If you were to ask a person walking down the street what pharmacists do, the most likely response would be, “They count pills and dispense prescription meds.” While that is part of what happens in a pharmacy, that is not the entire picture.
In fact, in the last 30 years the practice of pharmacy has changed tremendously. But public perception remains virtually the same.
“While different agencies are recognizing what pharmacists can bring to the health care team -- patient accessibility, medication expertise, ability to manage chronic illnesses, cost and hospital stay reductions, as well as the trustworthiness of the profession -- pharmacists are not generally considered “providers” nor are pharmacists’ patient care services recognized under the Medicare Part B section of the Social Security Act (SSA),” says Assistant Dean for Clinical and Professional Affairs Gina Moore, PharmD, MBA. The exclusion of pharmacists as providers has large implications for the health and well-being of patients, as well as for the profession of pharmacy.
What is provider status?
The real meaning of provider status is about ensuring that patients have access to care and coverage for valuable pharmacists’ patient care services. This can be achieved at the federal, state or private insurance level in a variety of ways. As noted above, “provider status” at the federal level refers to a listing in the SSA of those healthcare professionals whose services are eligible for Medicare Part B reimbursement. “Even though the law only pertains to Medicare Part B, it indirectly limits coverage by many state and private health plans, as the lack of federal provider status is often cited as a reason for denying coverage,” says Moore.
However, the introduction of the Affordable Care Act (ACA) has changed the healthcare landscape. In addition to providing access to health care, the ACA emphasizes reducing costs of healthcare and improving patient health outcomes. Studies have proven that pharmacists’ patient care services go a long way toward accomplishing these goals, reinforcing the argument for provider status. In many instances, the federal and state governments are realizing the powerful role that pharmacists can play in controlling diseases and reducing costs by reducing hospital stays and readmissions.
“Without changes in laws, pharmacists will never be
considered an equal player in the health care team,”
says Moore.
On both federal and state levels, pharmacists are trying to obtain provider status. Right now, a broad coalition of pharmacy organizations and stakeholders are calling on Congress to pass bills that would amend section 1861(s)(2) of the Social Security Act to enable Medicare beneficiaries to access pharmacist-provided services under Medicare Part B. These services would be reimbursable under Medicare Part B if provided to patients in medically underserved communities and if the services are consistent with state scope of practice laws. The amendment will come up for vote once the Congressional Budget Office (CBO) has analyzed the costs associated with such a change and determined the financial implications.
States’ efforts
Some individual states have been very successful in obtaining provider status, others are still working toward change. California, for instance, is leading the way and has been able to expand the scope of practice for pharmacists within the State through the passage of the California Pharmacy Practice Act, SB493.
According to the California Pharmacists Association, the law establishes an Advanced Practice Pharmacists (APP) recognition, and authorizes APPs to perform patient assessments and refer patients to other healthcare providers; order and interpret drug therapy-related tests in coordination with the patient’s primary care provider or diagnosing prescriber; initiate, adjust, and discontinue drug therapy pursuant to an order by a patient’s treating prescriber and in accordance with established protocols; and participate in the evaluation and management of diseases and health conditions in collaboration with other healthcare providers.
In addition to APP recognition, the California law authorizes all licensed pharmacists to:
- Administer drugs and biologics when ordered by a prescriber
- Furnish self-administered hormonal contraceptives pursuant to a statewide protocol, travel medications recommended by the CDC not requiring a diagnosis, prescription nicotine replacement products for smoking cessation pursuant to a statewide protocol
- Independently initiate and administer immunizations to patients three years of age and older
- Order and interpret tests for the purpose of monitoring and managing the efficacy and toxicity of drug therapies, in coordination with the patient’s prescriber
As shown, the expansion of pharmacists’ abilities under state law in California is quite extensive. Other states are pushing for expansions, too. The expansions range from pharmacists serving as triage points referring patients to health care providers to providing point of care testing and initiating therapy per approved medical protocols. Several states have seen legislative changes including North Dakota adding MTM as a covered benefit in Medicaid and Washington passing a bill that requires payment that incentivizes pharmacists and other qualified providers to provide comprehensive medication management services in health homes for Medicaid managed care patients with multiple chronic conditions.
Colorado is in the process of putting together a bill that is supported by the Colorado Pharmacists Society, Colorado Pharmacy Coalition, Regis University School of Pharmacy, Rx Plus Pharmacies, the University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Clinica Family Health, and Salud Family Health Centers. The focus of the bill is to increase access to pharmacist services and facilitate reimbursement.
Why does provider status matter?
There’s no doubt about it -- provider status is a touchy subject. “Change always is,” says Moore. “But pharmacists are already an integral part of the health care team, we’re just not being financially recognized for it. By being recognized and acknowledged for our contributions, we’ll be able to improve access and care to our patients.”
How can you help?
The Colorado Pharmacists Society or your state pharmacy association or society is an excellent place to get information and find out how you can help in the effort to obtain provider status. Contact your national legislators to advocate for pharmacists being part of the healthcare team as providers. Check out the APhA website to learn how you can help with the federal effort.
April 1, 2024