On The Cover
Loren Bonner
When the COVID-19 pandemic upended nearly every aspect of people’s lives this year, telehealth allowed patients to continue to access health care. Through video and phone consultations, health care providers have been there for their patients, and not surprisingly, patients have had an easier time showing up for their appointments.
Telehealth might even be the next big thing we can’t live without.
“With COVID-19, the adoption and use of this innovative tool has been tremendous,” said Sandra Leal, PharmD, MPH, FAPhA, CDE, Tabula Rasa HealthCare executive vice president of SinfoniaRx, during a June 12 webinar from APhA’s 15 on COVID-19 training series.
An analysis from Frost and Sullivan found that telehealth visits increased 50% in March amid the pandemic.
None of this would have been possible without the removal of certain telehealth restrictions. In response to COVID-19, the Trump administration and U.S. Department of Health and Human Services relaxed many telehealth barriers that have historically prevented it from taking off (see time-line sidebar).
During a May webinar on telehealth from the Brookings Institute, Dana Lichtenberg, assistant director of congressional affairs at the American Medical Association, called the policy changes a “linchpin, sea-change moment.” She said that the aggressive rollout of telehealth earlier this year normally would have taken 3 to 5 years to complete.
Like other health care providers, some pharmacists have had to make a leap to telehealth during the COVID-19 pandemic. The experience has been eye opening.
Meeting regularly
Caitlin McCarthy, PharmD, a clinical pharmacist at Henry J. Austin Health Center in New Jersey, has been using telehealth continuously during the pandemic.
After weekly telehealth visits with one of her patients with diabetes, she observed that he was always calling from inside of a car. “I told him I noticed this, and he broke down and told me he was living in his van,” said McCarthy. “I finally understood why he had been struggling for so long.”
McCarthy called in a social worker to get the patient the help he needed. She believed he was able to open up to her about his situation because they had a strong patient–provider relationship. But telehealth also gave her a clue into his life she wouldn’t otherwise have received in a traditional clinical setting.
McCarthy, who is also the director of pharmacy services at Henry J. Austin Health Center—a federally qualified health center—and the other pharmacists on her team have been able to provide the vast majority of their clinical services using telehealth since the COVID-19 crisis began. “Because we are under a CPA [collaborative practice agreement], we can prescribe and order labs, and we can do that via telehealth,” McCarthy said.
They do a mix of phone and video consultations and have been able to see more patients in a given day.
“Our patients have socioeconomic factors and often have trouble getting here,” she said. “I’ve found that there are less ‘no shows.’ Some patients we haven’t seen for a long time have even come back.”
Tom Bateman, PharmD, a clinical pharmacist who works with McCarthy at Henry J. Austin Health Center, said one of the challenges with disease state management using telehealth during COVID-19 is deciding when it’s time to check labs and bring a patient into the clinical setting, potentially exposing them to the virus.
“If we weren’t meeting regularly with our patients via telehealth, they would be making these decisions on their own and maybe presenting on-site to the health center when they don’t need to,” he said.
What is telehealth?
Telehealth is a broad term that refers to an array of remote health care services, which can include clinical as well as nonclinical services, monitoring of vitals, health education, and more.
Telemedicine comes under telehealth, but it refers to remote clinical services. Typically, telemedicine services are administered by physicians, while telehealth can be provided by a wide range of health professionals, “such as nurses, pharmacists, and others,” according to the World Health Organization.
Chronic care management
Telehealth has been extremely helpful for pharmacists providing ongoing monitoring and management to patients with chronic conditions, said Starlin Haydon-Greatting, MS-MPH, BSPharm, CDM, FAPhA, who currently serves as the Illinois Pharmacists Association’s director of clinical programs and population health.
“If COVID taught us anything about chronic conditions, it’s that we aren’t managing it,” she said. “You always have to have a meeting where someone holds you accountable—that support is needed lifelong.”
While pharmacists have been delivering Medicare Part D medication therapy management (MTM) services telephonically for years now, more are providing components of Medicare chronic care management (CCM) and transitional care man-agement (TCM) services virtually.
G. Blair Sarbacker, PharmD, BCACP, manages chronic care patients in a primary care office in Clinton, South Carolina. Since COVID-19 closed the practice to anyone who wasn’t acutely ill, a majority of the chronic care patient follow-up visits fell on Sarbacker, who conducts them by phone. The providers in her office said they hope that the use of telehealth is the new normal going forward.
“It’s helped so much with CCM, especially for our patients who have difficulty with transportation,” said Sarbacker.
In this model, pharmacists could be paid as part of a bundled pay-ment model through a physician or other qualified health professional providing the services as part of a health care team.
Haydon-Greatting stressed the importance of people with diabetes needing to be followed closely with telehealth during this time. But stand-alone accredited Diabetes Self-
Management Training (DSMT) programs, such as those in community pharmacies that are unaffiliated with a hospital or physician clinic, have not been addressed in recent CMS updates related to the provision of DSMT telehealth services during COVID-19.
