Advancing Multistate Licensure Is Vital in Telehealth Era

The COVID-19 pandemic has put increasing pressure on health care professionals over the past 2 years. As the virus mutates and variants emerge, demands for COVID-19 medication therapy and vaccinations have grown, and this has led to acute shortages of pharmacists and pharmacy technicians.

Since the pandemic started, patients’ access to care has been limited for many reasons, including canceled appointments (especially elective procedures and preventive care visits), cutbacks in transportation options, and fear of going to health care settings.¹ Health care providers, including technicians, quickly implemented telehealth solutions that have allowed patients to receive many health care services without leaving their homes. Fewer than 1% of Medicare fee-for-service visits were performed via telehealth before the COVID-19 public health emergency was declared in March 2020. One year later, more than 43% of these visits were performed using telehealth technologies.²

There are numerous challenges to pharmacy employees using telehealth to serve patients in multiple states, such as obtaining licenses to practice in each of these states. Pharmacists and technicians must maintain their original licenses and generally are required to be licensed in the state or territory where their patients are located when an encounter occurs, regardless of where the pharmacist or technician may be physically.

Discrepancies among states regarding continuing education requirements, the examinations needed to become licensed, and licensure renewal periods further complicate the process. In 2020, the American Society of Health-System Pharmacists (ASHP) House of Delegates adopted a policy on interstate pharmacist licensure, which in part states that the “ASHP advocates for interstate pharmacist licensure to expand the mobility of pharmacists and their ability to practice, especially during emergencies, and to enhance their ability to practice in multiple states, which is particularly important to telehealth pharmacy practice.”³

In 2021, the American Pharmacists Association (APhA) evaluated policies for the multistate practice of pharmacy. APhA’s House of Delegates then adopted policy statements that urge “state boards of pharmacy to reduce administratively and financially burdensome requirements for licensure while continuing to uphold patient safety.” The statements also note that the APhA “calls for development of professionwide consensus on licensing requirements for pharmacists and pharmacy personnel to support contemporary pharmacy practice.”⁴

The Public Readiness and Emergency Preparedness Act allows the US Department of Health & Human Services (HHS) to issue a variety of declarations in the event of a public health emergency.⁵ APhA leaders have reached out to HHS officials to advocate for the ability to facilitate multistate licensure during an emergency where pharmacy employees in one part of the country are needed to support the provision of pharmacy services in other areas.

In 2019 Idaho became the first state to enact a mutual recognition pharmacist licensure pathway. Pharmacists who are licensed in a state that enters a mutual recognition agreement with Idaho’s Board of Pharmacy do not have to obtain a license or registration in Idaho to practice pharmacy or provide pharmacy services to state residents.⁶ A mutual recognition agreement can be entered into by other states as long as they have similar requirements for licensure, require fingerprint criminal history background checks, and grant the same multistate practice privileges to Idaho-licensed certified technicians, interns, and pharmacists.⁶ However, as of February 2022 several states had considered Idaho’s proposal but none had yet entered into a mutual recognition agreement, according to Jennifer Adams, PharmD, EdD, FAPhA, FNAP, associate dean for academic affairs at Idaho State University College of Pharmacy in Boise.

Other health care professions have taken steps to allow multistate licensure and practice. In these cases, states’ licensure compacts allow an expedited pathway to licensure for care providers practicing in multiple states. For example, a nursing licensure compact has been in effect for more than 15 years with 34 member states. For physicians, an interstate medical licensure compact has been agreed to among 29 states and became operational in 2017.
A licensure compact for physical therapists also started in 2017 with 21 state members.⁴ Those streamlined systems allow licensees to obtain licenses in other states efficiently and quickly. However, one issue with licensure compacts is that state licensure authorities may suffer a loss of revenue because they are issuing fewer licenses than they would if the compacts did not exist. This loss of revenue may reduce their ability to provide suitable oversight and services
to licensees.

