The importance of pharmacists' expanded role in providing clinical care, particularly in addressing public health challenges such as HIV/AIDS, was discussed in a panel moderated by Aleata Postell, head of specialty pharmacy, Walmart, and included panelists Caroline Juran, executive director, Virgina Board of Pharmacy, National Association of Boards of Pharmacy, Mario Harper, director of Health Action Alliance, Meteorite, and Anne Scott, chief program and impact officer, Elton John Aids Foundation.

Traditionally, pharmacy operates in a siloed model with little consideration for retail as a channel for specialty care. Pharmacists have long been closed off from treatment decisions and working with primary care providers to proactively address treatment with patients who struggle to obtain appointments. Yet, pharmacists play a critical role in delivering clinical care, especially for specialty patients. Ms Juran argued that “patients view pharmacists with trust and confidence. [And] pharmacists are capable of stepping in to assist with the physician shortage” because they are part of the health care team. So why isn’t this a standard practice?

Taking a step back, Ms Juran continued to highlight why allowing pharmacists to provide treatment and care is now a necessity more than ever. Referring to an American Medical College report, Ms Juran noted there is an anticipated shortage of up to 86,000 fewer physicians by 2036. With these statistics in mind, pharmacist education has become incredibly robust in recent years. Previously, pharmacists would receive a 4-year BS, then a 5-year BS, but today, it is a 6-year doctorate. This shift in education allows physicians to delegate pharmacists to treat conditions like chronic diseases in Virginia. 

However, for reimbursement pathways for pharmacists and pharmacies, how does one make sense of the required workflow adjustments to move pharmacists into more clinical roles? Ms Juran explained that patients often view pharmacists with trust and confidence and that pharmacists are capable of stepping in to assist with the physician shortage because “they are part of the health care team.” 

“This past year, the Virginia General Assembly passed [legislation] mandating our state Medicaid agency to reimburse pharmacists as providers when they provide clinical services under collaborative practice agreements and statewide protocols,” said Ms Juran. A critical reimbursement model is necessary for pharmacists to make sense of the workflow adjustments needed to be in more clinical roles.

Many state laws require pharmacists to communicate with a primary care provider (PCP) about any therapies introduced to a patient before they can be prescribed. Meaning, a pharmacist cannot prescribe a treatment to a patient even though the pharmacist knows that the treatment in question will be administered after the patient visits with a PCP.

Ms Juran focused on a real-life example of this drawback regarding the drug Apertude. If a patient requires HIV treatment, a pharmacist is required to coordinate with a health department to get the drug administered. Ms Juran described this situation as “not optimal” since it doesn’t align with the state of Virginia’s larger initiative to expand access to care. 

“It is a protocol developed at the state level, usually with the state board of pharmacy in collaboration with the state board of medicine and the state department of health. It’s a very collaborative protocol on a specific disease state [that] authorizes pharmacists to initiate treatment under those statewide protocols,” she said. 

Ms Juran mentioned that Virgina requested Apertude be added to its statewide protocol to expand access to care by allowing pharmacists to administer it to patients.

The session continued its focus on the realm of HIV, as it remains a significant public health concern, with over 1.2 million people living with HIV in the US alone. 

“When thinking about training, why do you believe there should be an enhanced focus on HIV, and how can pharmacy influence those factors?” asked Ms Postell. 
Ms Scott stepped in to answer, given her work experience with the Elton John Aids Foundation. “13% of people do not know their [HIV] status. Over 1 million are recommended for PrEP but approximately 250,000 lack insurance [coverage].”

Ms Scott addressed the structural barriers to accessing HIV prevention and linkage to care services and that communities need increased access to PrEP, especially in areas of high need for prevention services. Walmart and the Elton John Aids Foundation are trying a different approach by using team-based care. The best care has an innovative variety of health professionals including pharmacists, highlighting the theme of the discussion.

Lifetime medical costs for HIV range from $300,000 to $500,000, and Ms Scott believed introducing pharmacy care not only saves lives but also saves money. A partnership between Walmart and Duke University discussed during the panel demonstrated commitment to helping foster team-based care through training over 120,000 pharmacists and resulted in a 70% increase in confidence in services.

Ms Postell posed another question to the group, asking “[When] we think about pharmacists, how are pharmacists uniquely qualified or positioned to improve health outcomes for people in the communities as a whole?”

The group discussed statistics published in 2020 by the CDC, stating that 90% of the US population lives within 5 miles of a community pharmacy practice. On average, a patient will visit a community pharmacist 12 times more often than their PCP. Mr Harper mentioned that, with these statistics in mind, pharmacists may be the only health care provider easily accessible for many patients and they’re “doing great work to increase medication adherence in [rural communities] and promote overall well-being.”

Along with the other panelists, Mr Harper that pharmacists can step in to fill the gaps created by physician shortages. However, he clarified that it is “not to usurp [the role] by any stretch…[but] they’re part of the health care team.”

About 80% of counties in the US don’t have an infectious disease physician, which exacerbates the challenges in seeking clinical care for HIV. Rural communities struggle with hospital closures, limited clinical services, recruiting, and retaining providers. People who are directly affected with HIV, “often have great barriers themselves to getting to nearby health facilities if they are available,” said Mr Harper. “We want to break down those barriers and try everything we can to meet people where they are.”

According to Mr Harper, there are over 70,000 community pharmacies are in the US and 56% of them are in medically underserved areas. This context, combined with the lack of infectious disease physicians, shows how it is important to seek alternative avenues for treatment such as pharmacists. 

While pharmacies are primarily positioned to administer medications, they can be change agents for increased awareness. Especially with HIV, there are numerous opportunities to tackle stigma through education and involvement throughout the care continuum.

To achieve the best outcomes the panel highlighted key next steps. Whether you’re a manufacturer, a caregiver, a physician, or a pharmacy, meeting patients where they are means allowing community pharmacies to do their part. 

Pharmacists should no longer have to turn a patient away because they don’t have the right tools to deliver care The panel aims to continue to embrace and combat patient care challenges while advocating for pharmacists to be empowered to take on a larger role in the care continuum while being reimbursed fairly.

Reference
Postell A, Harper M, Juran C, Scott A. Access to specialty pharmacy at retail. Presented at the Asembia Annual Summit; April 30, 2024; Las Vegas, NV.