While extending Medicaid to an additional 3% of Americans, the Affordable Care Act (ACA) will create significant gaps in care for the average taxpayer, not only in coverage but in the availability of provider services as well. This new environment creates an opportunity for pharmacists to deliver provider services that benefit average taxpayers and their payers. This system will be more efficient and save money for patients (exempted elites not included). But this opportunity won’t just happen.
Provider status will enable pharmacists to give basic care for UTIs, headaches, simple rashes, etc. While providing accessible care at a much lower cost, pharmacists can manage and treat minor problems and triage the more complicated issues to primary care physicians or acute-care facilities. This role of providing triage to patients is as old as the profession of pharmacy.
Under the ACA, there is growing realization that treatment options and costs must be limited or capped. The only way to do that without injuring patients is to have pharmacists perform medication therapy management (MTM) and consult patients on their options and the benefits of managing their medications, while ensuring compliance with their clinical goals.
By virtue of their profession and training, pharmacists are thoroughly prepared to help patients. To do so, they must have provider status.
The pharmacist's POV
The problems of polypharmacy have been discussed extensively in textbooks and articles. From the point of view of a corporate manager, however, a pharmacist’s efforts to limit a patient’s obsession with taking just one more medication should result in discipline or dismissal of the pharmacist.
When success is measured by quarterly increases in dollar volume, polypharmacy, overutilization, and even addiction are rarely viewed as problems. In fact, all such negative behavior by or “on behalf” of patients has been routinely encouraged. The corporate paradigm encourages dispensing in larger quantities and labels the polypharmacy patient a VIP.
MTM signifies a return to a traditional approach to pharmacy services. When patients were paying for their prescriptions, pharmacists routinely reviewed issues of care with each patient in an attempt to streamline therapy and reduce costs. The advent of third-party payers changed the relationship, and patients began to view themselves as beneficiaries and not as consumers.
Other providers did it
Years ago, most pharmacists were self-employed, and their incomes were similar to those of certified registered nurse anesthetists (CRNAs). Today, pharmacists are mostly employees, and their salaries are significantly below the incomes of CRNAs, many of whom are still self-employed.
More than 20 years ago, there was a battle to grant CRNAs provider status. For years they had been reimbursed as employees of MD anesthesiologists, who took the entire fee and then paid the CRNAs as employees with a production clause in their employment contracts.
Eventually, the CRNAs decided to band together and hire lawyers to seek “provider status” with major carriers, Medicaid, and Medicare. These goals were reached, in most instances, when we pursued this status on a state-by-state basis. (I was a lawyer hired to represent several groups of CRNAs.)
It didn’t just happen. It required an investment and some expense, but the results were well worth the effort.