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March 10, 2022

Inside the debate over Biden's 'Test to Treat' initiative

Daily Briefing

    The Biden administration last week introduced a new "Test to Treat" initiative that would allow individuals who test positive for Covid-19 at pharmacies to also receive antiviral pills free of charge. And while some praise the program for expanding quick access to potentially life-saving drugs, industry groups are voicing concerns.

    The Biden administration's 'Test to Treat' initiative

    During his State of the Union address last week, President Joe Biden introduced a new "Test to Treat" initiative that will allow people who test positive for Covid-19 at a pharmacy to receive antiviral pills "on the spot at no cost."

    According to Jeff Zients, the White House Covid-19 response coordinator, hundreds of "One-Stop Test to Treat" locations will open this month around the United States. These locations include pharmacy chains with onsite clinics, such as CVS, Walgreens, and Walmart, as well as long-term care centers, community health centers, and veterans' health centers.

    Cameron Webb, a senior policy advisor for equity on the White House Covid-19 response team, said the new initiative helps streamline the process of getting antiviral pills, particularly for those at high risk of severe Covid-19 outcomes.

    "[A high-risk person with Covid-19 would] have to identify that they have symptoms. They have to get a test, get a test result, contact a provider who can prescribe the medication, get that prescription sent over, and then go pick up that prescription. That's six different steps," Webb said, but the "Test to Treat" initiative would "compress that timeline" by allowing patients to get tested, prescribed, and receive the pills in one visit.

    Separately, Michael Ganio, a senior director at the American Society of Health-System Pharmacists, agreed, saying, "I think it's a step in the right direction in trying to make the process more seamless for patients."

    Industry groups voice concerns, push for expansion

    In response to the initiative, the American Medical Association (AMA) expressed concerns that it would bypass the expertise of primary care physicians, who the organization argues are the most suited to prescribe treatments.

    "Leaving prescribing decisions this complex in the hands of people without knowledge of a patient's medical history is dangerous in practice and precedent," AMA wrote in a statement. "We urge patients who test positive for Covid-19 to contact their physician to discuss treatment options."

    However, a quarter of Americans do not have primary care providers, and Webb noted that they are the ones who would likely benefit the most from the "Test to Treat" program. He added that the administration recommends people with easy access to primary care providers consult them about treatment first—which AMA said was "reassur[ing]."

    On the other hand, the National Community Pharmacists Association (NCPA) and the American Pharmacists Association (APhA) both said the program was too restrictive.

    Currently, only pharmacies with onsite clinics are eligible to participate in the program, which are often only available in certain areas. For example, CVS has almost 10,000 pharmacies nationwide, but just 10% of them have Minute Clinics with on-site prescribers.

    Rural areas in particular are less likely to have access to eligible pharmacy-based clinics, according to Theresa Tolle, president-elect of APhA.

    In addition, NCPA and APhA said they believe pharmacists should prescribe Covid-19 antivirals themselves, instead of relying solely on clinic providers for prescriptions. Under FDA's authorization for the antiviral pills, only "physicians, advanced practice registered nurses, and physician assistants that are licensed or authorized under state law to prescribe drugs" are allowed to prescribe the drugs.

    However, NCPA president Michele Belcher said pharmacists have already acted as prescribers during the pandemic. Under an amendment to the PREP Act made by the Biden administration last fall, pharmacists were authorized to order and administer certain Covid-19 treatments, including monoclonal antibodies.

    Pharmacists are also well-qualified to handle any prescribing challenges that come with the antiviral pills, including potential drug interactions and negative effects.

    "Pharmacists are medication experts," said Susan Davis, a pharmacy professor at Wayne State University and former president of the Society of Infectious Disease Pharmacists. "We have been managing drug interactions and dose adjustments routinely for decades. We could handle this."

    According to Belcher, NCPA has written to FDA about expanding the "Test to Treat" program to include pharmacists. "With the appropriate guardrails in place, I think that we could certainly get to a place where the FDA, the AMA, feel comfortable with a similar type of ability for pharmacists to be able to test and treat," she said. (Putka, MedPage Today, 3/8; Huang, "Shots," NPR, 3/8)

     

    Advisory Board's take

    The power of an accessible one-stop-shop

    Gina LohrBy Regina Lohr

    We've expressed our excitement about what the new 'test to treat' program could accomplish, but there are a few important clarifications to narrow in on as we wait for the initiative to roll out around the country.

    First, calling 'test to treat' a pharmacy specific program could be a misnomer—it is actually not taking place in most pharmacies. The program will only be available in a subset of pharmacies that also have clinics with on an on-site provider who is qualified to evaluate a patient's medical history and prescribe the appropriate medications. As the NPR article noted, only 10% of CVS locations across the country would qualify as test-to-treat locations.

    Initially, 'test to treat' seemed like the key to accessibility, but this caveat requirement of an on-site provider could still leave patients in under-served communities without an easy access point. And it may even cause confusion if patients arrive at a non-participating pharmacy expecting to be able to test and treat.

    The power of a one-stop-shop

    In theory, it makes complete sense to have a single location where patients can get tested, receive a prescription, and fill that prescription before heading home. For Covid-19 care, this process would be key to supporting quick recovery post infection. In practice, there would need to be a deep focus on equitable access to these one-stop-shops, which would involve designing them for communities hit hardest by Covid-19 with the least available resources. And since people of color tend to show up when Covid-19 is at a later stage in progression, community engagement critical to reducing disparate outcomes—working with community members to help navigate and educate.

    This integrated approach also holds promise in managing other emergent and chronic conditions. That’s what we’re seeing in the trend of pharmacies co-locating with clinics across the country (e.g., Walgreens/VillageMD collaboration and CVS HealthHubs investment). When designed appropriately, this colocation can make use of pharmacists' expertise in medication management to improve care for patients, especially those patients with challenging medication histories or whose chronic conditions are managed with a complex combination of medications. Physicians often tell me how important a pharmacists' drug knowledge and skill in medication education is in helping these patients manage their conditions.

    Addressing access gaps

    But what about those thousands of non-participating pharmacies? Especially those in under-served areas. This might be an opportunity for quick thinking from innovative pharmacists to streamline pathways for their patients. What about creating partnerships with local providers willing to provide telehealth appointments to patients seeking a covid test? Or even setting up a space where patients can have a confidential visit with an on-demand digital health provider? Throughout the pandemic, we’ve seen innovative pharmacists breaking down access barriers for their patients, and this may be one more opportunity for pharmacists to step in and save the day.

    Advisory Board's Andrew Mohama helped contribute to this article.

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