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    Pharmacist provider status gains traction

    Reimbursement will depend on state support for expanded scope of practice


    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.

    See also: Governors support provider status for pharmacists

    Thomas MenighanThomas 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 HillLucas 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.

    California leads the way

    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.

    See also: California pharmacists win provider status

    Jon RothJon 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.”

    Fred Gebhart, Contributing Editor
    Contributing Editor Fred Gebhart works all over the world as a freelance writer and editor, but his home base is in San Francisco.


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    • Mr. MJacobs
      Most pharmacists are trying to place the horse before the cart. Mr. Menighan says "If political wrangling overcomes bipartisan pragmatism, provider-status legislation may not pass until after the November 2016 presidential election. Or maybe not at all." If we gain provider status tomorrow... what will "you" do? That is my challenge to each and every pharmacist. Do your patients know what your skills are and how you can help them? Have you re-tooled your practice to encourage utilization of specialized pharmacy services? Dental, Optometry and Chiropractic services were not covered for years. Now some of their services have limited coverage, but most of their services are not covered. You still pay for them. Establish specialized pharmacist services and start providing them to patients above and beyond basic medication consultation required by law. Practice to the full extent of your state pharmacy practice act. No one said you cannot charge for services above and beyond dispensing requirements instructions for taking medicine and common side effects. Also establish a price list for your services. Your initial services may have to be at no cost... but not for long. Once you establish demand for something you do of value - you can then begin charging for your services. My experience in the 1990's and early 2000's while I practiced community pharmacy holds this to be true. Don't involve insurance companies. Don't worry about provider status so much. Don't involve insurance companies. My current job is helping pharmacies with PBM audits. Oh... and one more thing - Don't involve insurance companies. You'll regret it!
    • JoseLopez
      Recognizing pharmacists as providers is a total and utter nonsense. We have been providing care for decades, for free. The academia wants a quick fix to the decline in drug reimbursement and ultimate demise of the profession. The quick fix will be just that, quick and short. Third party payers will be paying us pennies for our cognitive services while making us jump through hoops and auditing us. You can read my blog https://jaguarx812.wordpress.com/2015/03/13/unsustainable/ where I discuss some of the issues. Provider status is a joke. It is simply a sign of desperation from everyone who benefits in the pharmacist supply chain. This includes the schools of pharmacy, and professional organizations. Want to see a real revolution, get rid of insurance companies. Leave them only for catastrophic care.
    • Anonymous
      This has been going around in schools for many years now which seems to be more talk by the major pharmacy organizations. These gains are trivial compared to the decline caused by pharmacy education expansion, period. Dr Wahlberg PharmD BCPS
    • JohnSowinski
      I have a signed collaborative practice agreement and I'm treating women hormone imbalance. It is an exciting practice. The possibilities are endless.
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