Opportunities Abound for Pharmacies to Administer Vaccines, So Why Aren’t They?

As of July 29, 2021, more than 38,000 community and long-term care pharmacies are administering COVID-19 vaccinations.¹ Each of those locations enrolled in the Federal Retail Pharmacy Program (FRPP), which
is an effort led by the CDC to allocate vaccines to those pharmacies who meet their requirements and can onboard through a contracted Network Administrator (chains, wholesalers, services administrative organizations, and clinically integrated networks).^1,2 The FRPP program was built and implemented in parallel to the “jurisdictional” program that also allocated vaccinations through states, territories, and large metropolitan areas like New York City. The FRPP added considerable capacity to the nation’s COVID-19 vaccination efforts, generating accessibility and leveraging existing relationships and foot traffic from the millions of Americans already frequenting these pharmacies.¹

Initial COVID-19 Vaccination Markets Largely Determined by Health Authorities

By the end of February 2021, more than 85 million doses of COVID-19 vaccines had been administered in the United States,³ yet according to public polling, just 9% of adults reported receiving the vaccination in a pharmacy (vs 38% for influenza vaccinations).⁴ At only a quarter of the rate of administration as prior flu seasons, community pharmacies rightly questioned why they were not allocated more of the vaccine, earlier in the effort, rather than sharing the allocation with entities that had less experience with throughput and immunization registries. Based on a self-reported capacity of well over a million jabs per day, FRPP participants alone could have handled the highest volumes of vaccine administration achieved in February and in March. Yet sparse allocation from health authorities to community pharmacies, despite ample capacity, stunted average pharmacy administration volume in those early high-demand, low-supply months of the effort.⁵ An unprecedented supply and demand imbalance necessitated a directed allocation effort by health authorities to ensure equity and population coverage. Which enrolled providers and provider types administered the COVID-19 vaccinations, where they administered them, and in what volume was largely determined by federal, state, and local officials rather than patients, and allocation often favored health departments and mass-vaccination sites.

With vaccine supply becoming more plentiful since then, more than 123 million doses have been administered and reported by US retail pharmacies, including 8 million doses administered through the Pharmacy Partnership for Long-Term Care Program.¹ As of August 2, 2021, 60.6% of adults (age ≥ 18) in the United States are fully vaccinated against COVID-19, a substantially higher rate than that seen for influenza in the 2019-2020 season (48.4%).^3,6

Additional Administration of COVID-19 Doses May Greatly Exceed Initial Volume of Pharmacy Vaccinations

Should boosters or additional doses of vaccine for COVID-19 be available and recommended in the fall and winter of 2021-2022, pharmacies should expect record volumes of vaccine administration and associated health care service delivery opportunities. Unlike the initial COVID-19 vaccination efforts, scarcity of supply for what may become recommended additional doses of COVID-19 vaccinations may not be as pronounced, allowing for more market-based, consumer-driven site-of-service selection for vaccine administration. Testing and referral services will become essential as the Delta (or other) COVID-19 variant(s) cause a predicted late summer and fall outbreak alongside influenza and other infections as stores, events, and schools stay open for face-to-face (air-to-air) interaction.⁷

Myths About Pharmacy-Administered Vaccinations Persist

Despite these opportunities, some pharmacies remain hesitant to jump into administering COVID-19 vaccinations and providing related services with both feet. Some have sat out the 2021 COVID-19 vaccination effort altogether and many others continue to avoid or otherwise delay providing noninfluenza vaccination services. Unfortunately, many largely unfounded myths linger about pharmacy-administered vaccinations.

MYTH #1: Most Patients Prefer Other Settings of Care for Vaccinations

Two decades ago, pharmacy-administered vaccines were not widely accepted as mainstream and consumers were largely unaware of or unfamiliar with pharmacies as vaccinators. We now live in a world where pharmacies are viewed as the “go-to” provider for population-based vaccination efforts.⁸ The public perception of pharmacies as acceptable and even preferred places of service for vaccination has been amplified by COVID-19.⁵

MYTH #2: Steep Learning Curve for Pharmacy Staff

Providing vaccination services is distinctly different from dispensing pills, yet most staff working in the average pharmacy have grown up with a local pharmacy providing vaccinations. It’s not a service in the abstract for either the public or the pharmacy staff (who also are members of the public at the end of the day). Ample resources now exist online and through continuing education for both influenza and noninfluenza vaccination labeling, protocols, and workflow.⁹ Once pharmacy staff have received training on influenza vaccinations, it is a relatively small leap to non-influenza vaccinations.

MYTH #3: Large Investment in Staff time

When they have been trained in administration technique, input workflow, and counseling, pharmacy staff can administer vaccinations very efficiently and effectively.

