The Progression of Immunization - Episode 10
Barriers to Vaccine Screening and Administration
Troy Trygstad, PharmD, MBA, PhD, leads a discussion on the challenges in vaccine screening and administration, including a consideration of nonflu vaccines, the distribution process, reimbursement issues, and accessibility restrictions.
Troy Trygstad, PharmD, MBA, PhD: The biggest barriers, at least when I’m moonlighting on nights and weekends, are 2 things. The screening for ACIP [Advisory Committee on Immunization Practices], particularly when they come out with a nuanced recommendation. And screening to make sure I know quickly at the point of capture there on the left or the right side of the counter—here are the 3.
If it’s flu, I’ve done a bunch of those, I’ve got experience doing those, I feel good about those. These other 2, scary. They're reconstitute or billing. I’ve never billed 1 of those before—am I doing the right NDC [National Drug Code]? Is this a part B, part D? I don’t know that world, right? What are the biggest barriers for nonflu vaccines that you see out there, and what are you doing to reduce those barriers with your staff?
Dorothy Loy, PharmD, MBA: One thing for nonflu, especially when it comes to reminding patients to come in—we talked a little about boosters—is really kind of automating that process. That’s 1 thing that we try to take off the staff to remember and keep track of what patient should I call, and when should they come back in?
Troy Trygstad, PharmD, MBA, PhD: So if your pharmacists don’t feel comfortable about it, give it to the experts, the technicians?
Dorothy Loy, PharmD, MBA: Yeah, exactly. I think it goes back to, as I was mentioning, automating some of that—so reminders. Reminders for patients. Giving them kind of like appointment cards. You mentioned going to your vet, the dentist—they give you appointment cards to come back. We do the same thing. Or making sure that there is a call when that patient needs to come in in advance of when they should be coming in. Taking some of that work off the pharmacist, so they don’t have to do the calculations, don’t have to remember in their head when this patient should be coming back. I think that that helps ease some of our pharmacists and technicians when it comes to, “I have so much to remember for an immunization.” Really, there’s not that much. There are a few things as far as which are the right patients; making it really simple.
If you see someone who’s getting travel-size items, they probably need some travel vaccines—making it as simple as that. If you see someone who’s picking up diapers, or if you see a new mother—making it as simple as that. Give them quick guidelines of which patients to go after. Rather than memorize all the ACIP guidelines, what are the quick patients and things that you can identify in the customers’ habit that may indicate that they need a vaccination? That’s the right person to go after.
From a billing perspective, try to streamline. Make the process easy for them, so when they’re billing, really there’s just 1 way to do it, and the system can kind of figure out how to rebill or give them a message of, “It probably isn’t the right way. Try this other way.” Again, trying to take all that mental thinking off our team members, because the billing really isn’t important in this whole process. It’s really making sure you’re engaging the patient and making sure that they buy into the fact that they need these vaccinations. We want to remove all the barriers from co-pays and confusion around how much a vaccine might cost.
Troy Trygstad, PharmD, MBA, PhD: So your goal is to remove administration from pharmacist providers and let the administrators do it.
Dorothy Loy, PharmD, MBA: Right, exactly.
Troy Trygstad, PharmD, MBA, PhD: And, Tana, that’s how you deal with it in independent pharmacies, right?
Tana Kaefer, PharmD: Right, they’re much smaller, so we do care if the claims go through, because it’s an expensive vaccine. That’s important for us. Really, our technicians, they’re billing specialists. That’s what I call them. They’re amazing.
Troy Trygstad, PharmD, MBA, PhD: You’re specifically focused on, “Look, here are 20 vaccinations. Here’s exactly how they work. You do this, so I can do the patient thing.”
Tana Kaefer, PharmD: Absolutely.
Troy Trygstad, PharmD, MBA, PhD: And I can say that with confidence. I’m not thinking in the back of my mind.
Tana Kaefer, PharmD: “I wonder if they billed it right. I wonder if they put in that administration code.”
Troy Trygstad, PharmD, MBA, PhD: You’re focused on the sale, closing the deal with the patient.
Tana Kaefer, PharmD: Absolutely.
Troy Trygstad, PharmD, MBA, PhD: Hey, great. We’re going to do this now. We know which ones are making that part easy at screening. Making sure there’s an expert who knows who the champion is for billing needs so that you’re focused as a pharmacist on having that patient conversation, administering the vaccination, and making sure there’s follow-up.
Tana Kaefer, PharmD: Yes, absolutely. And reporting. That’s very important, not just to the vaccine registry but just to get out the word that we’re doing this to providers. We always send a doctor’s note as well with the service that we provided, and our contract information about, “Hey, did you also know we do travel health consults,” and things like that.
Troy Trygstad, PharmD, MBA, PhD: What is the inventory of outreach after the patient leaves? What are the 3 or 4 things that still happen?
Tana Kaefer, PharmD: We post it to our vaccine registry, and we send a doctor.
Troy Trygstad, PharmD, MBA, PhD: Your state registry.
Tana Kaefer, PharmD: Yes. And then we send a doctor’s letter to the patient’s doctor.
Troy Trygstad, PharmD, MBA, PhD: And is that a law in your state, Virginia?
Tana Kaefer, PharmD: It’s voluntary.
Troy Trygstad, PharmD, MBA, PhD: But you do it anyway.
Tana Kaefer, PharmD: We do, and we always check that registry before we give vaccines as well.
