Economic Value and Immunization Requirements

SEPTEMBER 20, 2018


Troy Trygstad, PharmD, MBA, PhD; Ned Milenkovich, PharmD, JD; Mindy Smith, BSPharm, RPh; John Beckner, BSPharm, RPh; and Brian Hille, BSPharm, RPh, address the shift in need for pharmacists to obtain prescriptions from physicians and the economic value of providing immunizations.

Transcript: 

Troy Trygstad, PharmD, MBA, PhD: 
So, there’s certainly an advocacy for scope of practice, but it seems to me that what has driven acceptance perhaps more than anything else—other than pretty good stats on low risk of harm of pharmacists immunizing—is pay for value. So, if we’re holding health systems, physicians, and public health entities in geographies accountable for vaccination rates, that seems to melt the ice quite a bit. So, if I know that my HEDIS [Healthcare Effectiveness Data and Information Set] measures or my ACO [accountable care organization] measures, whether it’s hospitalizations or whether it’s vaccination rates, are associated with my population hat, I’m responsible for getting access to a vaccination. That melts down walls pretty quickly, doesn’t it?

Ned Milenkovich, PharmD, JD: Sure, it does. It starts with the pharmacist and the pharmacy being qualified to do that. Once you have the requisite clinical capabilities in order to deliver the immunization, then you’re looking at economics, and you’re looking at metrics that are showing that people are actually being immunized properly. And accessibility is there, because the pharmacy is right there in the neighborhood on the street corner. Patients can just walk in. They don’t have to go to a hospital; they don’t have to go to a doctor’s office. They can just go to their pharmacy. And in the case of Albertsons, they can even go grocery shopping and get all their goods while they’re waiting for their prescription medication and getting their immunizations, so it’s sort of one-stop shopping.

Mindy Smith, BSPharm, RPh: And you’re losing revenue, daily revenue.

Troy Trygstad, PharmD, MBA, PhD: Talk about that, Mindy. So, there’s a business aspect to this, as well, just like any practice or health system. What is the economic analysis looking back—first to Mindy and then to Brian—of vaccinations, net positive?

Mindy Smith, BSPharm, RPh: So, from our research that we have with our pharmacy clients, we have estimated an average across-the-board gross profit. You’ll have a better idea related to net, but gross profit is about $23 per vaccine. And if you look at statistics related to beyond flu on maximizing those opportunities, pharmacies are missing out on, at minimum, $40,000 of revenue per year, probably upward—more toward $90,000 if you were to really do a robust program and maximize all of those opportunities. So, with the revenue being left on the table that we see just through data and survey information related to community pharmacy, there are a lot of missed opportunities.

Troy Trygstad, PharmD, MBA, PhD: And mountains of evidence and missed health and wellness associated with the patients walking into the pharmacy, too.

Mindy Smith, BSPharm, RPh: That, without being said, is from a business, but it’s patient care opportunities and being that conduit for public health where pharmacists are the access point and should be delivering these services.

John Beckner, BSPharm, RPh: Just to add on to what Mindy said, I think in a lot of cases, immunizations have been the springboard to involvement in other patient care activities, whether it’s screenings, MTM [medication therapy management], things like that, that people started with immunizations and expanded outward.

Troy Trygstad, PharmD, MBA, PhD: What circumstances still exist, Ned, where you need a prescription from a physician or a practice to administer an immunization?

Ned Milenkovich, PharmD, JD: Well, I think it depends on the actual immunization. I’m not sure which ones are out there, to be honest, but there are certain immunizations that still require a doctor’s prescription because of, perhaps, the inherent risks associated with it. Perhaps when the manufacturer went through the FDA approval process, it was mandated as part of the approvals that took place. There are a few out there. Perhaps Brian is in a better position to comment on which ones require, or John.

Troy Trygstad, PharmD, MBA, PhD: Well, let’s use your example—travel clinic—or Mindy’s example with yellow fever. Virginia has travel clinics.

Brian Hille, BSPharm, RPh: Yes.

Troy Trygstad, PharmD, MBA, PhD: Pharmacies in Virginia do that, but not every state does that, right? So, why is that?

John Beckner, BSPharm, RPh: I think it’s an evolution. I remember when we first established our protocol and started out with flu and pneumococcal. And we had a physician to sign our protocol and, over time, the physician became comfortable with the pharmacists providing different vaccinations to different age groups. So, I think it’s really an evolution.

