Pharmacy staffing, PBM reform, and payment for pharmacists’ services

Recently, APhA polled you, our members, about the top issues you want the Association to address on your behalf. Not surprisingly, PBM reform was second only behind addressing workplace issues and staffing of pharmacies. Next was payment for pharmacists’ services. These issues are all intertwined: it’s about economics, and we can’t address one without addressing them all.

For many community pharmacies, revenue has historically depended heavily on dispensing prescriptions. Over time, declining and unpredictable reimbursement, retroactive payment reductions, restrictive networks, lack of contract negotiation opportunity, and other PBM reimbursement practices have placed increasing financial pressure on pharmacies. Pharmacy businesses have responded to those pressures. Some have sought to dispense more prescriptions with the same or fewer personnel. Others have reduced labor hours, centralized work, increased reliance on production metrics, consolidated locations, or closed pharmacies entirely. These decisions may be understandable from a financial perspective, but they are not without consequences. When prescription volume and patient-care responsibilities grow faster than staffing, pharmacists and pharmacy technicians are forced to do more with less. That contributes to burnout, moral injury, turnover, declining job satisfaction, and less time to identify medication-related problems, counsel patients, coordinate care, and perform other essential professional responsibilities. Economic pressures help explain these decisions, but they do not excuse them.

Ensuring adequate staffing, particularly in community pharmacy practices, has been problematic for at least two decades. It’s gotten much worse since the pandemic, and despite the efforts of APhA and others to advocate with employers to correct staffing issues, there have been only marginal improvements. Granted, some chain drugstores seem to have less turnover than others, but the impact of poor staffing in the community pharmacy space has caused a downward spiral of job satisfaction. That’s led many pharmacists in the community sector to either retire (sometimes early), find another area of pharmacy practice, or leave the profession altogether. All of this is happening at a time when there is unprecedented support by federal and state governments for pharmacists in primary care roles, and acknowledgment by other health care professionals and clinicians of the vital role of pharmacists on the team. The population is aging, and local communities need access to pharmacists and the care services they provide more than ever.

APhA is committed to solving the complex problems facing our profession in the community pharmacy sector and to convening national community pharmacy leaders who can effect change. We have redesigned our practice communities' experience to provide more opportunities for national networking, career support, and professional connection. APhA staff engages corporate leaders in real discussions about solutions to staffing challenges, including reviewing the policies states have implemented to protect pharmacists and pharmacy technicians. Along with the National Alliance of State Pharmacy Associations, we crafted and use the Pharmacist’s Fundamental Responsibilities and Rights statement, endorsed by dozens of pharmacy organizations across the nation, as the basis for change, as well as feedback you provide to APhA leaders and staff as we visit community pharmacies around the country.

On the issue of PBM reform, APhA has long supported legislation and regulations that eliminated clawbacks, and our advocacy in the U.S. Congress and states has been instrumental in getting federal PBM reforms signed into law and 22 bills enacted in 16 states just this year! Additionally, the APhA House of Delegates has taken action to clarify APhA's policy position opposing vertically integrated ownership structures involving PBMs and pharmacies. APhA will use that policy to support federal and state proposals that address conflicts of interest, anticompetitive conduct, patient steering, discriminatory reimbursement, and other harms associated with vertical integration.

As APhA evaluates specific structural or divestiture proposals, we will also advocate for implementation and transition provisions that protect patients from losing access to pharmacy services, particularly in rural and underserved communities. Protecting continuity of access should be part of implementing meaningful reform, not a reason to preserve business structures that harm competition or patients.

APhA has led the quest for pharmacists' services coverage and payment across the United States. Working closely with state pharmacy associations and with other national associations, we’ve made tremendous progress in creating new revenue opportunities for pharmacies. Why is this such a priority? The economics of community pharmacy require that, if we are to have a viable future that keeps community pharmacies open, both fair payment for medications and payment for pharmacists’ care services must be in place. PBM reform alone will not provide the economic solution long term. To see the progress we are making on the payment front, members can log in to our government affairs State Legislative Advocacy Tracker to view current maps of state legislation on coverage and payment for pharmacists' services. We also continue to need APhA members to engage with their members of Congress to secure passage of the Main Street Pharmacy Act/ECAPS and create the opportunity for payment for state-authorized pharmacist-provided patient-care services under Medicare.

APhA believes that if we can fundamentally address the underlying issues of payment for pharmacist care services and ensure fair reimbursement for medications for all community pharmacies, the staffing issue can be more robustly addressed. It is inexcusable that pharmacies are not staffed to support optimal patient care in a world where patient safety should be paramount. Our profession needs corporate pharmacies to invest in ways that amplify pharmacists' patient-care role, even if it means smaller bottom lines and reduced corporate profits in the short term. And then we need these partners to lock arms with APhA and the profession to push hard for laws and regulations that ensure routine payment for pharmacists' care services. Staffing can’t wait for service payment. There needs to be a commitment to do the right thing first, to prove to society and policymakers that investing in pharmacists is the right investment in health care.