The Challenge of Multistate Pharmacy Licensure in the Telehealth Era

Since the beginning of the COVID-19 pandemic, there has been increasing demand for, and demands on, health care professionals. As viruses constantly mutate and new variants emerge, the demands for medication therapy, COVID-19 testing and vaccinations have grown.

These challenges, when combined with factors that impact the ability of health care providers to supply services, have resulted in acute shortages of pharmacists and pharmacy technicians in certain geographic regions and across areas of practice.

These shortages can be exacerbated by licensure requirements for pharmacists and technicians, which generally require these personnel to be licensed in the state or territory where their patients are located when an encounter occurs, regardless of the location from which the pharmacist or technician may be physically providing these services.

During the pandemic, patients did not have access to care for a variety of reasons, such as cancelled appointments (especially elective procedures and preventative care visits), cutbacks in transportation options, fear of going to health care settings, or an altruistic desire to not be a burden on the health care system.¹ Health care providers, including pharmacists, quickly responded to these concerns by implementing telehealth solutions, enabling patients to receive many health care services without leaving their homes.

Telehealth removed geographic restrictions on providing care and has expanded tremendously during the pandemic. For example, although fewer than 1% of Medicare fee-for-service visits were performed via telehealth before the public health emergency pertaining to COVID-19 was declared in March 2020. One year later, more than 43% of these same visits were performed using telehealth technologies.²

Whereas telehealth use expanded in pharmacy over the pandemic, pharmacy personnel face challenges when implementing these services, beginning with regulatory requirements affecting their ability to provide telehealth. There are numerous challenges to pharmacy personnel who wish to fully use telehealth to serve patients in multiple states, such as obtaining licenses to practice in each of these states.

In the current regulatory environment, pharmacists and technicians must maintain their original license and then meet a variety of requirements to obtain an additional license in each state in which they wish to provide services.

Meeting these requirements requires a great deal of time and financial expense that quickly grows as the number of states in which these personnel hope to provide services increase.

Discrepancies between states regarding continuing education (CE) requirements, licensure renewal periods, and the examinations needed to become licensed further complicates the process. Several national pharmacy associations have recently adopted policies in support of reducing the administrative burdens for pharmacy personnel who would like to provide services across multiple states.

The American Society of Health-Systems Pharmacists (ASHP) has developed a series of policies that support the harmonization of laws and regulations impacting pharmacy practice across states and enhances the ability of pharmacists to practice in multiple states.

In 2020, the ASHP House of Delegates adopted a policy on interstate pharmacist licensure, which in part states that “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

According to David Chen, RPh, MBA, ASHP’s assistant vice president for Pharmacy Leadership and Planning, multistate licensure and harmonization of laws across states have become increasingly important to health-system pharmacists.

“As health systems grow larger, and there is the maturation and availability of audio-visual technologies, many are developing patient care models that include providing services across multiple sites, often in multiple states,” Chen said.⁴

ASHP’s advocacy to advance these policies has been to work with federal policymakers and leaders in their state affiliate associations supporting their efforts with their boards of pharmacy to make changes in state pharmacy laws and regulations. In 2021, the American Pharmacists Association (APhA) evaluated policies for the multi-state practice of pharmacy.

This evaluation resulted in policy statements that were adopted by APhA’s House of Delegates that year. Among the policy statements adopted include, “APhA advocates for continued development of uniform laws and regulations that facilitate pharmacists, student pharmacists, and pharmacy technicians’ timely ability to practice in multiple states to meet practice and patient care needs,” “APhA urges state boards of pharmacy to reduce administratively and financially burdensome requirements for licensure while continuing to uphold patient safety,” and “APhA calls for development of profession-wide consensus on licensing requirements for pharmacists and pharmacy personnel to support contemporary pharmacy practice.”⁵

APhA’s advocacy efforts also focus on working with state pharmacy associations, often in partnership with the National Association of State Pharmacy Associations (NASPA) to affect changes in state laws and regulations that affect pharmacy practice. But APhA is also looking to advocate for changes at a federal level, particularly when pharmacy personnel can contribute to how our nation responds to an emergency.

The Public Readiness and Emergency Preparedness (PREP) Act enables the Secretary of the US Department of Health and Human Services (HHS) to issue a variety of declarations in the event of a public health emergency.⁶ 

APhA leaders have reached out to HHS officials to advocate for the ability to facilitate multistate licensure during an emergency where pharmacy personnel in one part of the country are needed to support the provision of pharmacy services in other parts of the country.

“By focusing our federal advocacy efforts on pharmacists’ emergency response efforts, we feel that achieving success on this matter will enable not only multi-state licensure in the future, but also our further efforts for pharmacists to gain Medicare provider status,” said Ilisa Bernstein, PharmD, APhA’s senior vice president of Pharmacy Practice and Government Affairs.⁷

Individual states have begun to take actions to enable multi-state pharmacy practice. In 2019 Idaho became the first state to enact a mutual recognition pharmacist licensure pathway into law. Idaho’s 2019 House Bill No.10 established provisions regarding the multistate practice of pharmacy.

Under the law, 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 Idaho residents.⁸

A mutual recognition agreement can be entered into by any other state so long as they have similar requirements for licensure, require fingerprint criminal history background checks, and grant the same multistate practice privileges to Idaho licensed pharmacists, interns, or certified technicians.⁸

According to Jennifer Adams, PharmD, EdD, FAPhA, FNAP, associate dean of Academic Affairs at Idaho State University’s College of Pharmacy, as of February 2022 several states have considered Idaho’s proposal, but no other state had yet entered into a mutual recognition agreement (Jennifer Adams, PharmD, FAPhA, email communication, February 2022).

