharmacy’s Revenue Streams 

Therefore, building a robust and significant clinical services provision is essential to the success of all community pharmacies. Jennifer Donovan, PharmD, vice president of clinical services at Shields Health Solutions in Stoughton, Massachusetts, notes there is a need to balance how to deliver high-quality care while o setting the costs of caring for patients who are underinsured or not insured.

“Finding alternative ways to generate revenue is necessary to ensure all patients, regardless of ability to pay, have access to high-quality health care,” Donovan says.

Shelley Roberts, PharmD, owner of Grassroots Pharmacy in Lexington, Kentucky, shares that during the first part of the COVID-19 pandemic, the pharmacy’s front-end sales were severely depressed, although prescription sales went up.

“The reduction in cash flow that resulted really drove home the point of how important those sales truly are,” Roberts says.

“We have a thriving smoothie business and gift shop that bring in cash daily versus waiting on insurance reimbursement checks. It is so important to diversify all aspects of your business to account for when one piece is affected.” In Kentucky, there are numerous board-approved protocols that the pharmacy is beginning to delve into to create multiple revenue streams.

“From the beginning, we have looked for ways to be different—the look of our store, the offerings, the atmosphere,” Roberts says. “To be successful, you either have to be unique or do the same thing better than everyone else. With the big boxes’ hold on the market, it is hard to beat them on price, so we don’t try to.” In many states, public health departments are highlighting the fact that community pharmacists are trusted and highly accessible resources. Under the crisis of COVID-19 and the Public Readiness and Emergency Preparedness Act, all pharmacists can provide testing services to detect COVID-19. Additionally, as of September, pharmacists are empowered to provide monoclonal antibody treatment to patients who are positive for or have been exposed to the disease.

“So, we now truly have…testing, treatment, and immunization services that are comprehensive for serving our communities in the fight against COVID19,” Clark says. “This is a great revenue opportunity to look into right now.” “The state of Oregon was among the early adopters of the concept of pharmacists being enabled to provide subcutaneous injections of REGEN-COV [casirivimab and imdevimab] to COVID19–positive patients,” Clark continues.

“As such, the Oregon Board of Pharmacy with leading subject matter experts built a comprehensive clinical protocol to guide pharmacists through patient care. We have incorporated that resource into our turnkey solution at Prescryptive. Not only is the protocol available for utilization, Prescryptive has then built the model policies and procedures needed for independent retail pharmacies to operationalize this...service.”

Among other revenue opportunities, 15 states have extended pharmacists’ ability to provide birth control services to patients in some form. Other states have allowed pharmacists to provide services for tobacco cessation and postexposure and pre-exposure prophylaxis for HIV prevention. “In all cases, expanding clinical services and pharmacist scope of practice relate to meeting unmet public health needs,” Clark explained.

“My tendency is to advise pharmacists to move into areas that are directly reimbursable at a state level by Medicaid, such as birth control prescribing.” Trieu Bao, PharmD, of Soleil Pharmacy in Glen Burnie, Maryland, notes that pharmacists have excellent training that goes beyond filling prescriptions.

“As clinicians, we are driven to provide many other services for the overall health of our clients, thus improving patient outcomes,” he says. “As [many of us are] immigrants, we understand the unique needs of those from a multitude of cultures and provide culturally competent care. Then, we want to be sure they know where and how to get access to other elements of their health care.” As a Clinical Laboratory Improvement Amendments–certified pharmacy, Soleil Pharmacy offers COVID-19 testing.

They also provide international normalized ratio and glycated hemaglobin tests when appropriate for the patient and their care plan. “We o er and deliver in our pharmacy—or in other locations—many types of vaccines,” Bao says. “We are currently finalizing a plan to have primary care telehealth available in our pharmacy or in the homes of the uninsured population in our community.” As recent recipients of the National Community Pharmacists Association Diabetes Prevention Program grant, the pharmacy is also expanding its diabetes services in 3 languages.

“We have found if you focus on the unmet needs in your community and the unique strengths of your staff, you can create something pertinent and of great value,” Bao says. Soleil Pharmacy focuses on vaccinations, common medications, and supplies that support hospital discharge and make the discharge process easier for patients and caregivers.

Making changes to the layout or design of the pharmacy could also attract new customers. This has been key to many older pharmacies bringing in people and getting them interested in new services. Because Grassroots Pharmacy has been open for less than 5 years, Roberts feels fortunate that the store does not need a facelift yet.

