Regional Pharmacy Trends: The State of Provider Status

As the roles and responsibilities of pharmacists continue to evolve, perhaps no endeavor is more important to the profession than that of health care provider status.

The root of the provider status issue is the omission of pharmacists and their services from the Social Security Act (SSA), which determines eligibility for Medicare Part B and other health care programs. As a result of this exclusion, Medicare beneficiaries are restricted to using many of pharmacists’ services in outpatient settings. In addition, because pharmacists are not listed as providers, they cannot receive compensation for their services from many state and private health care plans.

Pharmacists today perform a number of patient-centered services that go well beyond their traditional roles, including medication coordination, medication therapy management (MTM), chronic disease management, and patient education. To many pharmacists, the knowledge and services that they provide to patients have already made them an integral part of the health care team.

“Pharmacists are finally being recognized as drug information experts, and patients turn to their local community pharmacist for this expertise,” said David J. Slomski, PharmD, a dispensary facility manager at the Healing Corner in Bristol, Connecticut, in an interview with Pharmacy Times. “A patient may be too rushed at the doctor’s office or too intimidated to ask questions about their medication. Patients trust their pharmacists and are able to ask the questions that they weren’t able to at their doctor’s office.

“Being officially recognized with provider status through legislation would be great, but I feel that most patients already view us as their health care providers, without regard to our official provider status, or lack thereof,” Dr. Slomski added.

One arena in which pharmacists have achieved a number of victories in their pursuit of provider status has been state legislature. As of January 2015, 37 states have recognized pharmacists as health care providers, removing barriers that had previously prevented pharmacists from billing health plans for their services.

In October 2013, California became one of the more recent states to enact this change with the signing of SB 493, a comprehensive bill that provides an important glimpse of the services that pharmacists would be able to offer patients if they attain provider status. In addition to recognizing pharmacists licensed in California as health care providers, SB 493 expands pharmacists’ scope of practice by authorizing them to, among other responsibilities, administer drugs via methods such as injection, participate in multidisciplinary reviews of patient progress, immunize patients 3 years and older, and furnish travel medications, prescription nicotine replacement products, and self-administered hormonal contraceptives.

SB 493 also establishes a new classification of pharmacist: the Advanced Practice Pharmacist (APP). Under SB 493, pharmacists who are recognized as APPs can collaborate with prescribers to provide more advanced services, such as performing patient assessments, ordering drug therapy-related tests, referring patients to other health care providers, and initiating, adjusting, or discontinuing drug therapy. Becoming an APP is not mandatory, but pharmacists who wish to do so must complete 2 of 3 requirements: become certified in one of several areas of practice (such as ambulatory care or oncology pharmacy), complete a postgraduate residency program, and provide clinical services to patients for 1 year under a collaborative practice agreement or protocol with a physician, APP pharmacist, Collaborative Drug Therapy Management pharmacist, or health-system pharmacist.

While their successes at the state level have given pharmacists much to celebrate, federal recognition remains the Holy Grail in their quest for provider status. For proponents of provider status, federal recognition (specifically, the listing of pharmacists’ services as a covered benefit under Medicare Part B) would establish definitive procedures through which pharmacists could be reimbursed for their services—something not necessarily guaranteed by state recognition.

Proponents of provider status say financial compensation would grant pharmacists the flexibility to properly focus on patient care.

“Pharmacists in the community and institutional setting are constantly being pushed to do more and more,” Dr. Slomski said. “For example, in community chain pharmacy, pharmacists are giving immunizations at the same time as filling prescriptions and performing rudimentary MTM. They are required to perform these tasks simultaneously, which cuts down on the quality of the intervention being made. If pharmacies were reimbursed by insurances for the services that they are providing, you would be able to more fully staff a pharmacy and be able to better serve your patients.”

Many pharmacists seeking provider status on a federal level have found hope in HR 4190, a bipartisan bill introduced by Representatives Brett Guthrie (R-KY), Todd C. Young (R-IN), and G.K. Butterfield (D-NC). HR 4190 amends the SSA to cover pharmacists’ service under Medicare Part B, but there are limitations to this recognition. The legislation only allows the services of pharmacists to be reimbursable under Medicare Part B if they are provided in areas of the country that the Health Resources Services Administration defines as medically underserved areas, medically underserved populations, or health professional shortage areas. HR 4190 is currently awaiting approval in the US House of Representatives.

Ultimately, patient care is at the heart of the provider status issue for many pharmacists. For both pharmacists and pharmacist organizations, such as the American Pharmacist Organization (APhA), granting provider status to pharmacists and allowing their services to be reimbursed will grant them the flexibility and resources to better focus on treating patients. The APhA maintains that including pharmacists in the health care process results in improved patient outcomes and lower health care costs—fruits that pharmacists feel cannot be fully reaped until pharmacists are legally recognized as health care providers.

Author's Note (February 16, 2015): In the time since this article was written, federal legislation to grant provider status to pharmacists has been reintroduced in Congress. On January 28, 2015, the Pharmacy and Medically Underserved Areas Enhancement Act (HR 592) was introduced by Representatives Guthrie, Young, Butterfield, and Ron Kind (D-WI). The following day, a companion legislation (S 314) was introduced by Senators Charles Grassley (R-IA), Sherrod Brown (D-OH), Mark Kirk (R-IL), and Bob Casey (D-PA). Similar to HR 4190, the new legislation will allow pharmacists serving in medically underserved communities to become eligible for Medicare reimbursement as health care providers.