Pharmacists, Nurse Practitioners, and Physician Assistants, Oh My!

There is a proliferation of state legislative actions to allow independent practice of nurse practitioners and physician assistants. At least 11 states have passed legislation or were in the process of doing so to provide for independent practice and prescribing in 2022,¹ with more bills to come in 2023. Arguments in favor of these bills are a growing shortage of primary care providers, particularly in rural and underserved areas, and a proven record of safety during the COVID-19 pandemic, when restrictions on practice were lifted. Sound familiar? Pharmacists have been asking for the same thing, using the same justifications.

APNPs Ask to Practice Primary Care Independently

The major difference between what advanced practice nurse practitioners (APNPs) and pharmacists are asking is the broad scope of independently practicing primary care that APNPs seek. Primary care is a generalist role, with initial assessments of all maladies, treatments, and triage based on knowledge gained from both didactic work and years of practice training to gain experience. Notably, many of the proposed bills require apprenticeship, extra training, or time under supervision before independence is conferred to an APNP.

EUAs PREP Declarations Are Expiring

The era of post–COVID-19 regulation and practice with expiring emergency use authorizations (EUAs), commercialization of COVID-19 vaccines, and expanded privileges for pharmacists and pharmacy technicians provided by the Public Readiness and Emergency Preparedness (PREP) Act declarations is coming to an end. As a result, state pharmacy associations have been busy at work trying to get bills passed and advocate for changing state laws and regulations to keep privileges that were granted during the COVID-19 era.

Pharmacists Ask to Practice Pharmacy and Assess, Treat Under Established Protocols

Pharmacists are not asking to practice primary care, which is the generalist’s assessment and treatment related to illness and pathology. Rather, they are seeking mass authorization or independent ordering of point-of-care testing, prescriptions for vaccines, or other treatments under narrowly and strictly defined protocols. In fact, very few pharmacists have ever advocated for—or want—broad privileges. Even expansions to refill authorizations, titrations, or other protocol-driven authoritizations do not approach a generalist practitioner’s scope.

Insurance Premiums Remain Low for a Reason

Pharmacists’ safety record for acting independently under protocol is stunning. After many years of advocating against pharmacists operating independently under protocol, with predictions of death and disability caused by reckless and underprepared pharmacists in chaotic care settings, pharmacists successfully ordered, conducted, administered, and documented more than 270 million COVID-19 vaccinations and approximately 50 million COVID-19 tests, along with antibody treatments and nirmatrelvir/ritonavir (Paxlovid).² Nary an event has occurred traceable to a pharmacist not following protocol that caused harm to a patient. Pharmacist malpractice insurance continues to be available for less than $300 a year, and for good reason, even with interventions that now include administering strep tests, prescribing oral contraceptives, and other highly protocolized services. Pharmacists are good at following prescriptive instructions, which should not be a surprise.

Congratulations on Prescriptive Authority; Insurers Still Will Not Pay Pharmacists

Of course, reimbursement for services remains elusive, with widespread imposition and adoption of pharmacist reimbursement in community pharmacies still years away, if ever. Scope-of-practice gains allow pharmacists to do what they are good at, which is filling health gaps, screening, and optimizing medication use—not the provision of a general practitioner’s diagnostics and delivery of primary care. Scope of work, remunerable or otherwise compensated, allows for scale and sustainability. For all other health professions, scope of practice and scope of work go hand in hand. Yet for pharmacists, the system resists, and when it yields, it favors pharmacies as the billers and not pharmacists.

Fee-for-Service Primary Care Has Become a Loss-Lead Proposition

Pharmacies and pharmacists may need to consider the reality that primary care struggles to survive on its own, and without the loss lead to specialty providers that generate large profits for health systems or the insurance captive of shared savings to primary care for the prevention of excess spending, practice and system owners now turn toward cheaper human capital and increased access points. Pharmacies have also been largely co-opted, for better or worse, by nonpharmacy practice interests and now rarely stand alone on the businessperson’s strategy whiteboard. What will that mean for pharmacists in practice? Well, very few graduating physicians are clamoring for family medicine residencies.

Do Pharmacists Really Want to Become Credentialed?

Perhaps there is no pot of reimbursement at the end of that rainbow that is worth seeking. Unlike pharmacy prescription reimbursement, where Medicaid tends to reimburse better than Medicare for commercially insured members, medical services billing favors the commercial members, and Medicaid providers are much harder to come by because of staggeringly low reimbursement for primary care in most instances. Most plans will not allow pharmacies or pharmacists to “balance bill” or charge members a fee above the established reimbursement. Thus, established price points such as $50 to $100 out of pocket for point-ofcare testing, without the use of insurance and with the rise of health savings accounts and less price sensitivity post COVID-19, may be much more sustainable than the hemoglobin A1C test that pays less than $10 and with no primary care visit to bill to offset the loss. The last of the remaining truly independent primary care practice bastions, direct primary care, where there is no third-party reimbursement but 100% out-of-pocket payment by patients, is instructive, as it is the fastest-growing model of primary care financing and delivery. The pharmacy profession should watch closely, as it may need to decide to bifurcate into 2 models: cash pay only and third-party reimbursement pharmacies.

About the Author

Troy Trygstad, PharmD, PhD, MBA, is the executive director of Community Pharmacy Enhanced Services Network USA, a clinically integrated network of more than 3500 participating pharmacies.

References

1. Jacobs J. Legislative update: initiatives to benefit NPs and PAs. Clinical Advisor. February 25, 2022. Accessed January 25, 2023. https://www.clinicaladvisor.com/home/topics/practice-management-information-center/legislative-update-initiatives-benefit-nps-pas/

2. Grabenstein JD. Essential services: quantifying the contributions of America’s pharmacists in COVID-19 clinical interventions. J Am Pharm Assoc (2003). 2022;62(6):1929-1945.e1. doi:10.1016/j.japh.2022.08.010