Troy Trygstad, PharmD, MBA, PhD: And the motivation for doing that is?
Tana Kaefer, PharmD: Doing our part in public health and in making this universal, because it’s so important to have that information so that you can adequately screen patients. And so you’re not giving unnecessary vaccines that they may have already had, which just raises costs even more.
Troy Trygstad, PharmD, MBA, PhD: Good answer.
Emily Endres: I think what’s really interesting between your response, Tana, and yours, Dr Trygstad, is that it’s such a common theme and something we hear a lot from our partner pharmacies at PQS [Pharmacy Quality Solutions]. It takes a team, whether it’s immunizations or focusing on quality in other areas. It takes the entire team to really make that whole process work. So getting everyone engaged in the process and everyone educated is really, really crucial, so continuing to move progress forward, improvement, etc.
Tana Kaefer, PharmD: You have to have the right people. That is very true.
Troy Trygstad, PharmD, MBA, PhD: Dorothy, you’re responsible for a lot of pharmacies in a lot of places. Do we still have a barrier in places on prescribing standard protocols, CPAs [collaborative pharmacist agreements]? Where are we at broadly across the United States’s health care system now on the ability for a pharmacist to identify and administer that vaccination without playing fax tag?
Dorothy Loy, PharmD, MBA: Yes. I would say well over 80% of the vaccines that a pharmacist can provide, throughout the country, can be done via protocol or prescriptive authority, which is a huge win.
Michael Popovich: It is.
Dorothy Loy, PharmD, MBA: We just talked about, within 10 years, how far have we gotten. And so that’s really helpful for the pharmacist and the patient because it removes all the work for having to go and ask a physician to write a prescription, send it to a pharmacy, get the patient back. There are a lot of extra steps. Being able to do that, I think, really provides the patient a concept of trust and respect for the pharmacist in what they’re doing and able to do. And for their expertise and being able to say, “I recommend this, and now we can give you the vaccine. I don’t have to call other providers. I’ve checked my registry. I know that you haven’t gotten these vaccines.” And so in some states we still have prescriptions that are required for different ages and/or vaccines if it’s travel, or usually specific cases.
Troy Trygstad, PharmD, MBA, PhD: Tana, do you run into any prescriptive authority issues with immunizations or other health care providers?
Tana Kaefer, PharmD: No, we’re very protocol driven, so we can give some during pregnancy if it’s on our protocol, and all that. Just as Dorothy mentioned, sometimes outside the travel health consults if it’s something beyond immunization. For travelers, diarrhea or malaria, we have to follow up on that, but we can still give the actual immunizations.
Troy Trygstad, PharmD, MBA, PhD: What about reimbursement issues? Medicaid—is that really still the barrier?
Tana Kaefer, PharmD: For administration fee in Virginia, yes.
Troy Trygstad, PharmD, MBA, PhD: And for you, you’re seeing it all over. What are the remaining barriers on access and billing?
Dorothy Loy, PharmD, MBA: Yeah. And I think it’s access to ensuring that there’s fair billing for pharmacies and for other providers.
Troy Trygstad, PharmD, MBA, PhD: Parity, you’re looking for parity.
Dorothy Loy, PharmD, MBA: Yeah, really. I think that’s what it comes down to. And again, for Medicare, administration fees are lower than other plans, other private plans and commercial plans. And then there are also the cohorts of patients who are uninsured. And so that’s also a barrier for us. There are programs out there, and having pharmacies that can partner with the departments of health so they know where they can recommend that patient to get vaccinated, to your point. We don’t want a patient to go unvaccinated. If they’re interested, and we’ve talked to them and they’re willing, we want to make sure that they get the appropriate care where they can get it.
Troy Trygstad, PharmD, MBA, PhD: Yes, absolutely. What about age restrictions? Are you seeing those still changing, they’re still evolving?
Dorothy Loy, PharmD, MBA: Still changing. Definitely still changing across the many states that we have. There are a lot of states that have really given pharmacists quite broad authority when it comes to immunizing for a lot of different vaccines. But there are some states, about a handful, that still have restrictions for 18 and over, 12 and over. I think those have been changing a lot lately with outbreaks that have been going on. A recent example would be in New York State, where previously they allowed pharmacists to immunize only 18 and over for flu vaccine.
And 2 years ago we had a really bad flu outbreak—an epidemic I would say—and so they allowed pharmacists to do immunizations that season. Since then, they have allowed pharmacists to immunize 7 and over. That was a huge win, because that was a great example of how pharmacists can partner and can be a part of that health care neighborhood. And so moments like that are the things that we rely on to constantly be enhancing and kind of strengthening the authority that pharmacists have.
Michael Popovich: I think another asset we all have here is that the technology and data and best practice in the pharmacy are moving so fast—they are actually ahead of the policies—that traditionally public health has had to implement—and the rules. When an outbreak does occur, it really is no big deal to go in and say, “OK, now we’re going to allow pharmacists to do X.” Because the pharmacists already have all the tools and assets available to do that because they’ve been doing it for all these other cases. I think what’ll happen is these state policies and regulations will begin to level out and will become more of a standard across the country. Even if they don’t, there’s so much information flowing, and best practice is occurring so fast that it’s almost not irrelevant. Everybody pays attention to it, but consumers will start demanding where those gaps are. And I hope that the politics of this allow these kinds of changes to occur, because everything is already in place. So I think that’s a good thing.