Other health care professions have taken steps to enable multi-state licensure and practice of their professionals. In these cases, states have implemented licensure compacts which allows an expediated pathway to licensure for care providers practicing in multiple states.

For physicians, an interstate medical licensure compact has been agreed to between 29 states and became operational in 2017. A nursing licensure compact has been in effect for more than 15 years, with 34 member states.

A licensure compact for physical therapists also started in 2017 with 21 state members.⁵ Those streamlined system employed by other health care professions allow licensees to obtain licenses in other states quickly and efficiently.

An issue that arises 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 enable their member boards to harmonize pharmacy practice regulations and to respond to the needs for pharmacy personnel to become licensed in multiple states, particularly in times of emergency. In April 2020, NABP launched the Emergency Passport Program.

The program facilitated the ability for participating states to provide the authority for pharmacists, pharmacy technicians and pharmacy interns to practice in other participating states on a temporary, emergency basis.⁹ As a temporary authorization, the NABP Emergency Passport Program facilitates pharmacists, technicians and interns practicing in another state to be efficiently granted temporary or emergency licensure, with no fees charged by NABP to participants to utilize this program.

Twenty states have participated the emergency passport program. As of February 2022, NABP has processed over 62,000 applications under the emergency passport program, primarily requests for authorizations to practice in another state made by pharmacists and pharmacy technicians. More than 57,000 of these applications were approved by the participating states (Al Carter, PharmD, RPh, executive director, email communication, March 2022).

The NABP has noted an increased need for pharmacies and pharmacy personnel to provide services across multiple states in situations that may not be considered an emergency. Building on what they have learned when implementing the emergency passport program, the NABP Verify Program launched in April 2022.

The program will provide a mechanism to verify that pharmacist applicants are in good standing in all states of licensure, enabling the issuance of a state specific credential. This credential has practice authority by means of state statutory or regulatory reference and allows pharmacists to provide services such as remote medication order entry and verification across states.

Applicants will be charged a fee of $50 per year by NABP to participate in the program, as well as fees that may be charged by each participating state.

“NABP would like to establish a platform that enables consistent processes and procedures across all states,” Carter said.¹⁰

Multi-state licensure of pharmacy personnel and the development of interstate pharmacy practice credentials are methods to resolve the maldistribution of the pharmacy workforce and prevent acute shortage of pharmacists. National and state pharmacy associations can work together with state regulatory agencies and pharmacy employers to break down many of the barriers that currently prevent pharmacy personnel from providing services across multiple states.

Enhancing multistate pharmacy practice will provide numerous benefits for both pharmacists and patients, including: (1) expanded access to care for patients in rural areas or living on state lines, (2)lower cost burden for pharmacists who are maintaining licenses in multiple states, (3) faster speed for transferring and reciprocating pharmacist license, (4) reduced burden on pharmacists and pharmacies and ensure continuity of care and increased access to medications.

References

1. Reduced access to care - research and development survey - COVID-19. Centers for Disease Control and Prevention. https://www.cdc.gov/nchs/covid19/rands/reduced-access-to-care.htm. Published August 6, 2021. Accessed February 22, 2022.
2. National Archives and Records Administration. https://trumpwhitehouse.archives.gov/presidential-actions/executive-order-improving-rural-health-telehealth-access/. Accessed February 24, 2022.
3. ASHP policy 2030, Interstate Pharmacist Licensure. In: Hawkins B, ed. Best practices: positions and guidance documents of ASHP. 2020-2021 ed. Betshesda, MD: American Society of Health-System Phamacists; 2021. https://www.ashp.org/pharmacy-practice/policy-positions-and-guidelines/browse-by-document-type/policy-positions?loginreturnUrl=SSOCheckOnly. Accessed February 22, 2022.
4. Chen D. RPh, MBA, ASHP’s Assistant Vice President for Pharmacy Leadership and Planning. ASHP’s Advocacy Approach for Advancing Multistate Licensure. February 7, 2022.
5. 2020-2021 House of Delegates Report of the Policy Committee. 2020-21_Policy_Committee_Report_DRAFT v6 10 25 2020. https://aphanet.pharmacist.com/sites/default/files/audience/2020-21_Policy_Committee_Report_DRAFT%20v6%2010%2025%202020%20-%20Full%20Report%20with%20page%20nos..pdf. Published 2021. Accessed February 22, 2022.
6. US Department of Health and Human Services. Public Readiness and Emergency Preparedness Act.https://aspr.hhs.gov/legal/PREPact/Pages/default.aspx.Accessed February 24, 2022.
7. Bernstein I, PharmD, APhA’s Senior Vice President of Pharmacy Practice and Government Affairs. APhA’s Advocacy Approach for Advancing Multistate Licensure. February 9, 2022.
8. Inthehouseofrepresentatives 1 ANACT 2 relatingtopharmacy ... https://legislature.idaho.gov/wp-content/uploads/sessioninfo/2019/legislation/H0010.pdf. Accessed February 23, 2022.
9. NABP Emergency Passport Program. National Association of Boards of Pharmacy. https://nabp.pharmacy/nabp-emergency-passport-program/. Published February 8, 2022. Accessed February 23, 2022.
10. Carter A, PharmD, RPh, Executive Director,. NABP. Telephone disscussion. February 24, 2022.