However, the pharmacy does consistently change the merchandise and store layout. “Keeping things fresh is important,” she says.

Partnering With Hospitals and Health Care Facilities

In some cases where collaborative practice agreements (CPAs) are required, partnering with other providers or organizations can be helpful in bringing in new revenue. “Partnering with health care providers and health systems allows for the best patient care,” Donovan says.

“The patient stays integrated within the health system and information is accessible by all health professionals in the multidisciplinary team. Integrating pharmacy services into care is necessary to drive meaningful changes in patient outcomes.” One strategy Donovan has found to be successful is aligning specialty pharmacy programs with the health system’s accountable care organization and at-risk populations to further drive quality and value.

“Developing programs and strategies to help the at-risk population has [been] shown to improve patient care and lower total medical cost,” she says. Hudson Pharmacy has a practice agreement and offers point-of-care testing with a local physician. “Early on in the pandemic, before we were able to obtain product, both the local health department and hospitals offered vaccines for us to vaccinate the elderly in long-term care facilities [who had been] missed, as part of a federal initiative,” Sanborn says.

“We have been partnering with the health departments in both counties to schedule and run clinics and obtain vaccines. We’re basically on call whenever they need help and it’s been very profitable; there’s administration money available from insurance companies to do this work.” The pharmacy has also worked with hospitals to o er a continuum of care for when patients leave the hospital and transfer to long-term care facilities or back home. “We’re there making sure there’s a proper coordination of care and to offer counseling,” Sanborn notes.

Pharmacists should also consider helping with things such as smoking cessation and weight-loss counseling. “The pharmacist can play a crucial role in these conditions as there are tremendous short-term and long-term benefits to their health and the health care system,” Donovan says.

“Even within our specialty pharmacy program, we stress the importance of smoking cessation, weight reduction, stress management, and nutrition as part of an overall care plan to ensure we are helping our patient today and in the future.” Hudson Pharmacy once tried offering diabetes management but found that it was very difficult to get insurance companies to pay for the service. In addition, it was something that people weren’t as willing to pay for. “Now we’ve been doing hormone replacement therapy consultations,” Sanborn says.

“And that the patients are happy to pay for directly, so that’s been successful.” According to Roberts, because the pharmacy is located in a city with multiple large hospital settings and a thriving health department, these services are available for free for most individuals, so she hasn’t instituted any programs. “This could definitely work in other locations, though,” she says. “What has been more helpful than anything is doing [adherence] packaging for their patients. This is what we were trained to do, and what we can excel at.”

Pharmacies can take advantage of alternative revenue opportunities to boost their bottom line.

Diversify Your Revenue Streams

During the COVID-19 pandemic many hospitals and health care services teams turned to telepharmacy to reduce delays in providing medications to patients while social distancing practices were in place.Hospitals quickly found that telepharmacy benefitted pharmacy services by providing patients with more efficient access to medical care and reducing costs. Thus, hospitals were able to focus more on patient care and less on logistics, which led to higher turnaround times and increased patient satisfaction.

Benjamin Kornitzer, MD, chief medical and quality officer of agilon health, noted that telepharmacy and meeting patients where they are can lead to higher-quality health care.

“During the pandemic we saw how challenging it was for a face-to-face encounter, and telepharmacy was a tremendous opportunity to continue offering these vital services to our patients, greatly increasing access to medications and medication adherence,” he said.

Randy Gerwitz, RPh, is pharmacy executive director at Vizient, a health care services company based in Irving, Texas. He notes that telepharmacy has expanded access to pharmacy services for patients, which is why hospital pharmacy teams benefit from implementing telepharmacy models into their workflows.

“There is a well-established history of operational benefits from these technologies remotely supporting common tasks such as prescriber order verification and the monitoring and verification of IV [intravenous] room production activities,” he said.

More recent efforts have focused on direct-to-patient and clinical services, including patient education, monitoring, and adherence support, as well as antimicrobial and opioid stewardship programs.

“These types of enhanced clinical offerings improve patient safety and allow [pharmacists] to reach patients that they may not have otherwise been able to care for,” Gerwitz said.

Ann Phan, PharmD, BCGP, manager of clinical programs for L.A. Care Health Plan in Los Angeles, California, said that telepharmacy in the inpatient setting allows a hospital’s pharmacy services to extend coverage, both temporarily and geographically.

