The Impact of Community Pharmacies on Immunization

JULY 21, 2019
Ned Milenkovich, PharmD, JD
The community pharmacist wears multiple hats in the daily delivery of health care to patients, one of which might be providing immunization services. Certainly, the patient who walks in for an immunization benefits from the convenience provided by the community pharmacy.

Over the past 20 years, growing numbers of pharmacists have completed training in vaccine administration, and for good reason. In 1997, the US Department of Health and Human Services requested the help of the American Pharmacists Association in drafting new guidelines to broaden the role of the pharmacist in service of the goal of increasing vaccination rates. Each of the 50 states now permits pharmacists to provide some vaccination services (specific laws vary by state because the practice is not regulated by federal law). Capitalizing on that opportunity by servicing patients who are seeking vaccination adds overall value to the pharmacy experience.

IMMUNIZATION SERVICE MODELS
In 2014, the National Vaccine Advisory Committee released its recommendations for adult immunization standards, recognizing pharmacists as having a vital role in increasing adult vaccination rates.1 In response, community pharmacies now offer 2 routes to providing immunization services: outsourcing these services and providing immunizations in-house. Both efforts are intended to increase vaccination rates among adults for vaccine-preventable diseases, such as influenza, shingles, and pneumonia, as well as to increase foot traffic in the pharmacy.

Outsourcing immunization services requires that the pharmacy reaches out to employers or community-center supervisors for permission to administer vaccinations to the general public off-site periodically throughout the year, most often during flu season and the period when students return to school. This approach requires some planning from the pharmacy, such as sending an immunizing pharmacist, supplies, and vaccines to the site. A major advantage of this method, however, is that it enables the pharmacy to plan its patient encounters without such encounters impeding the daily workflow.

Alternatively, a pharmacy can provide vaccination services in-house. This practice is the most cost-effective and can help generate the highest rates of vaccination.2,3 In contrast to outsourcing, providing vaccines in-house means that the pharmacy’s immunization-trained staff members do not have to leave the pharmacy. In-house vaccine services, versus off-site services, also have a higher rate of direct patient interaction.4

PHARMACIST–PHYSICIAN PROTOCOLS
Pharmacists who are trained to administer vaccinations usually need to set up a protocol with a physician. The protocol permits a single physician to sign standing orders and prescriptions for multiple pharmacists as well as for the patients whom they treat. Each state differs in the requirements that need to be met by an immunizing pharmacist; in some states, pharmacists have the right to administer certain immunizations by way of statute and without the need for a protocol.

APPOINTMENT-DRIVEN VERSUS WALK-IN TRAFFIC
Vaccination services can be offered by appointment, by accepting walk-ins, or both. Offering appointments minimizes interruptions in the transaction of daily business in the pharmacy; however, it lowers the possible number of patients who can be immunized. For this reason, a growing number of pharmacies have opted to serve walk-in patients. For a patient, simply walking into the pharmacy and getting a vaccination may be the most convenient option; however, walk-in patients interrupt the pharmacy’s prescription-fulfillment workflow. Offering walk-in vaccination services also requires that the pharmacy has a wide variety of vaccines on hand because walk-in patients cannot be screened in advance.

COMMUNITY PHARMACY–BASED VACCINATIONS LOWER COSTS
Despite modest improvements in the past 5 years, the adult vaccination rate in the United States remains below recommended standards.5 In contrast to a landscape where vaccinations may only be administered in a physician’s office, community pharmacy–based administration of vaccines can improve immunization rates among undervaccinated population sectors by offering expanded business hours, convenient locations, and lower costs. A recent study indicated that “the average direct costs paid per adult vaccination were lower in pharmacies compared with physician offices and other medical settings by 16%-26% and 11%-20%, respectively.”6 The average cost of vaccination was determined by analyzing the health plan– and enrollee–paid amounts for the vaccine itself, administration of the vaccine, the dispensing fee, and the visit, if applicable. For pneumococcal vaccinations, for example, the average costs were $65.69 at a physician’s office, $72.11 in other medical settings, and $54.98 at the pharmacy. Pharmacy-based administration of vaccinations drives value to both the patient and the pharmacy through convenience and access efficiencies.

