Pharmacist provider status gains traction
The country is moving toward provider status. But direct reimbursement isn't here yet.
The country is moving toward provider status for pharmacists. But don’t hold your breath waiting for direct reimbursement from federal, state, or private payors.
Federal legislation granting provider status under Medicare Part B was reintroduced in both houses of Congress in late January. Identical bills garnered significant bipartisan support in the last Congress.
Thomas Menighan“This legislation is about getting pharmacists on the care team and giving them the ability to practice to the greatest extent their respective states allow,” said Tom Menighan, CEO of the American Pharmacists Association. “Patients recognize pharmacists as providers, and physicians recognize pharmacists as providers. Even some states recognize pharmacists as providers. But federal law has not evolved to allow access to pharmacist services. Medicare patients need better access to care. Pharmacists are part of the solution, but pharmacists are not part of the Medicare team. Not yet.”
Nor is it clear when they will be. Continuing battles over the Affordable Care Act have turned healthcare into one of the most fiercely partisan issues in Washington. If political wrangling overcomes bipartisan pragmatism, provider-status legislation may not pass until after the November 2016 presidential election. Or maybe not at all.
Lucas Hill“Provider status would open a lot of opportunities,” said Lucas Hill, ambulatory care pharmacy resident at UPMC St. Margaret in Pittsburgh. “We are seeing increasing growth in patient-centered medical homes and primary care practices that include pharmacists. All pharmacists who provide patient care should have reimbursement, not just a few scattered pilot studies and demonstration centers.”
On the state side, the National Governor’s Association is pushing hard to integrate pharmacists into provider and payor networks. But each state sets its own rules and regulations for provider status and payment eligibility. Getting pharmacists paid directly for patient services is a battle that must be fought and won in each of the 50 states.
California leads the way
Winning the legislative battle is just the first step. California took the lead by passing its own legislation to recognize pharmacists as providers eligible for patient-care reimbursement back in 2013. Supporters spent 2014 working out the legislative kinks and building a regulatory framework with the State Board of Pharmacy. The state pharmacy association hopes to have at least one payor signed up for a demonstration project by the end of 2015. A few pharmacists might see their first provider reimbursements in early 2016.
Jon Roth“We are in the early stages of educating payors,” said Jon Roth, CEO of the California Pharmacists Association. “We have to work out details like how you credential pharmacists under our state provider legislation, how you incorporate pharmacists into provider networks, how you incorporate pharmacists into electronic health records.
“We know that when you get pharmacists directly involved in patient care, it improves outcomes and saves money. Payors want to be sure they aren’t just adding another provider and additional costs. Pharmacy has a solid history that goes back to the Asheville Project and even earlier. We just have to show payors the metrics and let them do their own math. But it can take a tremendous amount of education just to get them to the point where they are willing to run their own numbers.”
Provider status and scope of practice
The push to win provider status for pharmacists is distinct from efforts to expand the scope of practice for pharmacists, at least at the national level. The Pharmacy and Medically Underserved Areas Enhancement Act, presented as S. 314 and H.R. 592, was introduced in late January. The bills give pharmacists the same authority to provide medical services to Medicare patients as nurse practitioners (NPs) and physician assistants (PAs) now have.
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