As affordable access to healthcare continues to be a nationwide issue, many states are exploring the expansion of pharmacist prescribing authority as part of the solution. This creates the potential for pharmacies to leverage their staff pharmacists to provide additional value to patients in the “Test to Treat” space while generating an additional source of revenue.
Background
In the United States, the expansion of pharmacist authority began as early as 1993 in New Mexico, primarily with the goal to combat the AIDS epidemic by allowing pharmacists to prescribe HIV PrEP and PEP. The expansion of pharmacist authority has since grown to include all 50 states in some manner. To combat the COVID-19 public health crisis, the federal government granted pharmacists prescribing authority across all states in 2022.[i][ii]
While pharmacists in all 50 states may now prescribe Paxlovid, the patient must meet eligibility requirements to ensure safety.[iii][iv] For example, to prescribe Paxlovid, the pharmacist will need certain health records from the last twelve months, such as kidney and liver test results. Obtaining these health records requires some aspect of coordination with labs and/or provider’s office, an infrastructure that isn’t necessarily readily available to the pharmacy.
Potential Opportunities for Test to Treat Initiatives
While the federal government’s authorization for nationwide pharmacist prescribing authority is currently limited to combating the COVID-19 epidemic, the increasing economic burden of healthcare may eventually garner enough support for authorization to combat other common acute illnesses, such as influenza and streptococcus.
However, at present time, the push to expand Test to Treat initiatives is more likely to come from individual states, especially those with access issues. Such is the case with Illinois, which signed a bill to expand pharmacist prescribing authority (including treatment of COVID-19, influenza, and streptococcus) to 268 areas that are designated health professional shortage areas. States adopting legislation that give their pharmacists broader testing and prescribing authority are also better positioned to swiftly combat any “health conditions identified by a statewide public health emergency” as they emerge.[v]
According to a 2022 NASPA report, there are six states (Arkansas, Colorado, Delaware, Idaho, Iowa, and Kansas) where pharmacists have some type of direct prescribing authority. Seventeen additional states have some form of delegated prescribing authority or CPA (Collaborative Practice Agreement).[vi] NASPA further reports that in 2023, nine states (California, Colorado, Connecticut, Hawaii, Illinois, Michigan, North Carolina, New Mexico, and Virginia) specifically enacted “point-of-care testing and treatment authority” for pharmacists.[vii] We expect additional states to pursue legislation of this nature.
Challenges
The major impediments to widespread expansion of pharmacist prescribing authority are opposition from physician organizations and the operational and financial costs of program implementation.
The AMA is committed to fighting expansion of pharmacist Test to Treat initiatives, stating in a recent article, “Patients deserve care led by physicians, the most highly trained health care professionals. The AMA fights for physician-led care nationwide at the state and federal levels.”[viii] As the organization with the sixth largest lobbying spend in 2023, the AMA wields vast lobbying power in shaping policy across the United States. In 2023, the AMA spent over $21 million on federal lobbying, dwarfing the amount spent by all pharmacist associations combined.[ix]
Still, there is hope. Encouragingly, although the AMA CEO and Executive Vice President wrote a letter “strongly oppos[ing]” Montana Senate Bill 112, which would grant pharmacists the authority to diagnose, prescribe for, and treat certain health conditions, the bill ultimately passed in 2023.[x]
For those states that have granted pharmacists Test to Treat authority, financial and operational obstacles may hinder the speed of Test to Treat adoption. Pharmacies must consider the development of infrastructure to ensure patient safety that may not be in place today, such as coordination with labs and/or provider offices to gain access to patients’ necessary lab work, complete medication lists, and health history. This type of infrastructure investment would be best leveraged by the larger chains; however, without a pharmacist prescribing authority regulation that is consistent across all states, the returns on any infrastructure investment remain limited and potentially highly complex.
Additionally, four states (New Mexico, California, Montana, and North Carolina) that have some type of pharmacist prescribing authority require that these pharmacists obtain additional training and certification.[xi] However, less than 10% of the licensed pharmacists in these four states have completed this additional certification, suggesting that the value to the pharmacy may not yet be there to justify the training costs.[xii]
Test to Treat: Walgreens Example
Some pharmacies are seizing the opportunity, including chains such as Walgreens and Walmart, and some independent pharmacies that are part of CPESN.[xiii] Per Walgreens website (see screenshot below), patients may be eligible for flu and/or COVID-19 assessment and/or treatment. The pharmacist assessment fee is independent of the cost of any medication, which may then be prescribed by the assessing pharmacist or a physician, depending on the patient’s eligibility.
