Provider Status – A Work in Progress

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Written By: 
Anusha McNamara, Pharm.D., BCACP

Achieving provider status has been the latest buzz for many pharmacy organizations over the past year. Provider status will likely lead to increased access to pharmacists' services in the ambulatory care setting and inclusion of medication therapy management by pharmacists as an essential benefit in emerging healthcare delivery models. Arguably the most important goal in achieving provider status is payment for pharmacists' patient care services under Medicare Part B.  The key to achieving provider status will be consistent and persistent collaboration by pharmacists, pharmacy organizations, and stakeholder groups.  There are currently two bills that have been introduced at the Federal level.  

House bill H.R. 3890 and its companion Senate bill S.1932, entitled the “Better Care, Lower Cost Act,” would allow groups of practitioners to establish “better practices” and provides financial incentives for models of care that deliver care through fully integrated patient care teams, including pharmacists.  Board eligible pharmacists are among the “providers” that would be receive payments under this model but it does not explicitly cover medication therapy management services.  These bipartisan bills, introduced in January 214 and evaluated by the American College of Clinical Pharmacy, currently have a small number of co-sponsors.

H.R. 4190 is a bipartisan bill that was introduced to the House of Representatives in March 2014 (but no companion bill has been introduced in the Senate). This bill, if passed, would recognize all pharmacists in the United States as healthcare providers, and amends Title XVIII of the Social Security Act in order to enable patients to have access to and coverage for Medicare Part B services by licensed pharmacists in medically underserved communities.1   As of October 2014, 116 members of Congress have officially cosponsor H.R. 4190.2  The legislative language for H.R. 4190 was developed and endorsed by the following organizations and businesses:3

While this effort is taking place at a national level, much has been done at the state level too! There are at least 11 programs in nine states (Iowa, Florida, Minnesota, Mississippi, Montana, North Carolina, Ohio, Vermont, and Wyoming) that pay pharmacists for the patient care services they provide.  Several of these programs use CPT (Current Procedural Terminology) codes, which are used to bill state insurance programs.4

In October 2013, California passed a bill expanding the scope of pharmacy practice and became the third state to establish an advanced practice designation for pharmacists.6  New Mexico and North Carolina have had an “advanced practice” licensure category for pharmacists for many years.  Montana and Washington State also recognize pharmacists as health care providers.5  In 2014, bills intended to expand the scope of pharmacy practice were making their way through the Kansas, Kentucky, Minnesota, and Tennessee state legislatures.7  Moreover, Alabama, Indiana, Massachusetts, New Jersey, and Washington State have bills regarding payment of pharmacist services through various state-based programs.  The scope and limitations of provider status within individual states depends on the state laws regarding collaborative practice agreements and payment systems.

Meanwhile, grassroots efforts by pharmacists practicing in community pharmacies, clinics, and health systems have lead to relationships with providers and patients.  Payment through “creative mechanisms” are leading the way.   For example, payment for annual Wellness Visits conducted by pharmacists is one revenue stream that many ambulatory care pharmacy practitioners have started to pursue.8 

While payment for services is certainly important, we should not be seeking payment for our benefit, but rather the benefit of our patients. No matter what happens with provider status, our primary focus should always be the health of the patients we serve.

References:

  1. H.R. 4190 – To amend the title XVIII of the Social Security Act to provide coverage under the Medicare program of pharmacist services. 113th Congress. 2D Session. 2014.
  2. Yap D. House pharmacy caucus hosts provider status briefing. American Pharmacists Association, 2014.
  3. Provider status: What pharmacists need to know now. APhA. 2013.
  4. Daigle L, Chen D. Pharmacist provider status in 11 state health programs. ASHP Policy Analysis, 2008.
  5. D’Arrigo T. Provider status in California paves way for new patient-care opportunities. ASHP Intersections. 2013.
  6. Provider status is here!  California Pharmacists Association, 2013.
  7. State Provider Status Legislation and Initiatives.  American Society of Consultant Pharmacists, 2014.
  8. Medicare Annual Wellness Visits Presents Opportunities for Pharmacists.  American Pharmacists Association, 2014.