Inability to Bill Prevents Pharmacists from Prescribing Paxlovid

The sticking point is how to charge for the in-depth clinical assessment that pharmacists must perform to determine whether Paxlovid can be safely prescribed. Nurses COVID Article

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Inability to Bill Prevents Pharmacists from Prescribing Paxlovid

On July 6, 2022, the FDA updated the Emergency Use Authorization (EUA) for the COVID-19 antiviral Paxlovid, to permit pharmacists to prescribe Paxlovid under limited circumstances.  The FDA hoped to help populations at high risk of hospitalization or death from COVID-19 to quickly receive treatment. 

With the updated EUA, Pharmacists can prescribe Paxlovid within five (5) days of a positive COVID-19 test to two at risk groups:

  1. Those 65 years of age and older, or
  2. Those 12 years of age and older, weighing at least 40 kilograms (88 pounds), who are obese, diabetic, have a cancer diagnosis or another chronic disease. 

CVS has created a process for its pharmacists to follow in the limited locations where it does allow pharmacists to prescribe Paxlovid.   The first step involves the customer completing  a digital eligibility screen to determine if Paxlovid is potentially a treatment option.  If the customer is determined to be a candidate based upon the digital screening, the customer is then subject to a more in depth clinical assessment by a pharmacist.  The information gathered from the customer in the digital screen, includes:

  1. General identification information
  2. Weight screening (you must be at least 88 pounds or 40 kilograms)
  3. Confirmation that the customer has tested positive for COVID-19 in the past 5 days
  4. Whether the customer has at least one chronic condition
  5. Whether the customer has liver or kidney disease
  6. If the customer has had a blood test in last 12 months, so lab results can be accessed electronically or by talking with the person's physician
  7. Screening for potential drug interactions with Paxlovid
  8. Whether the customer takes supplements or over-the-counter medications
  9. Allergies to food or medication
  10. Whether the customer is a Medicare or Medicaid beneficiary

The pharmacist must then assess each candidate that makes it through the digital screen for potential liver and kidney disease and for potential drug interactions.  The clinical assessment is time-consuming, requiring that the pharmacist obtain access to electronic or printed health record information for lab results on the customer's hepatic and renal function that are no more than 12 months old.   If there are no records available, the pharmacist must then consult with the customer's health care provider regarding the individual's liver and kidney function.  This must all be done timely, as Paxlovid must be given within 5 days of a positive COVID-19 test.

The pharmacist must also obtain a comprehensive list of prescribed medications, supplements and over-the-counter medications so potential drug interactions with Paxlovid can be ruled out.  If there are potential interactions or any of the medications must be modified in order for the individual to take Paxlovid, the pharmacist cannot prescribe the medication.

As a result of the significant time involved in completing the clinical assessment, pharmacies, which are already short-staffed, must be able to bill for their pharmacists' time.  This fee is not covered by private insurance, Medicare or Medicaid.  CVS has determined that a fee of up to $60 will be charged by its participating pharmacies for the clinical assessment.  Customers can pay in cash, by using a flexible spending account (FSA) or through a health spending account (HSA). 

Currently, the Medicare and Medicaid programs do not have a way to submit or authorize a clinical assessment fee for pharmacists.  As a result, CVS is temporarily excluding Medicare and Medicaid beneficiaries from the group of high-risk candidates for whom its pharmacists can prescribe Paxlovid. The website specifically instructs Medicare and Medicaid beneficiaries to see their physician to get a Paxlovid prescription. 

The American Society of Health System Pharmacists, representing over 60,000 pharmacists, pharmacy technicians and pharmacy students, crafted a letter on July 21, 2022, to the Administrator for the Centers for Medicare & Medicaid Services and to the Deputy Administrator and Director of the Center for Medicaid and CHIP Services explaining that no reimbursement mechanism exists for the patient assessment and counseling that pharmacists are required to do in connection with the prescribing of Paxlovid.  ASHP indicated that given the current uptick in COVID-19 cases, it is imperative for pharmacies to be able to allow their pharmacists to prescribe Paxlovid.  However, due to the time involved in conducting the clinical assessment, the costs associated with providing this service will not be feasible without some form of reimbursement.  

The result is that those over 65 (and covered by Medicare) and those with low income who are chronically ill (and covered by Medicaid) are at higher risk of hospitalization or death from COVID-19 and will not be able to get a timely prescription for Paxlovid from their neighborhood pharmacist.  They will have to see another licensed health care provider to try to get treated with Paxlovid within 5 days of a positive COVID-19 test, which is not always possible.

Medicare and Medicaid beneficiaries constitute a large portion of the population that the updated EUA was designed to protect.  The lack of reimbursement for pharmacist clinical assessment services by Medicare and Medicaid is having a chilling effect on the ability of pharmacies to decrease potential negative outcomes in this population.  It is unclear how long it will take for the Centers for Medicare and Medicaid to act; however, pharmacies are unlikely to roll out training and allow pharmacists at all locations to prescribe Paxlovid until reimbursement mechanisms exist.  The result will be a chilling effect on what could have been an early intervention tactic in the treatment of COVID-19 in high-risk populations.


References/Resources

Coronavirus What You Need to Know NCPA National Community Pharmacists Association: Billing for assessment by a pharmacist for Paxlovid treatment

CVS® pharmacists can now prescribe Paxlovid to treat COVID-19

FDA Paxlovid Patient Eligibility Screening Checklist Tool for Prescribers

ASHP July 21, 2022 Letter to Administrator of CMS and Deputy Administrator of Medicaid & CHIP

Terry Ann Donner, RN, BSN specializing as Freelance Healthcare Writer

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toomuchbaloney

12,662 Posts

Specializes in NICU, PICU, Transport, L&D, Hospice.

