Challenges and Opportunities Facing Independent Community Pharmacies

Despite long-standing challenges, independent community pharmacies continue to fight on the front lines of the pandemic and prioritize the health of their patients. AmerisourceBergen (AB) and Good Neighbor Pharmacy (GNP) are committed to fighting for independents in Washington and in the states to improve and expand pharmacy practice.

During ThoughtSpot 2021, Beth Mitchell, senior director, government affairs, AmerisourceBergen, and Brian Nightengale, president, Good Neighbor Pharmacy, sat down with Drug Topics® to discuss current federal and state legislation affecting independent pharmacies, how pharmacists can support policies that will help advance the profession, and the ways that AB and GNP are investing and advocating on behalf of customers to protect their long-term viability.

AmerisourceBergen was the first pharmaceutical wholesale distributor to have a presence in Washington DC. Since 2004, AB’s government affairs and policy team has continuously supported issues affecting provider customers and independent community pharmacies in particular.

“I think independent pharmacists have clearly shown, throughout the COVID-19 pandemic, just how critical and essential…they are to our health care system,” Mitchell said.

The team collaborates with legislators from both sides of the aisle and at the state and federal levels. “We work with all parties, so Republicans, Democrats, Independents in Congress, state legislatures, governors, and the administration,” Mitchell said. “I am fortunate to spend a lot of time on pharmacy legislation, which is very fulfilling because pharmacists provide such an important element of care to their communities which I have felt and seen because I grew up going to a community pharmacy in my home town in North Carolina, and this pharmacy continues to provide quality care for my parents and many friends in the community.” she added.

AmerisourceBergen and Good Neighbor Pharmacy Invest in Independents

AB and GNP recognize the unique and trusted experience independent pharmacies offer their customers and have continually supported their viability. Through the Elevate Provider Network, AB’s pharmacy services administrative organization (PSAO), the company has heavily invested in add-on services that may bolster the financial viability of independents. “We really enhanced our service offerings,” Nightengale said. “We built, with our partners, a central pay mechanism to complete cash flow visibility, incorporated pre and post-edit services so small mistakes don’t jeopardize their full reimbursement, as well as reconciliation services, where pharmacy owners can simply verify their payments. We also enabled a patient engagement center that gives owners all the data they need to focus their efforts on patients,” he added.

During the pandemic, one of AmerisourceBergen’s most significant investments centered around enlisting GNP pharmacies into the Federal Retail Pharmacy Program (FRPP), which was designed to leverage pharmacy networks to quickly disseminate COVID-19 vaccines to Americans.

“We invested heavily in personnel time, content training, education materials, and IT infrastructure to be able to do the ordering and recording [of COVID-19 vaccinations] to make sure our customers could participate in this program,” Nightengale said. “Hundreds of thousands of personnel hours, millions of dollars in hard development costs, in order to enable our pharmacies to be able to order, receive, administer, and report the vaccines back to the CDC.” The investments helped nearly 1600 GNP pharmacies in nearly every state the ability to administer COVID-19 vaccines to patients. “We have shipped more than two million vaccines to independents since the start of our program,” Nightengale said.

Federal and State Priorities for Pharmacy

Amid COVID-19 vaccination rollouts, the last several months have also been witness to a surge of legislation impacting pharmacies. “At the same time that our staff and teams are working full time on supporting customers in our network, the legislative and regulatory activity escalated quickly,” Nightengale said.

At the federal level, Mitchell explained that for pharmacists to administer COVID-19 vaccinations and be reimbursed by Medicare, the federal government had to issue several guidances under the Public Readiness and Emergency Preparedness (PREP) Act.“ At the onset of COVID-19, the AB Government Affairs & Policy team partnered with many pharmacy entities to advocate for the federal government to empower pharmacists to be able to provide COVID-19 vaccinations and additional services to patients during the pandemic, including fair reimbursement by Medicare and Medicaid.We are grateful that our advocacy efforts were successful as these federal actions had to take place for the FRPP to be successful for independent pharmacies and patients,” Mitchell said.

Mitchell also explained that many pieces of legislation pending in state legislatures and Congress aim to address big-picture issues on drug pricing. “We know that the Democrats in the House and the Senate have ideas of what they’d like to do on drug pricing, and President Biden does as well,” she said. In addition, the Department of Health and Human Services (HHS) is expected to release its drug pricing plan, per President Biden’s July Executive Order, in the next few weeks. This is an opportunity to push for policy changes that can address long-standing drug pricing and reimbursement challenges that have been affecting pharmacies.

“I think a broader focus in Washington on drug pricing provides a great opportunity for many important pharmacy priorities to be included in some of those larger packages that Congress is likely to consider this fall,” Mitchell said.

Nightengale pointed to the complex issue of reimbursement as being one of those priorities. Reimbursement issues can severely impact other facets of a pharmacy, Nightengale explained, including patient and product access. “You’ve got this balance between patient access and reimbursement, and it really hits the independents hard,” he said.

Direct and indirect PBM remuneration (DIR) fee reform is currently facing Congress, Mitchell noted. AmerisourceBergen’s pharmacy segments fully support the legislation in Congress that would give Medicare beneficiaries greater access to prescriptions and create necessary reforms that would result in fair, accurate and timely reimbursement to pharmacies. The Pharmacy DIR Reform to Reduce Senior Drug Costs Act, or H.R. 3554, has bipartisan support and was introduced by Reps. Peter Welch (D-VT), Morgan Griffith (R-VA), Vicente Gonzalez (D-TX), Buddy Carter (R-GA), Raja Krishnamoorthi (D-IL), John Rose (R-TN), Abigail Spanberger (D-VA), and Diana Harshbarger (R-TN) and S. 1909 by Sens. Jon Tester (D-MT), Shelley Moore Capito (R-WV), Sherrod Brown (D-OH), and James Lankford (R-OK).

