Medicare Reforms Aim to Pay Pharmacists for Clinical Care

In the fight over who controls patients’ access to medicines, pharmacists are emerging as pivotal—but under-recognized—health care providers. As Congress wrestles with funding bills and long-delayed reforms, independent and long-term care pharmacies are sounding the alarm about policies they say threaten both their survival and patients’ ability to get essential therapies.

At the center of this debate are three intertwined issues: provider status for pharmacists, pharmacy benefit manager (PBM) reform, and the fallout from federal drug-pricing and reimbursement policies, including the Inflation Reduction Act (IRA) and looming cuts to the clinical laboratory fee schedule.

For years, pharmacists argued that their clinical expertise—managing complex medication regimens, preventing adverse drug events, and counseling vulnerable patients—is not adequately recognized or reimbursed. Two new provider status bills in Congress aim to change that. One would expand pharmacists’ immunization authority, while another would empower pharmacists to provide HIV pre-exposure prophylaxis therapy and education to Medicare beneficiaries. Together, they represent a significant expansion of pharmacists’ scope and a potential shift in how Medicare pays for clinical services.

At the same time, pharmacies are pressing lawmakers to move beyond incremental pharmacy benefit manager (PBM) tweaks toward sweeping reform. Critics say their spread pricing practices and ownership ties to insurers and specialty pharmacies distort reimbursement, steer patients, and siphon off dispensing fees that were intended for frontline pharmacies. The proposed PBM Act, backed by pharmacy advocates, would seek to unwind these financial entanglements.

Compounding the pressure, IRA implementation and proposed double-digit cuts to lab reimbursement are straining long-term care and community pharmacies that depend on timely diagnostic data to manage frail nursing-home residents. Jim Lewis, senior director of policy and advocacy for the American Society of Consultant Pharmacists, explores how these converging policy battles could reshape pharmacy practice—and what’s at stake for patients if Congress fails to act.

“Congress is debating whether or not it's going to pass the funding bills that include some PBM provisions,” Lewis said. “There's still a lot more that needs to be done, prevention of vertical integration stuff in the Medicaid space, so there's still a lot of work on PBM reform.”