The Progression of Immunization - Episode 6

Prevalence of Vaccination, Risks, and Record Sharing

Troy Trygstad, PharmD, MBA, PhD; Brian Hille, BSPharm, RPh; John Beckner, BSPharm, RPh; Ned Milenkovich, PharmD, JD; and Mindy Smith, BSPharm, RPh, discuss the limitations of data sharing and the prevalence and risks of immunizations in community pharmacies.

Transcript:Troy Trygstad, PharmD, MBA, PhD: Does anybody know what percentage of pharmacies offer immunizations across the country? We’re about 65,000 pharmacies.

Brian Hille, BSPharm, RPh: You’ve got to believe it’s 100%.

Troy Trygstad, PharmD, MBA, PhD: It should be 200%.

Brian Hille, BSPharm, RPh: It should be. We talked about if you’re not giving immunizations today, you are way behind. And like what John said, if it’s not the full breadth of vaccines that are available out there, you’re still behind, because this has been going on for a good number of years.

Troy Trygstad, PharmD, MBA, PhD: So, there’s not much left of the lagging curve that needs to adopt, but that doesn’t mean that the leading edge of the curve still isn’t moving forward.

Mindy mentioned something earlier that was interesting in the way they view their technology systems, in that you’re thinking about it as a patient record, not a product record, which in and of itself is an evolution within pharmacy—a really important evolution. We sort of see this with MTM [medication therapy management], though a lot of MTMs are still product level. Anything that moves us more toward a patient record rather than a product record is an important evolution, because it helps us figure out those work flows that are at the patient level. The other thought I had is, Brian, is there is a DIR [direct and indirect remuneration] fee associated with immunizations?

Brian Hille, BSPharm, RPh: So interesting. I was going to comment on Mindy’s thought. This is a win-win kind of a situation. Making vaccines so much more accessible to people, it does all the right stuff in our communities that we want to be doing, and it helps you take care of the patients who you really care about in your pharmacy—and interestingly enough, DIR is a very complex thing. And so, you can’t just say wholeheartedly that it’s yes or no, because there are so many different elements to a DIR fee. But the interesting thing is that doctors are affected through HEDIS [Healthcare Effectiveness Data and Information Set] scores for many of these vaccinations, and so they’re highly interested in making sure that patients are protected, because they have skin in the game when it comes to their HEDIS scores. And so, there are opportunities for us as pharmacists to partner with physicians and practices that are at risk for making these HEDIS scores, and what a great place to do it. We see these patients all the time, and we have an opportunity to be able to identify the patients who need a certain vaccination and make sure that we get it to them when they’re visiting the pharmacy.

Troy Trygstad, PharmD, MBA, PhD: And interestingly enough, we’re seeing a little bit of a flip of the coin in what occurred for a long time, whether it’s medical supplies or types of activities that require medical billing that are challenging to administer in the pharmacy from a claims reconciliation and submission perspective—so oftentimes, maybe making the referral or sending that somewhere else. We’re seeing the opposite of that now where practices are saying, “This is very difficult for me to bill, because I’m not used to the pharmacy arena, so I’m sending a patient down to the pharmacy.” So, it’s an interesting turn of events, right?

Brian Hille, BSPharm, RPh: It is. Systems have gotten more sophisticated, and data are more sophisticated. Our abilities are more sophisticated, and so we try to keep things as invisible to the pharmacy staff as possible, so everything processes just like a prescription claim. On the back end, we’re doing all kinds of work. We’re taking that and we’re turning it into a medical claim, or it’s going off to a vendor that’s submitting it as a roster bill off to Medicare. So, a lot of things are happening behind the scenes, but for the pharmacists and the technicians, it looks like any other claim to them.

John Beckner, BSPharm, RPh: If you’re trying to see a pharmacy or a pharmacist on providing that service, if they’ve not historically provided that service, you tell them it takes no longer to administer an immunization if you involve your ancillary personnel than it does to fill a regular prescription.

Troy Trygstad, PharmD, MBA, PhD: And it’s very difficult to administer immunizations by mail, right?

John Beckner, BSPharm, RPh: I’ve yet to see one.

Ned Milenkovich, PharmD, JD: Troy, if I could just echo what the group is saying, it seems like a tale of 2 cities. Some pharmacists and pharmacies have wholly embraced the whole concept of immunizations, whereas other pharmacists seem to continue to feel like there’s some enigmatic unknown component related to administering vaccinations. The fact is, if the pharmacist understands the state laws that allow that pharmacist to administer vaccines, embrace clinical education, continue education, and be aware of what their responsibilities are, not only can they help individual patients in their community, but they also will increase their revenue stream, as Mindy suggests. There’s a lot of missed opportunity out there that could be capitalized on, particularly in a shrinking world of reimbursements, where there’s constant pressure on the pharmacy to get paid on their product. This affords the professional pharmacist a new avenue, a new way of accessing patient care, as well as delivering patient care and getting paid for it.

Troy Trygstad, PharmD, MBA, PhD: You said a word that scares a lot of people: liability. It’s still remarkable to me when I look at my malpractice insurance bill every year, how much lower it is than other care team members’. That tells me that there is risk but that pharmacists and the professionals are doing a pretty good job of mitigating that risk if the premiums are relatively low. For pharmacies out there or folks thinking about leaning in further into vaccinations—we talked about immunocompromised, etc—what is the state of risk that’s out there? It seems to me that there aren’t a whole lot of reported cases of harm being done by pharmacists administering vaccinations. Is that a true statement?

Ned Milenkovich, PharmD, JD: Well, the statistics probably show that this is a very low risk, and that’s reflected in the premiums that pharmacists and companies that insure their pharmacists pay. The question for the pharmacist is, do I have the proper coverage? And whether the pharmacist is buying their own coverage or the employer is extending coverage to them, the question still remains whether that coverage extends to the immunizing practice. And so, the pharmacist should ask and determine whether they have that coverage. If they don’t, they should add that coverage as a rider just in case things go bump in the night. It’s not a perfect world. Liability is out there everywhere, no matter how low the risk is. But at the end of the day, they should make an inquiry on that, and obviously, along with that, take steps to minimize the risks, getting the insurance but minimizing the risk by staying abreast of clinical training, continuing education, getting your proper credentials in place so that if things go bump in the night, you will have the most protection.

Mindy Smith, BSPharm, RPh: And even the service collaborative practice agreements, as we mentioned, are related to certain states. I think there are 19 states that still require some form of collaborative practice agreement. So, we even provide that service for independent pharmacies to help them, so they don’t have to deal with the paperwork of getting that collaborative practice agreement. The trending to states where I think we’re seeing loosening on the requirement of a CPA, or a collaborative practice agreement, where you’re seeing more statewide protocols, and that trending of legislation we’re seeing in the marketplace is very, I think, refreshing. And I hope that trend continues to really get more than 7 states that allow essentially prescriptive authority for public health services like vaccines that pharmacists can and should be providing.

John Beckner, BSPharm, RPh: Just to interject, I think the pharmacists have proven to be a solution many, many times when it comes to a public health issue. And I think that’s why you’re seeing that particular trend.

Ned Milenkovich, PharmD, JD: It’s also a question of awareness, too. Associations like NCPA [National Community Pharmacists Association] and others who are advocacy groups on behalf of pharmacists should be talking to their general assemblies—and their respective states to their governors’ offices—and making the case as to why a statute should be passed that reflects more independence on the part of the pharmacist and getting away, perhaps, even from collaborative practice arrangements to something far more independent than statutory enabling.