Just like pharmacies, doctors’ offices must also have enough of the most common vaccines on hand to meet their patients’ needs. However, according to a recent survey, almost 70% of family physicians and 80% of general internists reported that they did not stock all recommended adult vaccines because the costs of stocking and administering these vaccines were prohibitive.7

OBSTACLES EXIST DESPITE PROVEN SUCCESS
Although community pharmacy–based immunization programs have amply demonstrated their success, they still face obstacles that prevent pharmacies from assuming full vaccination responsibilities. In addition to different reimbursement and compensation programs across pharmacies, state reporting requirements lack uniformity. Pharmacists in all 50 states are legally permitted to administer vaccines; however, more than 60% of states still restrict vaccine administration at pharmacies by requiring a prescription from a physician or demanding that a protocol be created with a physician. In addition, state laws vary considerably with regard to the minimum age of the patient and the types of permissible vaccines they can receive. And, of course, compliance with these state regulations imposes added expenses on pharmacies.

Nevertheless, the benefits of convenience, efficiency, and public health education that pharmacies provide bring value to the patient and increase opportunities for the pharmacy to engage in cross-selling its other services to that patient.

WHAT THE FUTURE HOLDS
The continued success of community pharmacy–based immunization services may be secured by focusing on serving
patients, national legislative reform, and the standardization of both reimbursement programs and pharmacy information management systems.

One such agency that supports these efforts is the Pacific Research Institute (PRI) for Public Policy. In its mission state- ment, PRI champions “freedom, opportunity, and personal responsibility for all individuals by advancing free-market policy solutions” through policies that stress private initiative and limit- ed government. PRI recommends that pharmacists be granted the power “to independently screen, assess, and administer all CDC- recommended adult vaccines without a protocol or prescription from a physician on a national basis.”8

Continuing these reforms would likely drastically reduce the needless regulatory costs that encumber pharmacists and would further give patients more choices in vaccination services. This would result in greater and more effective health care quality as well as an increased symbiotic value-based relationship between patients and pharmacists.
 
Ned Milenkovich, PharmD, JD, is chairman of the health care law practice at Much Shelist PC, based in Chicago, Illinois, and is the former vice chairman of the Illinois State Board of Pharmacy.

REFERENCES
  1. National Vaccine Advisory Committee. Recommendations from the National Vaccine Advisory Committee: standards for adult immunization practice. Public Health Rep. 2014;129(2):115-123. doi: 10.1177/003335491412900203.
  2. Prosser LA, O’Brien MA, Molinari NA, et al. Non-traditional settings for influenza vaccination of adults: costs and cost effectiveness. Pharmacoeconomics. 2008;26(2):163-178. doi: 10.2165/00019053-200826020-00006.
  3. Grabenstein JD, Guess HA, Hartzema AG, Koch GG, Konrad TR. Effect of vaccination by community pharmacists among adult prescription recipients. Med Care. 2001;39(4):340-348.
  4. Westrick SC. Pharmacy characteristics, vaccination service characteristics, and service expansion: an analysis of sustainers and new adopters. J Am Pharm Assoc (2003). 2010;50(1):52-61. doi: 10.1331/JAPhA.2019.09036.
  5. Vaccination coverage among adults in the United States, National Health Interview Survey, 2016. CDC website. cdc.gov/vaccines/imz-managers/coverage/adultvaxview/pubs-resources/NHIS-2016.html. Reviewed February 8, 2018. Accessed May 23, 2019.
  6. Singhal PK, Zhang D. Costs of adult vaccination in medical settings and pharmacies: an observational study. J Manag Care Spec Pharm. 2014;20(9):930-936. doi: 10.18553/jmcp.2014.20.9.930.
  7. Hurley LP, Bridges CB, Harpaz R, et al. U.S. physicians’ perspective of adult vaccine delivery. Ann Intern Med. 2014;160(3):161. doi: 10.7326/M13-2332.
  8. Mission statement. Pacific Research Institute website. pacificresearch.org/mission-statement/. Accessed May 10, 2019.


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