In my experience, most pharmacies scheduled patients
for COVID-19 vaccinations in 8- to 12-minute increments, occasionally using 15-minute increments. Much of that time is used for registry log-in and data entry, which is becoming less manual and time intensive with greater availability of automated registry lookups and data integration. Furthermore, nonpharmacist staff are playing a larger role in queuing up patients for their “jab,” and technicians and pharmacy students have become the primary administrators of the vaccine in many pharmacies.¹⁰

MYTH #4: Complicated Billing

Many influenza and noninfluenza vaccinations are adjudicated through conventional National Council for Prescription Drug Programs standard claims submissions. However, many pharmacies use medical claims and individual provider credentialing and enrollment for reimbursement of vaccine administration services.¹¹ Medicare Part B is the most common recipient of pharmacy-based immunization billing and COVID-19 greatly accelerated pharmacies’ participating in medical billing as there was no “buy-sell” margin associated with COVID-19 vaccinations but a rather healthy $40 per administration standard set by the Centers for Medicare & Medicaid Services for the uninsured.¹² Many plans followed suit with those rates and also began to accept medical claims from pharmacies. No doubt, there were (and remain) some wrinkles to work out, particularly with smaller plans having smaller volumes of members and unique billing requirements, but COVID-19 has greatly accelerated pharmacy benefit managers’ acceptance of payment for vaccine administration services. Additionally, technology providers have become much more adept at providing integrations into pharmacy management systems to ensure that vaccine administration billing is not a valid reason to avoid providing the service.¹³

MYTH #5: Low Return on Investment

Meeting payroll or pleasing owners are certainly priorities for any business. If training is poor, workflow inefficient, marketing listless, and technology underutilized, vaccination services (even for influenza) can become economically unsustainable. Yet for most pharmacies who participated in COVID-19 vaccination efforts, the opportunity will be the greatest contributor to their end-of-year margin. For some it has been practice-changing: adopting online scheduling and developing trusted relationships with health departments, employers, and policymakers, with a resultant 1990s-level of prosperity, has kept many pharmacies afloat. At $40 per administration for many COVID-19 jabs, generating a healthy immunization practice is becoming a cornerstone of community pharmacy sustainability. Of all the vaccine-related pharmacy myths, low return on investment is the most unfounded of them all.

REFERENCES

1. Understanding the Federal Retail Pharmacy Program for COVID-19 vaccination. CDC. Updated June 29, 2021. Accessed August 3, 2021. https:// www.cdc.gov/vaccines/covid-19/retail-pharmacy-program/index.html
2. Fact sheet: President Biden announces increased vaccine supply,
   initial launch of the Federal Retail Pharmacy Program, and expansion
   of FEMA reimbursement to states. The White House. February 2, 2021. Accessed July 12, 2021. https://www.whitehouse.gov/briefing-room/ statements-releases/2021/02/02/fact-sheet-president-biden-announces-increased-vaccine-supply-initial-launch-of-the-federal-retail-pharmacy-program-and-expansion-of-fema-reimbursement-to-states/
3. Trends in number of COVID-19 vaccinations in the US. CDC. Updated July 13, 2021. Accessed August 3, 2021. https://covid.cdc.gov/covid-data-tracker/#vaccination-trends
4. Dobson Jr LA, Trygstad T. We must use the vaccination infrastructure we already have. Pharmacy Times®. 2021;89(4):10. Accessed July 12, 2021. https://www.pharmacytimes.com/view/we-must-use-the-vaccination-infrastructure-we-already-have
5. Banco E. Biden admin remakes vaccine strategy after mass vaccination sites fizzle. Politico. March 29, 2021. Accessed July 15, 2021. https://www. politico.com/news/2021/03/29/covid-vaccine-sites-478233
6. Flu vaccination coverage, United States, 2019–20 influenza season. CDC. October 1, 2020. Accessed August 2, 2021. https://www.cdc.gov/flu/fluvax-view/coverage-1920estimates.htm
7. Lovelace Jr B. Americans will need masks indoors as U.S. heads for ‘dangerous fall’ with surge in delta Covid cases. CNBC. July 8, 2021. Updated July 14, 2021. Accessed July 12, 2021. https://www.cnbc.com/2021/07/08/ us-heading-for-dangerous-fall-with-surge-in-delta-covid-cases-and-return-of-indoor-mask-mandates.html
8. Shen AK, Peterson A. The pharmacist and pharmacy have evolved to become more than the corner drugstore: a win for vaccinations and public health. Hum Vaccin Immunother. 2020;16(5):1178-1180. doi:10.1080/21645515.2019.1660119
9. Immunization education & training. CDC. May 7, 2019.
   Accessed July 12, 2021. https://www.cdc.gov/vaccines/ed/index.html
10. HHS authorizes pharmacy technician and pharmacy intern administration of COVID-19 tests and vaccines. American Society of Health-System Pharmacists. October 21, 2020. Accessed July 12, 2021. https://www.ashp. org/Advocacy-and-Issues/Key-Issues/Other-Issues/HHS-Authorizes-Pharmacy-Tech-and-Intern-Administration-of-COVID-19-Tests-and-Vaccines?loginreturnUrl=SSOCheckOnly
11. CDC COVID-19 Vaccination Program provider requirements and support. CDC. April 30, 2021. Accessed July 14, 2021. https://www.cdc.gov/vaccines/ covid-19/vaccination-provider-support.html
12. Biden-Harris administration increases Medicare payment for life-saving COVID-19 vaccine. Press release. Centers for Medicare & Medicaid Services. March 15, 2021. Accessed July 15, 2021. https://www.cms.gov/newsroom/ press-releases/biden-harris-administration-increases-medicare-payment-life-saving-covid-19-vaccine
13. Offering vaccines could cost pharmacies—unless they have help. FDS. Accessed July 19, 2021. https://www.fdsrx.com/vaccine-help-for-pharmacies/