Brian Hille, BSPharm, RPh: And pharmacy board rules have evolved with time, too, that have allowed more vaccinations to a broader range of ages. Now it’s something we monitor very closely, because we’re excited when we get the chance to be able to have Japanese encephalitis and yellow fever authority. That means we can open up a travel health clinic in that state, and so we’re advocating for that, and we’re pushing for those kinds of changes because it’s very clear. Just the same with flu. Access is a key, and when you improve access through a community pharmacy, that is what changes the uptake. It’s true with travel, just the same as all the other non flu vaccinations as it was with flu.

Ned Milenkovich, PharmD, JD: I think Brian raises a good point also there, with respect to boards of pharmacies, because although I believe there are boards like Idaho’s board that are very progressive, there are other boards around the country that simply are not aware of some of the more current progressive changes that are taking place. And so, it becomes incumbent upon the industry to raise that awareness. And if the industry does not educate the states and the boards of pharmacies about the expanded pharmacist role, it may not happen on its own.

Troy Trygstad, PharmD, MBA, PhD: And my impression is we’ve got advocates in public health, true?

Ned Milenkovich, PharmD, JD: Perhaps, yes. I think there are advocates everywhere in public health and in other areas, but are they being deployed in unison, in harmony…? We have many, many different associations in our pharmacy world. Sometimes they don’t walk in lockstep on issues, and so it’s important to get everybody speaking from the same page.

Mindy Smith, BSPharm, RPh: Sorry. Some of our vendors who house the vendor registries have really tight relationships with the public health or the immunization unit in the state, Medicaid, which is…I’ve seen them in action and bringing those stakeholders together, they have done a really good job from a public health perspective and advocating even for pharmacy to be involved. So, there are entities that have been and have created those relationships to really promote these opportunities.

Troy Trygstad, PharmD, MBA, PhD: John, you were about to say?

John Beckner, BSPharm, RPh: I was just going to tack onto what Mindy said. I think we probably have more allies in the public health arena than we realize because of our track record.

Troy Trygstad, PharmD, MBA, PhD: And the CDC has been incredibly supportive.

John Beckner, BSPharm, RPh: Yes.

Troy Trygstad, PharmD, MBA, PhD:And that’s what their role is, disease control at population level.
 


Troy Trygstad, PharmD, MBA, PhD; Ned Milenkovich, PharmD, JD; Mindy Smith, BSPharm, RPh; John Beckner, BSPharm, RPh; and Brian Hille, BSPharm, RPh, address the shift in need for pharmacists to obtain prescriptions from physicians and the economic value of providing immunizations.

Transcript: 

Troy Trygstad, PharmD, MBA, PhD: 
So, there’s certainly an advocacy for scope of practice, but it seems to me that what has driven acceptance perhaps more than anything else—other than pretty good stats on low risk of harm of pharmacists immunizing—is pay for value. So, if we’re holding health systems, physicians, and public health entities in geographies accountable for vaccination rates, that seems to melt the ice quite a bit. So, if I know that my HEDIS [Healthcare Effectiveness Data and Information Set] measures or my ACO [accountable care organization] measures, whether it’s hospitalizations or whether it’s vaccination rates, are associated with my population hat, I’m responsible for getting access to a vaccination. That melts down walls pretty quickly, doesn’t it?

Ned Milenkovich, PharmD, JD: Sure, it does. It starts with the pharmacist and the pharmacy being qualified to do that. Once you have the requisite clinical capabilities in order to deliver the immunization, then you’re looking at economics, and you’re looking at metrics that are showing that people are actually being immunized properly. And accessibility is there, because the pharmacy is right there in the neighborhood on the street corner. Patients can just walk in. They don’t have to go to a hospital; they don’t have to go to a doctor’s office. They can just go to their pharmacy. And in the case of Albertsons, they can even go grocery shopping and get all their goods while they’re waiting for their prescription medication and getting their immunizations, so it’s sort of one-stop shopping.

Mindy Smith, BSPharm, RPh: And you’re losing revenue, daily revenue.

Troy Trygstad, PharmD, MBA, PhD: Talk about that, Mindy. So, there’s a business aspect to this, as well, just like any practice or health system. What is the economic analysis looking back—first to Mindy and then to Brian—of vaccinations, net positive?