I think it's interesting that they thought that this was a good idea.  I wonder who convinced the FDA that retail pharmacists were staffed and prepared to complete that level of patient assessment?

Specializes in Primary Care, Military.

This just in: Pharmacists decline to work for free just because Insurance agencies so frequently find ways to get Physicians, PAs, and NPs to. ?‍♀️

Daisy4RN

2,221 Posts

Specializes in Travel, Home Health, Med-Surg.

 "No way for medicare or medicaid to submit and authorize for assessment fee".

I guess nobody (gov) could foresee the necessity of that. More incompetence from the government, I am shocked!

They also didn't cover at home covid tests for medicare. 

londonflo

2,906 Posts

Specializes in oncology.
On 9/7/2022 at 5:59 AM, Terry Ann Donner said:

The result will be a chilling effect on what could have been an early intervention tactic in the treatment of COVID-19 in high-risk populations.

HIgh risk populations already have an MD lined up for their other RXs

On 9/7/2022 at 5:59 AM, Terry Ann Donner said:

The clinical assessment is time-consuming, requiring that the pharmacist obtain access to electronic or printed health record information for lab results on the customer’s hepatic and renal function that are no more than 12 months old.   If there are no records available, the pharmacist must then consult with the customer’s health care provider regarding the individual’s liver and kidney function.  This must all be done timely, as Paxlovid must be given within 5 days of a positive COVID-19 test.

Wouldn't it be easier for the patient to go see their (health care provider)  MD? Meanwhile, I am standing in line behind 'the identified' patient waiting to get my asthma inhaler RX filled? I go to the MD to have my health problems evaluated and for continuity of care as I should, I go to my hairdresser to get my hair cut not my pharmacist, I go to the gas station to fill up my car with gasoline , not my pharmacist, I go to the grocery store for edibles, not my pharmacist,  I do not go to my pharmacist to get evaluated for a drug that my MD can prescribe (after looking at my overall health assessment) and with a positive test. 

32 minutes ago, Daisy4RN said:

I guess nobody (gov) could foresee the necessity of that. More incompetence from the government, I am shocked!

They also didn't cover at home covid tests for medicare. 

The incompetence was anyone thinking a pharmacist can perform a doctor's functions. 

toomuchbaloney

12,662 Posts

Specializes in NICU, PICU, Transport, L&D, Hospice.
30 minutes ago, Daisy4RN said:

 "No way for medicare or medicaid to submit and authorize for assessment fee".

I guess nobody (gov) could foresee the necessity of that. More incompetence from the government, I am shocked!

They also didn't cover at home covid tests for medicare. 

Less testing means fewer cases, right?

JKL33

6,768 Posts

6 hours ago, Daisy4RN said:

I guess nobody (gov) could foresee the necessity of that. More incompetence from the government, I am shocked!

Oh, no, no--

If they authorize pharmacists to gather the information and prescribe the medication, they don't have to pay the PCP who has to comb through the records and get information to said pharmacist, and they don't have to pay the pharmacist for doing the job that the PCP would've been paid to do.

There's a saying, never attribute to malice that which is explained by stupidity [incompetence]. But some things are so convenient that it's difficult not to consider them quite purposeful.

Susie2310

2,121 Posts

20 hours ago, londonflo said:

HIgh risk populations already have an MD lined up for their other RXs

Wouldn't it be easier for the patient to go see their (health care provider)  MD?

Not necessarily.  As far as I know, the recommendation is that Paxlovid is started as soon as possible or within 5 days of a positive Covid test.  Some people are unable to get an appointment with their physician within that time period.

toomuchbaloney

12,662 Posts

Specializes in NICU, PICU, Transport, L&D, Hospice.
17 minutes ago, Susie2310 said:

Not necessarily.  As far as I know, the recommendation is that Paxlovid is started as soon as possible or within 5 days of a positive Covid test.  Some people are unable to get an appointment with their physician within that time period.

When they call their provider with that reason for an appointment the delay is not acceptable. 

JKL33

6,768 Posts

17 minutes ago, Susie2310 said:

Some people are unable to get an appointment with their physician within that time period.

These practices have no mechanism for handling the covid positive patients on their panels?

It's more feasible that a completely different entity would develop said mechanism from the ground up? Unfunded?

Susie2310

2,121 Posts

44 minutes ago, JKL33 said:

These practices have no mechanism for handling the covid positive patients on their panels?

It's more feasible that a completely different entity would develop said mechanism from the ground up? Unfunded?

I see this as a remedy for problems with access to care experienced by some people.  This is a problem in my area - long waiting times in the UC/ER, staff and provider shortages, difficulties/inability to get through to a Practice on the phone.  I understand other areas experience this problem also.  It makes sense to me to bring in an extraordinary measure in the hope of preventing increased morbidity/mortality from Covid.  I hope the problems will be worked out.  Also, flu season will soon be here, and there will be more pressure on health systems along with Covid.  This is a public health measure.

 

toomuchbaloney

12,662 Posts

Specializes in NICU, PICU, Transport, L&D, Hospice.
9 minutes ago, Susie2310 said:

I see this as a remedy for problems with access to care experienced by some people.  This is a problem in my area - long waiting times in the UC/ER, staff and provider shortages, difficulties/inability to get through to a Practice on the phone.  I understand other areas experience this problem also.  It makes sense to me to bring in an extraordinary measure in the hope of preventing increased morbidity/mortality from Covid.  I hope the problems will be worked out.  Also, flu season will soon be here, and there will be more pressure on health systems along with Covid.  This is a public health measure.

 

I think this was a remedy suggested by a retail pharmacy conglomerate that didn't consider that prescribing and screening for a medical treatment isn't the same as prescribing a vaccination. The deal was made by the executives before the retail pharmacists realized that none of the screening process was part of their normal work and was outside of their scope.