“Even the Centers for Medicare and Medicaid Services (CMS) recognize [that] the astronomical growth of retroactive PBM DIR fees,” Mitchell said. Mitchell noted that a recent report from CMS, which was sent to Congress, found that DIR fees in Medicare have grown by more than 91,500% in the last decade.

“I think there’s no denying that this is an issue that needs to be addressed,” Mitchell said.

As senior director of government affairs, part of Mitchell’s job is to share pharmacist experiences that demonstrate the crushing impact that DIR fees can have on pharmacies and patients. “I was actually in communication with a pharmacist customer today, who is based in Ohio, on how we can work together to share some of the real-world examples that this customer is facing related to DIR fees…and how we translate that and share those examples with Congress to try to garner more support and then drive the legislation forward,” she explained.

One of the most encouraging legal and policy developments has been the Supreme Court decision in the Rutledge v. Pharmaceutical Care Management Association (PCMA) case, which involves a challenge to an Arkansas law regulating the conduct of pharmacy benefit managers (PBMs). The Supreme Court ruled that PBMs must reimburse pharmacies for generic drugs at a price equal to or higher than the pharmacies’ acquisition cost for the drug from its wholesaler.

“That decision is notable because I think it paves the way for other states to enact similar legislation or take similar regulatory action,” Mitchell said. In fact, many are already following in the footsteps of Rutledge v. PCMA, according to Mitchell. “Just this year…our team has seen more than 300 bills introduced in 48 states across the country that are seeking to regulate PBMs or create some form of accountability or transparency related to PBMs,” she said.

Other relevant policies include those that aim to recognize pharmacists as providers in Medicare, according to Mitchell.

The PREP Act gave pharmacists expanded ability to serve their patients during the pandemic, particularly reaching under-resourced communities that serve Medicare patients, “these are not guaranteed permanent reimbursement infrastructure pathways, and so that is something that we’re working on with many pharmacy allies,” Mitchell said.

“There’s a renewed effort amongst the pharmacist community to really come together and advocate for some form of a permanent pharmacist provider status in Medicare,” Mitchell said.

Even prior to COVID-19, independent pharmacies were juggling myriad challenges. The pandemic doubled down on pharmacy workflow disruptions, according to Nightengale. “You’re trying to fill prescriptions and be on the phone, counsel patients, do medication synchronization…and not being identified as an essential business by many communities – it was a huge downside,” he said. And while, in theory, the pandemic gave pharmacists the opportunity to be a bigger player in point-of-care (POC) testing, many independents faced barriers where larger chains and retailers were given opportunities. “What that did – coming back to patient access – it took away the patient’s ability to go to their normal independent pharmacy and forced them to elsewhere,” Nightengale added.

Mitchell also stressed that AmerisourceBergen is supportive of new ideas and solutions for pharmacies in all settings: independent, specialty, long-term care, hospital, chain, and retail, to develop creative and sustainable pathways for permanent Medicare reimbursement. “I think the time is now, and this is the opportunity to ensure pharmacists are recognized as providers in Medicare for critical services, such as COVID-19 and flu tests and immunizations,” she said.

AB often collaborates with the National Community Pharmacists Association (NCPA). The partnerships that AmerisourceBergen and GNP have with their customers also provide valuable support and effective advocacy for pharmacy-related policies. Pharmacy customers often reach out to Mitchell and her team asking for advice on how they can support grassroots and grasstops calls to action.

At the state level, policies related to vaccine authority are top of mind right now. AmerisourceBergen is a member of the American Disease Prevention Coalition (ADPC), an organization with the goal of improving health by eliminating restrictions on pharmacists’ authority to administer vaccines. Although all 50 states currently allow pharmacists to administer vaccines, “there are several state laws that have limitations on how or which vaccines pharmacists can administer, such as limitations based on age, consent, or physician authorization,” Mitchell explained. For pharmacies to be able to provide timely and convenient disease prevention, particularly for under-resourced patients, removing barriers is key. So far, ADPC and its members have been successful in helping to enact legislation in in several states in 2021, such as Georgia and Florida, that would remove some of those limitations.

For Mitchell, the importance of pharmacists getting involved and supporting policies that affect them cannot be understated. “At the end of the day, while we actively and directly advocate on behalf of pharmacists in Washington and the states, the pharmacist's own direct voice is the most effective because they are constituents, local business owners, voters, and health care providers in their community,” she said.

“It’s important [for pharmacists] to be involved, because elected officials need education from subject matter experts…and the best person to do that education is the person closest to the issue. At AB, we try to create opportunities to rally our pharmacy customers to support an issue – help educate them and connect them with legislators to tell their stories,” Mitchell said.

There are many ways for pharmacists to support pharmacy legislation, such as calling their state senator, a member of Congress, or their staff, sending a handwritten letter, or writing a personalized email. No matter what it is, “continued action is vital,” Mitchell highlighted.

“It doesn’t happen overnight, but the continued involvement, the continued fight, will yield positive change,” said Mitchell.

For Nightengale, AB and GNP’s investments in independents are more than financial. “We are invested emotionally, because we believe that the best health care is delivered locally,” he said. “We are united in our responsibility to create healthier futures.”

This article was written in partnership with AmerisourceBergen and Good Neighbor Pharmacy.