350 Million Interventions
A 2022 article in the Journal of the American Pharmacists Association estimated that the pharmacy workforce in the United States produced more than 350 million interventions in the roughly 2 years following the beginning of the COVID-19 pandemic. These interventions principally included point of care testing (POCT) and vaccinations as well as prescribing and administration of antivirals and antibody infusions, among other interventions. Considering an outpatient pharmacy workforce of roughly 185,000,1 upwards of 2000 interventions per pharmacist were performed, and likely much higher per full-time equivalency.
All of this was done without a single report of major harm or death, following decades of concern raised by advocates in medicine that allowing pharmacists to order, oversee, and administer POCT, vaccinations, and therapies under protocol would cause a cacophony of care gaps and medical errors, causing harm to tens of thousands of Americans.
About the Author
Troy Trygstad, PharmD, PhD, MBA, is the executive director of CPESN USA, a clinically integrated network of more than 3500 participating pharmacies. He received his PharmD and MBA degrees from Drake University and a PhD in pharmaceutical outcomes and policy from the University of North Carolina. He has recently served on the board of directors for the Pharmacy Quality Alliance and the American Pharmacists Association Foundation. He also proudly practiced in community pharmacies across the state of North Carolina for 17 years.
Public Perception of Pharmacists and Pharmacies Has Shifted
Patients, care team members, public health officials, employers, administrators, and legislators alike all changed their perceptions of pharmacy practice in one way or another. Fully 90% of all adult vaccinations are now administered in a pharmacy (update: still nobody dead in the streets yet). Test-to-treat, prescribing oral contraceptives, HIV prophylaxis, and other convenience-based offerings are becoming quite popular where pharmacies are able to offer these services. Pharmacy-provided chronic condition care is also becoming commonplace among health plans and, to a lesser extent, the public, though medication synchronization and adherence packaging are more well-known thanks to Amazon’s pharmacy launch before the pandemic. Despite being 5 years out from the pandemic, the public continues to be cognizant of the convenience and competence of pharmacy services when not overrun, understaffed, or set to close.
A Broken Business Model Remains
Although COVID-19 brought 2 new payment models to pharmacy, the dominant model persisted while the new payment models have waned. The federal government’s COVID-19 vaccine response included a prepurchase of vaccines. In this model, the pharmacy did not buy inventory nor sell it to pharmacy benefit managers, health plans, or patients. Rather, the prevailing rate for vaccine administration was $40, a rate that was combined with economy of scale (workflow and patients) to create new scheduling systems, workflows, and processes that yielded economic sustainability.
The second model was an explosion of cash payments without the contracting or submission of claims to third-party insurers. Tens of millions of Americans gladly paid out of pocket for convenient and competent access to POCT. Both models remain viable economically for community pharmacies to adopt, should demand be sufficient for a given service, state and federal laws allow for continued pharmacist prescriber authorities, and the supply chain structure adapts so that pharmacies get out of the buy-and-sell business. A default to an $8 to $14 dispensing fee with the opportunity for cognitive services and performance bonuses would be sufficient to allow for a meaningful gross margin on labor, supplies, and other operating costs, and would be the budgeting equivalent of a rounding error on global health care spend. At the current moment, the product buy-sell model is on life support.
Part D Medication Therapy Management Is On the Brink…of Destruction or Evolution?
The Centers for Medicare and Medicaid Services (CMS) have thankfully realized that as currently implemented, Part D medication therapy management (MTM) and comprehensive medication reviews (CMRs) are an exercise in finding drug therapy problems (without any directive to fix them) through an unfunded mandate to the prescription drug plans, using technology solutions that are not native to pharmacy workflow, with a small number of case opportunities. This system is not working to accomplish its original objectives. CMS has demoted the CMR measure to “display status” (it no longer contributes to a plan’s star ratings) as it reevaluates its relevance and ponders other means of optimizing medication use among our most at-risk populations.2 CMS is considering the reintroduction of the concept as a new measure in 2027, offering the opportunity for an evolution toward effective and sustainable medication optimization services.2 Now, more than 2 decades on without any significant improvements or evolutions, it’s worth keeping in mind that MTM was conceived formally in the Medicare Modernization Act of 2003 alongside Part D drug coverage3—one of the most damaging pieces of legislation for pharmacy ever passed.
Are We Ready for the Next Pandemic?
Speaking of COVID-19, are we ready for the next pandemic? Pharmacists, the greater pharmacy workforce contingent, and community pharmacy sites are most definitely ready to deploy, likely even more effectively and more efficiently than they did during the peak(s) of the COVID-19 pandemic. However, whether therapies, health care policy, popular culture, and supply chain capabilities will be ready is anyone’s bet, as well as consideration of emerging pharmacy deserts from a broken business model. As author Jeannette Y. Wick, RPh, MBA, FASCP, writes in this issue of Pharmacy Times in her article “The COVID-19 Pandemic: 5 Years Later,” rapid response is essential, and community pharmacies are currently the ultimate setting of care to provide convenient, competent, and effective care response to 330 million Americans within days.
But pharmacies need to remain open to be effective. As the well-worn saying goes, you really may not know what you’ve got until it’s gone.
REFERENCES
1. Occupational employment and wage statistics. US Bureau of Labor Statistics. Updated April 25, 2023. Accessed March 3, 2025. https://www.bls.gov/oes/2022/may/oes291051.htm
2. PQA executive summary: CMS-4201-F3 and CMS-4205-F. Email to PQA Members. May 29, 2024. Accessed March 3, 2025. https://www.pqaalliance.org/assets/library/PQA_Summary_CMS-4201-F3_CMS-4205-F.pdf
3. Medicare Prescription Drug, Improvement, and Modernization Act of 2003, HR 1, 108th Cong (2003). Accessed March 3, 2025. https:// www.congress.gov/bill/108th-congress/house-bill/1
