Provider Status is Inevitable

Support at the state level will fuel pharmacists’ path to payment.

Pharmacists provide high-quality, cost-effective care, improving patient access and outcomes. Lack of reimbursement is the greatest barrier we face in extending our services to more patients. Under the federal Social Security Act, pharmacists are not recognized as providers, which means we can’t bill Medicare directly for clinical services. However, there is strong support to recognize pharmacists as providers at both the state and federal level.

On The Horizon

Significant progress has been made to advance pharmacy practice and move us closer to federal provider status. But once passed, what will this look like? We can investigate states with progressive pharmacist scope of practice laws to learn more.

Many states have expanded scope of practice laws, however, few pharmacists exercise these abilities. There are great examples of innovative care models out there, but on the whole we are still practicing in the past.

There are a few reasons for this:

  1. No replicable, scalable business model for clinical services without reimbursement from health insurance plans
  2. Confusion caused by variation in state scope of practice laws creates implementation difficulties
  3. Lack of software/technology solutions needed to coordinate care with patients and other members of the healthcare team
  4. Comfort in doing things “the way we’ve always done them”

So even after provider status legislation passes, we’ll still have problems #2, #3, and #4 to address. Before we worry about that, let’s take a look at federal support for pharmacist provider status.

Progress at the Federal Level

A long and winding road led us here. However, federal support has been steadily building. A report entitled Improving Patient and Health System Outcomes Through Advanced Pharmacy Practice was presented to Dr. Regina Benjamin in 2011, then U.S. Surgeon General, acknowledging pharmacists as a key stakeholders in addressing access, safety, quality, cost, and provider shortages. Dr. Benjamin responded with a letter of support, commending the information and recommendations.

In January 2017, the Centers for Medicare and Medicaid Services (CMS) issued an informational bulletin highlighting the expansion of pharmacists’ scope of practice at the state level (e.g. prescriptive authority) could facilitate access to enhanced and timely care, specifically identifying naloxone dispensing to curb opioid overdose deaths.

Newly appointed U.S. Department of Health and Human Services Secretary Tom Price (R-GA), an orthopedic surgeon, voiced his support for pharmacist patient care during the confirmation process.

All of this support (and many other examples) culminate in the 115h U.S. Congress, as both the House and Senate reintroduced the Pharmacy and Medically Underserved Areas Enhancement Act (S. 109/H.R. 592) in January 2017. This bill grants pharmacists’ provider status and, subsequently, the ability to directly bill Medicare Part B for patient care services in Medically Underserved Areas (MUAs). This bill had bipartisan support in both the House (68% co-sponsored) and Senate (52% co-sponsored) in 2016. We hope to see this bill approved during this 2017 legislative session.

But…to quote an very wise mentor of mine, “Hope is not a strategy.”

Progress at the State Level

We’ve been building our value-proposition for years, so we’re used to this grind. While we wait impatiently for federal action, we’re seeing innovative models powered by leadership at the state level. Pharmacist scope of practice is governed by state law and regulations issued by state Boards of Pharmacy.

In California, a 2014 law granted pharmacists provider status along with permission to furnish certain medications (e.g. hormonal contraceptives, nicotine replacement, travel medications) pursuant to statewide protocols.

Many states already have laws allowing pharmacists to initiate, modify, discontinue, and administer medications, order labs, and perform physical assessments based on collaborative practice agreements (CPAs) with physicians.

However, implementing and maintaining CPAs can be challenging. For example, CPAs may need to be established with each individual physician (or similar provider — this varies by state) and renewed annually. Some states require CPAs to specify which disease states and/or medication classes pharmacists are able to address under the agreement. Other states require advanced licensure prior to exercising additional responsibilities. All of this is confusing to the average pharmacist (and patient) and the paperwork is burdensome. All we want to do provide patient care.

Thankfully, the National Alliance of State Pharmacy Associations (NASPA) convened a stakeholder group to develop consensus recommendations on statewide protocols. This will help streamline pharmacist scope of practice laws moving forward.

The National Governors Association signaled support by publishing The Expanding Role of Pharmacists in a Transformed Healthcare System, calling for united efforts to remove restrictions on CPAs, recognize pharmacists as providers, and connect pharmacy software systems with other healthcare providers through Health Information Exchange (HIE) networks.

Reimbursement for Services

One year after the California legislation, Washington state passed a provider status law mandating pharmacist inclusion in health insurance provider networks (triggering reimbursement), one-upping Californians.

Great progress has been made at the state level, but the Washington legislation is a game changer. Mandating the inclusion of pharmacists in health insurance provider networks is a huge win and creates a viable business case for pharmacist service expansion.

Taking the state-by-state approach won’t address the largest opportunity to improve patient care access (Medicare), but it’s an effective strategy that moves the needle, providing fertile ground to demonstrate success and scale.

Other states are following suit, leveraging relationships with commercial payers and state Medicaid programs to conduct demonstration projects.

Tennessee pharmacists are listed as healthcare providers in the state pharmacy practice act and insurance regulations, but this does not mandate reimbursement. Utilizing grant funding from BlueCross/BlueShield of Tennessee Health Foundation, Tennessee Department of Health, and Centers for Disease Control and Prevention (CDC), project participants intend to demonstrate the value of pharmacist services on the “micro” level to stimulate “macro” level reimbursement.

Efforts to organize enhanced pharmacy service networks are taking off in more than 40 states, aiming to replicate this type of model across the country.

Most states have deployed or are actively developing networks of pharmacies and pharmacists providing enhanced services. Pharmacy networks are a hallmark of the pharmaceutical industry. Large pharmacy networks are able to survive on razor-thin prescription profit margins, leaving smaller pharmacy practices out to dry.

Enhanced service networks aim to change the way value is calculated, demonstrating improved health outcomes leading to reduced medical benefit expenditures.

This model aligns very well with state demonstration projects mentioned previously and creates a clear path to payment.

We Control Our Own Destiny

Provider status will pass at the federal level…it’s only a matter of time. Regardless, states are taking matters into their own hands and forging ahead.

But what about after provider status becomes law? What’s the next step? How will pharmacists bill for services?

Moving forward, we must have appropriate infrastructure in place for training, credentialing, and privileging pharmacist providers in each state. Software solutions, billing practices, operations, and workforce readiness must also be examined.

We’ll leave that discussion for another day.

Stay tuned :D


Samm Anderegg, Pharm.D., MS, BCPS is CEO at DocStation, a patient care platform for pharmacists. Learn more at docstation.co.
P.S. If you want to advocate for increased pharmacist patient care, educate your friends and family about the great things pharmacists do every day and support the Pharmacy and Medically Underserved Areas Enhancement Act.
P.P.S. NASPA also has some great resources for advocating at the state level. Find your state on this list and contact your state representative to voice your opinion.