Before the pandemic, telepharmacy and telehealth were nice ideas. Today, they’re crucial to delivering personalized care with limited in-person contact.
Telepharmacy is on a roll. In 2001, when North Dakota became the first state to enact regulations allowing the practice.1 By early 2023, 28 states will allow some form of telepharmacy, and Kansas is poised to finalize regulations later this year, according to telepharmacy services provider TelePharm. Approval is advancing in other jurisdictions as well.
“Through the pandemic, there has been a drastic uptake in technology, especially remote technology,” said Brett H. Barker, PharmD, vice president of operations for NuCara Pharmacy, which operates physical stores and telepharmacies in Illinois, Iowa, Minnesota, North Dakota, and Texas. “I think we jumped forward a decade in about 2 weeks back in March 2021 with [individuals’] comfort levels, uptake, and acceptance of remote care. Telepharmacy is good for patients, good for communities, and good for pharmacists.”
Telepharmacy is also a challenge. Roughly 40% of states do not allow telepharmacy, cautioned Mary Ann Kliethermes, PharmD, director of medication safety and quality for the American Society of Health-System Pharmacists. Among states allowing telepharmacy, no two have adopted the same practice regulations.
Payers take similarly diverse approaches. Washington and some other states require commercial insurers to reimburse pharmacists on the same basis as physicians, nurse practitioners, and other health care providers. However, most states are silent on payment parity and most commercial payers still balk at paying for nondispensing services, although that could change as the profession continues to push for provider status at state and federal levels.
Medicare does not recognize pharmacists as providers, Kliethermes noted, although the program does reimburse pharmacists up to $150 per month for complex chronic care management. Medicaid reimbursement for pharmacists varies by state.
The biggest financial difference between a traditional pharmacy and a telepharmacy is the cost structure. The return on investment for a traditional pharmacy depends largely on prescription volume, front-end sales, and pharmacist costs. Telepharmacy lowers the financial bar by sharing pharmacist time across multiple dispensing locations.
According to Barker, reimbursement for remote dispensing is similar to conventional in-person dispensing. The current telepharmacy break-even point is around 70 to 80 prescriptions daily, he said, but the number varies by patient population, prescription mix, payer mix, and other familiar factors.
On the cost side, telepharmacy requires more video hardware than conventional pharmacy to facilitate real-time pharmacist monitoring and conversations, but the cost of off-the-shelf hardware is low—and falling. But best practices, and in many cases state regulations, call for off-site storage of all video and still images from both the remote telepharmacy site and the supervising pharmacist, which increases cloud storage costs.
Telepharmacy software providers typically charge an activation fee and monthly use fees, Barker added. The total cost is roughly equivalent to having a pharmacist on site 1 day per week. Telepharmacy providers should expect to pay for the best technicians available.
“You absolutely need rock star pharmacy technicians because they have a higher level of responsibility and visibility in telepharmacy,” Barker said. “You need good problem solvers who can think on their feet and you need a high level of trust. When you have a telepharmacy, the technician is the public face of the pharmacy.”
Getting paid for virtual clinical services can be as challenging as payment for face-to-face clinical services, Kliethermes said. Medicare reimburses pharmacists for telehealth complex chronic care management. One pharmacy provider, Tabula Rasa HealthCare, is being reimbursed under PACE, the federal Program of All-Inclusive Care for the Elderly, which covers frail older adults who are often eligible for Medicare and Medicaid. However, Medicare payments to pharmacists are more the exception than the rule.
“Because Medicare does not recognize pharmacists as providers, it limits reimbursement regardless of the applicable practice act,” she said. “That makes reimbursement challenging because not all of the Medicare telehealth codes are applicable to pharmacists.”
Technicians are also part of the clinical service and revenue mix. A growing number of states allow pharmacy technicians to administer point-of-care tests, immunizations, specimen collection, and other clinical services under pharmacist supervision, Barker noted.
“All of those clinical services can happen safely and effectively through the telepharmacy model,” he said. “At this point, the model is proven and works well. Telepharmacy is letting us extend the reach of our pharmacists and their clinical services. Pharmacists are delivering the same care they provide in a traditional community pharmacy; they’re just delivering it in a different model.”