Source: https://www.walgreens.com/topic/promotion/covid-testing.jsp
Declining prescription reimbursement rates mean that pharmacies need to look for alternative revenue streams to support their businesses. While pharmacies may look to vaccines to boost revenue, additional sources should be continually evaluated. Although legislation is still ongoing, Test to Treat initiatives may provide an opportunity for struggling pharmacies to gain an additional revenue stream by providing a valuable healthcare service to their community. PHSL will continue to monitor and report upon this topic.
[i] Alex Evans, “Prescribing Authority for Pharmacists: Rules and Regulations by State,” GoodRx Health, July 22, 2022. https://www.goodrx.com/hcp-articles/pharmacists/prescriber-authority-for-pharmacists. Accessed 8/27/2024.
[ii] “Fact Sheet: COVID-19 Test to Treat,” Administration for Strategic Preparedness & Response (ASPR), Health and Human Services (HHS). https://aspr.hhs.gov/TestToTreat/Pages/fact-sheet-covid19-t2t.aspx. Accessed August 30, 2024.
[iii] Leigh Ann Anderson, “Can pharmacists prescribe Paxlovid?,” Drugs.com, August 26, 2024. https://www.drugs.com/medical-answers/pharmacists-prescribe-paxlovid-3577842/#:~:text=If%20you%20are%20eligible%2C%20Paxlovid%2C%20an%20oral,well%20as%20a%20list%20of%20current%20medications. Accessed 8/28/2024.
[iv] “Questions for Pharmacist Prescribers,“ FDA, March 13, 2024. https://www.fda.gov/media/155052/download. Accessed 8/28/2024.
[v] Bruce Japsen, “States Move To Allow Pharmacists To Prescribe More Treatments,” Forbes, June 17, 2024. https://www.forbes.com/sites/brucejapsen/2024/06/17/move-to-allow-pharmacists-to-prescribe-more-prescriptions/. Accessed August 28, 2024.
[vi] “Pharmacist Prescribing: “Test and Treat,” NASPA, October 10, 2022. https://naspa.us/blog/resource/pharmacist-prescribing-for-strep-and-flu-test-and-treat/. Accessed August 30, 2024.
[vii] “2023 Provider Status End-of-Year Legislative Update,” NASPA, January, 12, 2024. https://naspa.us/blog/resource/2023-provider-status-end-of-year-legislative-update/#:~:text=180%20bills%20pertaining%20to%20pharmacist,the%202023%20state%20legislative%20sessions. Accessed August 30, 2024.
[viii] Jesse M. Ehrenfiel, MD, MPH, “Expanding test-to-treat policies is a harmful prescription,” American Medical Association (AMA), June 10, 2024. https://www.ama-assn.org/about/leadership/expanding-test-treat-policies-harmful-prescription. Accessed August 30, 2024.
[ix] “American Medical Assn.,” Open Secrets. https://www.opensecrets.org/federal-lobbying/top-spenders?cycle=2023. Accessed August 30, 2024.
[x] James L. Madera, AMA, letter to Montana House of Representatives in opposition to SB 112. February 7, 2023. https://searchlf.ama-assn.org/letter/documentDownload?uri=%2Funstructured%2Fbinary%2Fletter%2FLETTERS%2Flfdr.zip%2F2023-2-7-Letter-opposing-MT-SB-112-Final.pdf. Accessed 8/28/2024.
[xi] Alex Evans, “Prescribing Authority for Pharmacists: Rules and Regulations by State,” GoodRx Health, July 22, 2022. https://www.goodrx.com/hcp-articles/pharmacists/prescriber-authority-for-pharmacists. Accessed 8/27/2024.
[xii] Marc Joffe and Jeffrey A. Singer, “Let Pharmacists Prescribe,” CATO Institute, March 21, 2024. https://www.cato.org/briefing-paper/let-pharmacists-prescribe. Accessed 8/28/2024.
[xiii] https://www.cpesniowa.com/testing-and-treatment. CPESN Iowa. Accessed 9/4/2024.