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A pioneer in the battle to win medical provider status tells how its done.
For pharmacists who want to be designated as medical providers and be reimbursed for their clinical services, working through each state’s legal system is just one approach, said Donald Downing, clinical professor and director of the Institute for Innovative Pharmacy Practice at the University of Washington School of Pharmacy, Seattle, Wash.
Don DowningA pioneer in the movement to gain provider status for pharmacists, Downing successfully championed the request for an opinion from the Washington State Attorney General on pharmacist compensation and provider status. He then wrote legislation that led to credentials for pharmacists and their enrollment as medical providers on commercial health plans in Washington, permitting their compensation through major medical providers rather than through PBM-based pharmacy benefits. Under collaborative practice agreements, pharmacists in Washington have been able to prescribe all categories of legend drugs since 1979.
“Pharmacists are making decisions, rather than just taking orders. We conduct assessment tests when necessary, evaluate the results, and then make the therapeutic decision based on our clinical expertise, not someone else’s,” said Downing, who spoke during a recent Wolters Kluwer webinar, “Pharmacists as Medical Providers: More Than a New Job Title.”
Downing outlined seven tips for pharmacists seeking reimbursement for medical services.
1. Use states’ anti-discrimination laws to fight the battle through the legal system. “It’s discrimination not to pay a pharmacist for providing those services, such as diabetes care, that are paid when another category of provider provides the same care,” Downing said.
2. Get support from the state attorney general and assistant attorneys general. “I met with numerous assistant attorneys general and educated them on how pharmacists and patients are being discriminated against. By the time I got a majority of our state assistant attorneys general to understand and received a favorable informal attorney general opinion, I thought I could use this legal leverage to get health plans and legislators to understand,” Downing said. “Getting an AG opinion gives you credible leverage when you introduce a bill in the legislature.”
3. Align with patient advocates who will talk to legislators and tell personal stories. In some cases, these stories can accomplish more than a legally worded plea can. “They [patient advocacy organizations] speak with a larger and louder voice than pharmacists,” Downing said.
4. Enlist the help of individuals and organizations in other health professions, such as nurse practitioners. “Nurse practitioners have been through this battle themselves, and they will come to your aid. They need your help - many are working in rural areas,” Downing said. “We also turned in letters from medical directors representing multiple clinics and tribal clinics, stating that pharmacists not only should be recognized but need to be recognized and compensated. We cannot do this alone.”
5. Be aware that you might need pharmacy location licensure for mobile pharmacy services, and that you might need to get regulations on this issue changed in your state. “Most states have laws that require pharmacists to practice in a licensed pharmacy. It might be important to have your state board commission amend that,” Downing said. “I have worked in tribal health for years. If I had to have a pharmacy location license everywhere I provided services, I wouldn’t be able to provide clinical services.”
6. Use established CPT/ ICD-10 codes when billing for medical provider services. “It is easier for health plans to reimburse when those codes are already in their systems,” Downing said. It is important to fight against being compensated for “incident to” care when you are making the clinical decisions and taking personal responsibility, he added. “Similarly, you have to escape the ‘drug benefit’ side of the healthcare system. Your services are clinical and must be recognized under major medical.”
7. Track and measure the outcomes of the services you provide. “You absolutely need to do that. There will be naysayers who say, ‘Are you providing better or worse outcomes compared to usual care?’ ” Downing said. “You need to be able to respond with evidence of your value. You haven’t really accomplished pharmacist medical provider status until you’re compensated for the major medical services that you provide as a credentialed network clinical provider.”