32 Operations & Management
Pharmacy Practice News • July 2020
Ambulatory Care
Reimbursement, PPE shortages remain barriers
Pharmacists Get Green Light for COVID-19 Testing T
o many Americans across the country, one sight has become increasingly familiar: a tent pitched outside a community pharmacy, advertising drive-thru testing for COVID-19. People who want to schedule an appointment often simply go to the retailer’s website and receive a time slot, with no doctor’s authorization required. And yet, significant barriers remain to pharmacists’ ability to order and administer tests for COVID-19. At a time when experts say increased testing is one of the key components o off reopening reo openiing the country as safely as possible, pharmacy ossiblee, pha arm macyy groups—including those ose representing repressenttingg health-system pharmacy—are asking macy— —are ask kingg officials to make it easier to let this thiis highly skilled workforce screen patients ce scr reen p atieentts for the coronavirus. On May 19, the Department Health artmen nt of Hea alth h and Human Services (HH (HHS) tried HS) tr ried d to o remove some of those existing barriers. existting ba arrie ierss. The move came in thee form new m of a n ew w advisory opinion, which concluded ch h con ncludeed tthat haat the Public Readiness and Eme Emergency erg r encyy Preparedness (PREP) Act gives pharph harrmacists the ability to provide authorized rovidee autho horizzed d COVID-19 diagnostic ttests patients ests to p atieentss without a doctor’s supervision, preemptervisio on, preem mptting any state or local barriers. HHS’s arrrierss. The HH HS’’s guidance “highlights the administraadmin inisttraation’s confidence in pharmacists proharmaacists tto op ro ovide expanded and widespread testing capacity in the United States,” said Eric Maroyka, PharmD, the senior director of the Center for Pharmacy Practice Advancement at ASHP. But the HHS advisory opinion did not address the major obstacle to pharmacists’ ability to test for COVID-19: reimbursement, noted Starlin HaydonGreatting, BSPharm, the director/owner of SHG Clinical Programming and Population Health, in Springfield, Ill. In too many states, the path to payment for pharmacists providing any aspect of diagnostic testing for COVID-19 is unclear and riddled with roadblocks, she said. The new HHS missive may permit pharmacists to perform these services, but if they can’t cover the costs, what’s the point? “Billing and reimbursement are the No. 1 barrier for adding any of these services,” Dr. Haydon-Greatting said.
More Than 40 States on Board The HHS guidance clarified that pharmacists can, in theory, order and administer a diagnostic test for COVID-19, without involving a doctor or nurse practitioner. This is not unprecedented: According to the National Association of Chain Drug Stores (NACDS), more than 40 states have opened doors to pharmacists performing point-of-care
testing for several diseases, such as HIV, hepatitis C, flu and tuberculosis; in some of those states, pharmacists also can initiate treatments for certain conditions. But when it comes to pharmacists and COVID-19 testing, it’s not full speed ahead. Similar to almost every other health care worker, pharmacists are limited by ongoing shortages of personal protective equipment (PPE). To collect a nasopharyngeal sample, for instance, pharmacists must wear a gown, nonsterile gloves, a protective mask (rated N95
extended wait times for the results—and the logistics of getting the results back to the patient—are another challenge in community pharmacist–coordinated COVID-19 testing and follow-up, she noted. It’s not clear how that arrangement— collecting specimens and sending them to a lab versus actually administering and reading the tests—will play out for pharmacists in terms of reimbursement, Dr. Maroyka said. “Reimbursement for a specified test may be determined by
A new report commissioned by America’s Health Insurance Plans estimates that
diagnostic testing for COVID-19 could cost up to
$25 billion per year.
or higher), and a face shield. Even the swabs used to collect samples have been in short supply. “There aren’t enough supplies in the system to provide all the COVID-19 testing supplies, and all the PPE supplies, for everybody to have everything,” Ms. Haydon-Greatting said. “That’s a major limiting factor.”
Impediments From Medicare And Medicaid Then there’s the issue of payment. A new report commissioned by the trade group America’s Health Insurance Plans estimates that diagnostic testing for COVID-19 could cost up to $25 billion per year. But Medicare won’t pay for COVID-19 diagnostic testing unless pharmacies enroll as a laboratory certified by the Clinical Laboratory Improvement Amendments. In many states, Medicaid won’t pay pharmacists for COVID-19 testing at all. Some chain pharmacy– and health-system pharmacy–run ambulatory care practices (see page 1) are offering testing, but pharmacists often do not administer the test or read the results, Ms. Haydon-Greatting said. Instead, they oversee self-administered tests, in which they train patients to take the nasopharyngeal sample themselves, and the specimen is sent to an external lab for processing. The
the requirements of the different payors and whether the payor requires processing and payment of the claim under the medical or prescription benefit,” he said. Federal and state rules also can affect the billing process, and pharmacies need proper coding and billing infrastructure to receive reimbursement, he noted, as well as assurances of coverage for patients without adequate health insurance.
In the Health System Setting For some health-system pharmacists, the persistent barriers to ordering and conducting diagnostic tests for COVID-19 aren’t a big issue: As members of a hospital network, they likely have access to a laboratory that’s qualified to process the samples, and can bill through the hospital. Yet, few are doing it. In a May ASHP survey of hospital pharmacists, only 1% of respondents said pharmacists are performing COVID-19 testing at their location. Another 9% are exploring adding this service. “We are not seeing much of this activity within health systems,” Dr. Maroyka said. In a hospital setting, most patients will likely be tested at their bedside or sent to the hospital-affiliated lab, he noted. “The capability and capacity of COVID-19 testing in hospital settings is largely an
interprofessional effort, and primary responsibility may be coordinated with the facility's laboratory services, which can support moderate- to high-complexity molecular and serological testing.” If hospital pharmacists do expand testing for COVID-19, they could collect specimens in or outside a registered pharmacy, such as in an ambulatory care setting, and then send the specimen to a lab for analysis, Dr. Maroyka said. In states where pharmacists are allowed to read test results, that final step won’t be necessary, he added. “In some states, pharmacists may interpret and analyze COVID-19 or COVID-19 antibody test results and provide the results to patients, with appropriate guidance for follow-up care.” Ideally, more states will move in that direction, loosening up the restrictions on diagnostic testing by pharmacists, said Kathleen Jaeger, BS Pharm, JD, the senior vice president of pharmacy care and patient advocacy at NACDS. “We mainly want to acknowledge the Department of Health and Human Services, and certainly Secretary Alex Azar, for expressing clearly the sense that pharmacists and pharmacies are critical for the deployment of COVID-19 testing,” she said. NACDS also appreciates the efforts that state governments are taking to make it even easier for pharmacists to provide COVID-19 testing, she added. “We are working directly with the federal and state governments on any barriers that persist.” Other groups are also reaching out to lawmakers about remaining issues, including reimbursement, Dr. Maroyka said. “The pharmacy association partners, including ASHP, have been meeting with CMS [Centers for Medicare & Medicaid Services] and congressional staff to get clarity and make these payment pathways more clear, predictable and financially supportable as a business model.” Hopefully, opening doors to participation in diagnostic testing for COVID-19 will also ease the way for pharmacists to pitch in with other looming health issues, such as ordering and administering diagnostic tests and treatments for seasonal flu, and providing vaccinations for COVID-19 when they become available, Dr. Maroyka said. “If allowed to test, treat and vaccinate, pharmacists can improve capability and capacity of response. Pharmacy fits as a patient educator and a connector to treatment within the broader health care system.” —Alison McCook The sources reported no relevant financial relationships.
