Paving the Way for Provider Status

By Peter Kounelis, R.Ph. |

Why the time is right for pharmacists to be recognized for the patient care that they provide.
Dating back nearly 20 years to the Asheville Project1, the seminal study that demonstrated how pharmacists could improve the health of a chronically ill population over time while reducing direct medical costs, evidence strongly supports the case to have pharmacists recognized as providers of clinical services.
Similar studies up to the present have repeatedly substantiated that pharmacist intervention in patient care results in positive outcomes, fewer hospitalizations and complications, and the need for other medical expenditures. Through this progression, recognition of pharmacists' value has grown, paving the way for their designation as providers who will be reimbursed for delivering an expanding array of services.
As recently April 8, 2016, regulations became effective in California authorizing pharmacists to provide contraceptives to women without a prescription.2 The legislation specifies a clinical protocol pharmacists must follow in dispensing birth control prescriptions as well as requirements for reporting back to the patient's primary care provider. California has entrusted pharmacists to implement the protocol, which includes blood pressure screening to identify women who may be susceptible to heart attack or stroke if given the wrong type of birth control. If a woman passes the screen, the pharmacist dispenses the contraceptive. If the screen detects medical issues, the pharmacist takes appropriate action by alerting the patient's physician.
This latest development in pharmacist empowerment follows the pattern established when the Centers for Medicare and Medicaid Services (CMS) required Part D plans to offer medication therapy management (MTM) independent of drug dispensing. Subsequently, CMS directed managed care plans to implement MTM interventions. CMS recognized the incremental value of the pharmacist consulting with patients on the importance of medication therapy and adherence to it, as well as its impact on their health and management of their disease state, including potential lifestyle changes such as losing weight or limiting sodium intake.
Similarly, pharmacists are now widely accepted as providers of immunizations and screenings for chronic diseases such as diabetes, hypertension and asthma. The healthcare system as a whole derives financial and clinical benefits from prevention of downstream effects through these provider activities. Positioning pharmacists as an entry point to preventive care via provider status increases the probability that patients will be properly diagnosed early in the process before detrimental consequences manifest.

Pushing into underserved areas.

In one regard, provider status enables pharmacists to practice to the full extent or scope of their license. However, often missing is not only provider status, but the reimbursement that would accompany clinical services outside of medication dispensing. Under provider status it would be necessary for pharmacists to be able to submit claims that would document encounters and establish reimbursement for the value of clinical services provided.
Federal legislation, the Pharmacy and Medically Underserved Areas Enhancement Act (H.R. 592/S. 314)3 - which was introduced in Congress in 2015 and has been co-sponsored by 275 members of the House and 42 senators4 - would amend Medicare provisions to cover an expanded scope interventional services. At the state level, California, North Dakota, Washington and Oregon have also passed legislation related to provider status.
Provider recognition increases patients' access to healthcare while reimbursing pharmacists for the services they provide beyond prescription dispensing. Additionally, pharmacists' in-depth education and unique expertise in areas such as therapeutic pharmacology positions them to be the go-to authorities for making clinical pharmaceutical decisions.

Prioritizing medically underserved areas for pharmacy participation would bring vital services to places with shortfalls of primary care providers at a time when patient demographics are skewing heavily toward seniors and demand for care is skyrocketing. In many respects, forces are aligning in favor of a ready-made population of highly trained pharmacists filling the void and earning compensation that matches the services they provide.

From a broader policy perspective, provider services delivered by pharmacists would create value with healthcare system cost savings offsets - as in reduced hospitalizations, better outcomes, increased longevity and fewer expenses in other parts of the medical spectrum. Accordingly, eventual passage of provider status legislation will depend on successfully demonstrating to deficit-focused members of Congress the budgetary "pay-fors" that such a bill would generate: long-term cost benefits, not just incremental costs.

Gearing up for provider status

Passage of provider status will also bring about an evolution in patient interactions from a series of transactions to clinical encounters - during which patients recognize the pharmacy as the place to go for benefit-covered preventive services and chronic disease management. In that light, patients need to be educated about how their benefits match up with pharmacist services.
A pharmacist providing specific clinical services may consider in-store banners or outbound calls to inform patients about available lab tests or screenings, all of which can scheduled by appointment.
At a grassroots level, independent pharmacies should partner with state and local pharmacy associations who are advocating for recognition and payment in their respective states and consider joining the National Community Pharmacists Association (NCPA), which is working to keep this a top priority in Washington, DC.

Pharmacists need to let their congressional representatives know, too, why it's important to sign on in support of provider status legislation that recognizes how easily patients can access local pharmacies. Legislative representatives may not realize the frequency with which a pharmacist typically engages a patient. On average, Medicare recipients visit their community pharmacy 35 times a year, while these same patients only see their primary care physician about four times a year.5 It is important for pharmacists to emphasize the set of services they could deliver - and be compensated for - while the patient is engaged if they were to be authorized as a provider.

Some independent pharmacists have also arranged to conduct health screenings at local businesses or worksites to raise awareness of available services and to detect potential disease among employees. A simple blood pressure screening, for instance, could start a conversation with a worker about how their community pharmacy can also provide diagnostic and treatment services.
Forward-thinking and progressive pharmacists are quickly learning that providing reimbursable clinical services is an infinitely better model than merely filling scripts. When it comes to caring for the community, provider status allows pharmacists to deliver all their valuable skills for the betterment of the healthcare system.
AmerisourceBergen remains committed to pharmacist recognition through the passage of provider status. On September 21, AmerisourceBergen urged congressional action on this pending legislation. Learn more.



About the Author

Peter Kounelis

Peter Kounelis, R.Ph.

Vice President of Elevate Provider Network
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