“In this sense, rural and small-volume hospitals with limited resources could especially benefit from telepharmacy,” she said. “The benefits of telepharmacy can lead to expansion of service hours if [a location is] not already providing around-the-clock coverage, more available clinical pharmacy services, and improved safety and overall patient care.”

According to Seun Bammeke, managing director of PharmaServe in Winnipeg, Manitoba, telepharmacy can increase patients’ medication adherence. Additionally, these services allow an external licensed pharmacist to review and double-check the prescription to ensure it is correct, which can ease the workload of busy hospital pharmacists. He added that telepharmacy needs to be taught about from a return on investment (ROI) perspective as well, with plenty of savings available.

“Hospital pharmacies would require [fewer] pharmacists and technicians as a lot of the duties will be outsourced to the telepharmacy,” Bammeke said. “Plus, by using a JIT (Just In Time) system, the hospital can maintain less stock of medications [that] are not used on a daily basis, knowing they will arrive the next day. This prevents medications from expiring [or] being stolen, and [means] less work in process inventory, which frees up their finances to be used on things that are more needed.”

Eric Maroyka, PharmD, senior director of the Center on Pharmacy Practice Advancement at the American Society of Health System Pharmacists (ASHP), said telepharmacy has grown exponentially over the past year.

“We see it as an opportunity to improve patient outcomes, expand access to health care—whether it’s an acute or ambulatory care setting—and find that it’s also a way to enhance patient safety. It could in many ways achieve more effective delivery of care as well,” he said.

According to Maroyka, hospital pharmacy teams can benefit from implementing telepharmacy models into their workflows for medication selection order review. Dispensing the IV admixture verification can be done remotely. For instance, if you have a technician in a clean room, there could be a pharmacist who is working remotely to help with that verification process.

Then there are patient monitoring and counseling benefits. Maroyka explained that health systems that employ clinical pharmacy specialist can have them reach out to smaller facilities to provide patient counseling or consultations and real-time monitoring through telehealth services.

“It’s a solution for order review
and verification in tertiary medical centers when staffing—particularly in specialty areas [such as] oncology or pediatrics––is limited and provides a mechanism for health systems to provide enterprise-level pharmacy services throughout the system, even when those pharmacies may not operate 24-7,” he said.

It also provides a tool for virtual monitoring, assessment, detection, and decision-making for adverse drug reaction prevention and management. One major advantage, Phan noted, is the positive ROI produced by telepharmacy in decreasing pharmacy operating costs and repurposing pharmacists to other clinical services to improve patient outcomes, such as discharge medication counseling or antimicrobial stewardship.

Another advantage is increased accessibility. For instance, Gerwitz explained that telepharmacy allows the pharmacist to provide services in locations that are inefficient, impractical, or unfeasible.

“This is particularly true for services provided to at-risk populations and in rural or remote areas where distance and population density would make it impossible to pro- vide care in a way that is convenient for the patient and financially sustainable for the health care organization,” he said.

A disadvantage is patients’ dependence on technology and broad- band access.

As many learned and experienced during the pandemic, technologies and the internet ser- vices that support them are not always perfect. Gerwitz said glitchy connections, lag, and band- width challenges can at times cause frustration.

During the pandemic, the industry saw more widespread adoption of regulations that allow and even encourage the use of telemedicine and telepharmacy, but challenges still exist.

“The lack of a standardized regulatory environment and limitations on what pharmacy technicians can do under remote supervision in many states will continue to act as an obstacle to optimization of these technologies,” Gerwitz said.

There are plenty of new technologies available to help with a smoother transition and workflow.

Video conferencing has become a standard tool for telepharmacy to provide discharge medication counseling and medication therapy management.

Thankfully, systems have dramatically improved in recent years. Further maturation of technology and expanded access to broadband will continue to push the boundaries for telepharmacy, particularly in rural areas that struggle with access to health care.

“Certainly, video conferencing has existed for some time, but not always in a secure and compliant environment that was appropriate for the health care environment.,”Gerwitz said. “[Video communication] is especially beneficial when supporting patients on highly specialized therapies such as those seen in posttransplant care and oncology but can be very helpful as well in the setting of postdischarge medication reconciliation and home care.”

A graduate of the University of Miami, Keith Loria is a D.C.-based, award-winning journalist who has been writing for major publications for close to 20 years.

Increases in service hours, programs, and locations lead to higher patient satisfaction, and lower costs.