The National Association of Boards of Pharmacy (NABP) has taken steps to allow its member boards to harmonize pharmacy practice regulations and respond to the need for pharmacy employees to become licensed in multiple states, particularly during times of emergency. In April 2020, NABP launched the Emergency Passport Program, which allows participating states to provide the authority for interns, pharmacists, and technicians to practice in other states on an emergency, temporary basis.⁷ The program lets interns, pharmacists, and technicians practicing in another state be efficiently granted emergency or temporary licensure, with no fees charged by the NABP to participants.

Twenty states, including Idaho, have participated in the Emergency Passport Program, and as of February 2022 NABP had processed more than 62,000 applications. More than 57,000 of these applications were approved by the participating states, according to Al Carter, PharmD, RPh, the NABP’s executive director.

Noting an increased need for pharmacies and pharmacy employees to provide services across states in nonemergency situations, the NABP launched the Verify Program in April 2022.⁸ This program, which is only accepted by North Carolina right now, provides a way to verify that pharmacist applicants are in good standing in all states of licensure, allowing for the issuance of a state- specific credential.⁸ This credential has practice authority by means of state regulatory or statutory reference and allows pharmacists to provide services such as remote medication order entry and verification across states.

The NABP will charge applicants $50 per year to participate in the program.⁸ The “NABP would like to establish a platform that enables consistent processes and procedures across all states,” Carter said.

Multistate licensure of pharmacy employees and the development of interstate pharmacy practice credentials can help redistribute the pharmacy workforce and prevent acute staffing shortages. National and state pharmacy associations can work with pharmacy employers and state regulatory agencies to break down many of the barriers that prevent pharmacy employees from providing services across multiple states.

Enhancing multistate pharmacy practice will provide numerous benefits, including ensured continuation of care, expanded access to care for patients in rural areas or living on state lines, a faster speed for transferring and reciprocating pharmacist licenses, increased access to medications, a lower cost burden for pharmacy professionals who are maintaining licenses in multiple states, and a reduced burden on pharmacies and pharmacist professionals.

About The Authors

Jisu Eo, PharmD, BsPharm, works in the Advance Pharmacy Practice Experience: Community rotation at Beth Israel Lahey Health in Boston, Massachusetts.

David Zgarrick, PhD, MS, is a professor in the Department of Pharmacy and Health Systems Sciences in the School of Pharmacy at Northeastern University in Boston, Massachusetts.

References

1. Reduced access to care. CDC. August 6, 2021. Accessed February 22, 2022. https://www.cdc.gov/nchs/covid19/rands/reduced-access-to-care.htm

2. Executive order on improving rural health and telehealth access. National Archives and Records Administration. August 3, 2020. Accessed February 24, 2022. https://trumpwhitehouse.archives.gov/presidential-actions/executive-order-improving-rural-health-telehealth-access/

3. Policy positions. American Society of Health-System Pharmacists. Accessed February 22, 2022. https://www.ashp.org/pharmacy-practice/policy-positions-and-guidelines/browse-by-document-type/policy-positions?loginreturnUrl=SSOCheckOnly

4. 2020-2021 House of Delegates report of the Policy Reference Committee. American Pharmacists Association. 2021. Accessed February 22, 2022. https://aphanet.pharmacist.com/sites/default/files/audience/2021%20Policy%20Reference%20Cmt%20Report%20-%20DRAFT_0.pdf

5. Public Readiness and Emergency Preparedness Act. US Department of Health & Human Services. Accessed February 24, 2022. https://aspr.hhs.gov/legal/PREPact/Pages/default.aspx

6.House bill No. 10. Legislature of the State of Idaho. 2019. Accessed February 23, 2022. https://legislature.idaho.gov/wp-content/uploads/sessioninfo/2019/legislation/H0010.pdf

7. NABP Emergency Passport Program. National Association of Boards of Pharmacy. 2020. Accessed February 23, 2022. https://nabp.pharmacy/nabp-emergency-passport-program/

8.NABP Verify. National Association of Boards of Pharmacy. Accessed May 4, 2022. https://nabp.pharmacy/programs/licensure/verify/#:~:text=NABP%20Verify%20is%20a%20credentialing,current%20proof%20of%20your%20status.