Mindy Smith, BSPharm, RPh: So, from our research that we have with our pharmacy clients, we have estimated an average across-the-board gross profit. You’ll have a better idea related to net, but gross profit is about $23 per vaccine. And if you look at statistics related to beyond flu on maximizing those opportunities, pharmacies are missing out on, at minimum, $40,000 of revenue per year, probably upward—more toward $90,000 if you were to really do a robust program and maximize all of those opportunities. So, with the revenue being left on the table that we see just through data and survey information related to community pharmacy, there are a lot of missed opportunities.

Troy Trygstad, PharmD, MBA, PhD: And mountains of evidence and missed health and wellness associated with the patients walking into the pharmacy, too.

Mindy Smith, BSPharm, RPh: That, without being said, is from a business, but it’s patient care opportunities and being that conduit for public health where pharmacists are the access point and should be delivering these services.

John Beckner, BSPharm, RPh: Just to add on to what Mindy said, I think in a lot of cases, immunizations have been the springboard to involvement in other patient care activities, whether it’s screenings, MTM [medication therapy management], things like that, that people started with immunizations and expanded outward.

Troy Trygstad, PharmD, MBA, PhD: What circumstances still exist, Ned, where you need a prescription from a physician or a practice to administer an immunization?

Ned Milenkovich, PharmD, JD: Well, I think it depends on the actual immunization. I’m not sure which ones are out there, to be honest, but there are certain immunizations that still require a doctor’s prescription because of, perhaps, the inherent risks associated with it. Perhaps when the manufacturer went through the FDA approval process, it was mandated as part of the approvals that took place. There are a few out there. Perhaps Brian is in a better position to comment on which ones require, or John.

Troy Trygstad, PharmD, MBA, PhD: Well, let’s use your example—travel clinic—or Mindy’s example with yellow fever. Virginia has travel clinics.

Brian Hille, BSPharm, RPh: Yes.

Troy Trygstad, PharmD, MBA, PhD: Pharmacies in Virginia do that, but not every state does that, right? So, why is that?

John Beckner, BSPharm, RPh: I think it’s an evolution. I remember when we first established our protocol and started out with flu and pneumococcal. And we had a physician to sign our protocol and, over time, the physician became comfortable with the pharmacists providing different vaccinations to different age groups. So, I think it’s really an evolution.

Brian Hille, BSPharm, RPh: And pharmacy board rules have evolved with time, too, that have allowed more vaccinations to a broader range of ages. Now it’s something we monitor very closely, because we’re excited when we get the chance to be able to have Japanese encephalitis and yellow fever authority. That means we can open up a travel health clinic in that state, and so we’re advocating for that, and we’re pushing for those kinds of changes because it’s very clear. Just the same with flu. Access is a key, and when you improve access through a community pharmacy, that is what changes the uptake. It’s true with travel, just the same as all the other non flu vaccinations as it was with flu.

Ned Milenkovich, PharmD, JD: I think Brian raises a good point also there, with respect to boards of pharmacies, because although I believe there are boards like Idaho’s board that are very progressive, there are other boards around the country that simply are not aware of some of the more current progressive changes that are taking place. And so, it becomes incumbent upon the industry to raise that awareness. And if the industry does not educate the states and the boards of pharmacies about the expanded pharmacist role, it may not happen on its own.

Troy Trygstad, PharmD, MBA, PhD: And my impression is we’ve got advocates in public health, true?

Ned Milenkovich, PharmD, JD: Perhaps, yes. I think there are advocates everywhere in public health and in other areas, but are they being deployed in unison, in harmony…? We have many, many different associations in our pharmacy world. Sometimes they don’t walk in lockstep on issues, and so it’s important to get everybody speaking from the same page.

Mindy Smith, BSPharm, RPh: Sorry. Some of our vendors who house the vendor registries have really tight relationships with the public health or the immunization unit in the state, Medicaid, which is…I’ve seen them in action and bringing those stakeholders together, they have done a really good job from a public health perspective and advocating even for pharmacy to be involved. So, there are entities that have been and have created those relationships to really promote these opportunities.

Troy Trygstad, PharmD, MBA, PhD: John, you were about to say?

John Beckner, BSPharm, RPh: I was just going to tack onto what Mindy said. I think we probably have more allies in the public health arena than we realize because of our track record.

Troy Trygstad, PharmD, MBA, PhD: And the CDC has been incredibly supportive.

John Beckner, BSPharm, RPh: Yes.

Troy Trygstad, PharmD, MBA, PhD:And that’s what their role is, disease control at population level.
 
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