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.
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.”
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.
See also: Healthcare provider status for pharmacists is long overdue
“We are supporting increased access to patient care for pharmacists,” said Carmen Catizone, executive director of the National Association of Boards of Pharmacy. “There is not much resistance or hindrance from the states. If provider-status agreement can be reached, NABP and the states would support it.”
State support is crucial. As are NPs, PAs, and physicians, pharmacists are bound by state practice acts in the healthcare services they may provide. The federal bills expand access to care for patients but do not affect scope of practice for providers.
In January, the National Governors Association (NGA) issued a white paper, “The Expanding Role of Pharmacists in a Transformed Health System.” Pharmacists are already practicing well beyond the traditional retail drug-dispensing role. But few pharmacists are practicing at the top of their professional training or scope of practice on a regular, or even occasional, basis.
Because scope of practice is governed at the state level, pharmacists and payors must navigate a patchwork of 50 different practice acts. While 48 states allow some sort of collaborative practice agreement between pharmacists and other providers, administrative barriers and lack of regulatory flexibility limit direct patient care.
Reimbursement for patient care is spotty. Most states do not recognize pharmacists as providers and cannot reimburse pharmacists for patient care. The few states that have tried paying pharmacists for patient care are seeing positive results.
MTM programs targeting Medicaid recipients in Mississippi and Minnesota, for example, showed both improved care and reduced costs. CareSource, a Minnesota Medicare managed care plan, reported more than a 4:1 return on investment. Every dollar in MTM provided by local pharmacists reduced total healthcare spending by $4.40.
NGA advised states that allowing pharmacists to provide MTM services can improve outcomes and reduce costs. The organization advised governors to integrate pharmacists into provider programs.
Dan Crippen“State governors influence healthcare professional supply and utilization,” said NGA Executive Director Dan Crippen. “States can have a major impact on healthcare by increasing the supply of providers. Pharmacists are very much a part of that discussion. As we spend more on chronic diseases, somebody needs to be in charge of sorting out all these complex and sometimes conflicting medication regimens and programs. Who better than pharmacists? We have already seen that pharmacist involvement in patient care can cut hospital readmission rates by 46%. I hope pharmacists will help us get that message out to their states.”
A few states have already tried to integrate pharmacists more deeply into healthcare. North Carolina, New Mexico, and other states have tried to create reimbursement opportunities for pharmacists who provide patient care. Most linked reimbursement to expanded scope of practice with new training, certification, reporting, and record-keeping requirements but stopped short of adding pharmacists to the official list of healthcare providers entitled to direct reimbursement.
California did both. Its provider status law declared pharmacists to be healthcare providers and expanded their scope of practice.
In California, new practice areas include drug administration via injection and other routes; patient consultation, training, and education on drug therapy, disease management ,and disease prevention; review of patient progress, including access to medical records; provision of travel-related medications recommended by the Centers for Disease Control and Prevention that do not require a prior diagnosis; independent initiation and review of immunizations for patients three years of age and older; and the ordering and interpretation of lab tests to monitor and manage the efficacy and toxicity of drug therapies in coordination with the primary care provider or diagnosing prescriber.
Pharmacists can also provide self-administered hormonal contraceptives (oral medications, transdermal patches, vaginal rings, etc.) and smoking cessation products/programs under standardized statewide protocols approved by the Board of Pharmacy.
The law also created an Advanced Practice Pharmacist (APP) classification that requires additional training, certification, and regulation. APPs can perform patient assessments; order and interpret drug therapy-related tests; refer patients to other providers; initiate, adjust, and discontinue drug therapy under protocol; and participate in the evaluation and management of diseases and health conditions in collaboration with other providers.
What this expanded scope of practice means for practicing pharmacists is unclear. Roth said CPhA will launch its initial training and credentialing programs at its annual meeting in April. Smoking cessation and travel medicine are emerging as the most popular new practice areas, he said. Many pharmacists already have practical experience in these programs under existing protocols with physicians.
What the expanded scope of practice and provider status means for pharmacist reimbursement is equally unclear. Few pharmacists are currently being paid for MTM or other services under existing programs, Roth said. The record-keeping, reporting, and payment systems needed to integrate pharmacists into provider networks and create payment mechanisms are still in the talking stages.
Pharmacists may begin seeing income from smoking cessation, travel medicine, and contraceptive services to cash patients over the next few months. But widespread participation by public and private payors isn’t likely before 2016 at the earliest. Roth declined to speculate on initial reimbursement levels.
“We are not seeing active resistance from payers. This is just a new program,” he said. “We are all dealing with a shrinking fee-for-service sector and growing use of integrated care teams and direct pharmacist care. We have to get provider and payer systems aligned before we can talk dollars and cents reimbursement issues.”
Once California works out the details on provider and payer systems needed to fully implement pharmacist provider status, the other 49 states will still be faced with the same problem. Crippen noted that while the NGA takes the position that state initiatives and legislation take precedence, uniform practice models and language could help states move more directly to incorporating patient care by pharmacists into their own programs.
The Joint Commission of Pharmacy Practitioners (JCPP) has already developed a uniform practice model, the Pharmacists’ Patient Care Process, which can be used in any practice setting and any scope of practice. The PPCP, plus JCPP’s vision statement, “Pharmacy Practice in 2015,” lays out a comprehensive commitment to care for - and about - patients. Stipulated principles include the following:
• Pharmacists must have an in-depth knowledge of medications plus the biomedical, sociobehavioral, and clinical sciences, as well as the ability to apply evidence-based principles to pharmacy practice.
• Pharmacists should have the authority and autonomy to manage medication therapy, and should be accountable for therapeutic outcomes.
• Pharmacists will be responsible for the rational use of medication, including the measurement and assurance of therapeutic outcomes; promotion of wellness, health improvement, and disease prevention; and the design and oversight of safe, accurate, and timely medication distribution systems.
Anne Burns“Recognition of pharmacists as providers is one of the overarching goals of JCPP,” said Anne Burns, vice president of Practice Affairs for APhA, one of 11 JCPP member organizations. “Consistency in the provision of care by pharmacists is critical to reaching that goal. Just as you know what to expect when you visit your physician or dentist for an annual checkup, you should know what to expect when you visit your pharmacist.”
APhA, like other national pharmacy groups, is focusing on the Pharmacy and Medically Underserved Areas Enhancement Act. (Information is available at www.PharmacistsCare.org.) Gaining provider status under Medicare is the wedge that opens other doors.
Sandra Guckian“Historically, what Medicare does, other payors follow,” said Sandra Gukian, vice president of State Government Affairs for the National Association of Chain Drug Stores. “Where you create opportunities in Medicare, other opportunities follow.”
MTM took the national stage as part of Medicare Part D, she noted. States soon began adding MTM to Medicare programs and private payers followed. Provider status is expected to follow a similar trajectory.
Kasey Thompson“There is a clear recognition that teams work better than individuals when it comes to providing healthcare,” said Kasey Thompson, vice president of Policy, Planning, and Communications for the American Society of Health-System Pharmacists. “This bill better enables Medicare’s team-based care model that is already in place. It doesn’t expand health coverage. It expands access to care for people who are already covered. Provider status for pharmacists is one of those issues where no one loses.”