“They forgot about pharmacists in the stand-alone accredited diabetes programs,” said Haydon-Greatting.
Regulations are subject to change. Overall, APhA has been advocating for telehealth flexibility for pharmacist-provided patient care services and has been seeking additional clarification from CMS.
Timeline on CMS’ COVID-19 telehealth flexibilities
March 6, 2020:
The Coronavirus Preparedness and Response Supplemental Appropriations Act, as signed into law by the President, includes a provision allowing the Secretary of the Department of Health and Human Services to waive certain Medicare telehealth payment requirements during a public health emergency and to allow beneficiaries in all areas of the country to receive telehealth services, including at their home.
March 13, 2020:
CMS expands the benefit on a temporary and emergency basis under the 1135 waiver authority and Coronavirus Preparedness and Response Supplemental Appropriations Act.
March 17, 2020:
Telehealth flexibilities were issued for site requirements, place of service, equipment requirements, provider type, patient type, supervision, and payment methodology.
March 30, 2020:
Interim rule provides clarification on pharmacists providing services incident to a physician’s service as well as a host of other changes, including being allowed to provide services to both new and established patients.
April 17, 2020:
Flexibilities were issued for federally qualified health centers and rural health clinics.
Telehealth: The new frontier for advocacy
“As pharmacists, we’ve been advocating for a number of things, but I feel telehealth should become a focus for us,” said Leal during APhA’s 15 on COVID-19 training series webinar. Specifically, pharmacists should be included as providers in any legislation going forward.
During the pandemic, federal legislation called for more telehealth flexibilities in several key areas: site requirements, place of service, equipment requirements, provider type, patient type, supervision, and payment methodology.
For example, said Leal, there is no limitation on the site requirements and the originating place of service. “I think that’s one of the most significant additions because [the patient] can be at home to have the encounter,” Leal said. Previously, only patients in rural areas and in a medical clinic, hospital, or certain other types of medical facilities could receive telehealth services.
In addition, the equipment require-ments have relaxed. “Before you had to have HIPAA-compliant audio and visual equipment, and now people can use FaceTime or Zoom to conduct these visits,” said Leal.
While the new flexibilities in COVID-19 federal legislation did add new providers, such as physical therapists and occupational therapists, pharmacists were not included.
“Although pharmacists are not one of the listed providers, it doesn’t mean you can’t use telehealth,” said Leal. “In fact, it might mean a state opportunity or an opportunity with a commercial payer. Don’t feel like you are restricted, but maybe look at those opportunities to continue to advocate for your role.”
Telehealth tips from practicing pharmacists
- Smile to improve the tone of your voice.
- Personalize—“Hi, Mrs. Smith…”
- Set the stage: 1) Explain the purpose of the call 2) Ask permission to chat/share 3) Set expectations.
- Keep patient engaged by asking questions.
- Ask open-ended questions.
- Continually check in to see if patient has questions.
- Identify early on what their chief concern is and weave
- that through the conversation.
- Pause for responses and be OK with silence.
- Ask for their help.
- Prepare all references and resources.
Resources
Information is rapidly changing, and pharmacists should consult the regulations from their respective boards of pharmacy or check for updates on the National Alliance of State Pharmacy Associations (NASPA) or the Center for Connected Health Policy websites. Other excellent resources are state pharmacy associations and public health departments, as they may have state-specific information for pharmacists.
In addition, the National Association of Boards of Pharmacy has a passport program, in response to COVID-19, which allows states to grant temporary or emergency licensure in another state: https://nabp.pharmacy/coronavirus-updates/passport/
CMS also broadened access to telehealth services under Medicare so that beneficiaries can receive a wider range of services from their physician without having to travel to a health care facility.
“But again, pharmacists were not one of the listed providers in the 1135 waiver authority [and Coronavirus Preparedness and Response Supplemental Appropriations Act],” Leal pointed out.
Many pharmacists performing telehealth during this time are in an “incident-to” physician services arrangement.
They are considered “auxiliary personnel” by CMS. These arrangements permit the physician they work with to bill for certain services such as evaluation and management (E/M) delivered by the pharmacist under direct physician supervision.
The physician then makes the appropriate payment to the pharmacist under the terms of their financial agreement. The CMS 1135 waiver says that E/M services can be provided via telehealth, and physician supervision is allowed virtually using real-time audio and video technology.
The future of these relaxed barriers with telehealth is undecided, and when this story went to press, CMS still had not clarified certain flexibilities for pharmacists.
Lawmakers have introduced some bills to Congress aimed at studying telehealth use during the pandemic to make sure the evidence is there to support extending telehealth coverage permanently.
Haydon-Greatting stressed the importance of pharmacists consistently documenting and collecting data to prove their benefit and make the case for payment.
“We have to collect and share data through this, keep track of our time and how many medication therapy problems were identified,” she said. “It’s the only way to prove and stand our ground.”