SPECIAL REPORT

Will pharmacists win provider status?

There's a new push on to convince Uncle Sam to formally recognize pharmacists as health-care providers so they can be paid by Medicare for their drug therapy management and patient consultation services.

Winning federal provider status for R.Ph.s is the top national legislative priority of the Pharmacist Provider Coalition recently formed by ASHP and the American College of Clinical Pharmacists (ACCP). The goal is to convince Congress to pass a bill to amend the Medicare title of the Social Security Act. This would put pharmacists on the same footing as other nonphysician practitioners—such as clinical social workers, dietitians, nurse midwives, nurse practitioners, and physician assistants—when it comes to being paid for their services. Provider status is the key to unlocking the Medicare moneybox to reimburse R.Ph.s for cognitive services.

The foundation for the ASHP-ACCP legislation is the concept of collaborative practice agreements between pharmacists and prescribers, which are currently legal in 30 states. Although the details may vary from state to state, such agreements generally allow pharmacists to initiate, monitor, or modify a patient's drug therapy as permitted under a written protocol with the prescriber, who has overall responsibility for the patient.

"We are in the process of finalizing the legislation, but the basis of the activity would be collaborative drug therapy management functions now authorized in 30 states," said C. Edwin Webb, Pharm.D., M.P.H., ACCP's director of government and professional affairs. "If pharmacists authorized to engage in collaborative drug management provided such services to Medicare patients, they would be recognized as providers and could bill for those services. Authority for what pharmacists would be able to do is based in their state pharmacy practice act. Pharmacists in any setting would be eligible as long as they qualify under state law."

Any requirements for pharmacist education and training to participate would be worked out between the secretary of Health & Human Services and national pharmacy organizations under the ASHP-ACCP legislation. The menu of such requirements would most likely parallel stipulations in the collaborative practice regulations already in place, according to the sponsors.

While the legislation does not restrict provider status to specific pharmacy settings, many pharmacists will not be providing the higher level drug therapy management envisioned by the bill's sponsors, said Kathleen Cantwell, ASHP counsel and director of federal legislative affairs and government affairs. She said the bill's cosponsors are still being lined up but added that it represents a two-pronged strategy. In the first place, it will get pharmacists inside the Medicare reimbursement tent, and, second, it will position them to capitalize on the addition of a drug benefit to the federal program.

"Pharmacists are being replaced by nurse practitioners and physician assistants, who are recognized as providers," Cantwell said. "Pharmacists should care about this issue of provider status because it's their livelihood."

Under the current cumbersome Medicare rules, pharmacists can bill only for patient services that are "incident to" a physician's service. And even if pharmacists do clear the regulatory hurdles, they can bill only at the lowest billing code. Such restrictions do not permit more sophisticated services, such as anticoagulation therapy management.

Medicare's billing constraints on pharmacists put a damper on the advancement of drug therapy management in hospitals, clinics, and physician offices that can't justify subsidizing activities that won't be reimbursed. "If pharmacists can't bill for their services and generate revenue, they become a negative financial drain," ACCP's Webb said. "A couple of ASHP members have even become physician assistants so they can bill, even though they're doing the same thing they did as pharmacists."

A positive development for R.Ph.s in their drive to gain provider status is that they will be able to bill for their services separate from payments tied to a drug product under the new Version 5.1 telecommunications standard developed by the National Council for Prescription Drug Programs. HHS chose Version 5.1 as the pharmacy standard for electronic transactions under the Health Insurance Portability & Accountability Act. But HHS selected the X12N 837 transaction as the HIPAA standard R.Ph.s will have to use to bill for their professional services under a patient's medical coverage. In other words, pharmacists will use the same billing guide that physicians will use. This change takes place late next year.

Many pharmacy leaders view provider status and Medicare reimbursement as critical for the profession to be able to expand beyond the traditional dispensing role that's becoming a loss leader.

"Getting the pharmacist paid is critical to the appropriate use of medications," said Susan Winckler, R.Ph., group director of policy and advocacy for the American Pharmaceutical Association. "So from the consumer perspective, it's really almost useless to pay for medications if you don't pay for the pharmacists to work with the patients to make sure they know how to use those medications. Our bottom line for any program that wants to expand drug coverage, whether it's a state assistance program or a Medicare drug program, is that you have to pay for the product and you also have to pay for the services to use those products."

STATES PERMITTING COLLABORATIVE DRUG THERAPY MANAGEMENT

Alaska

*Louisiana has statutory authority to allow collaborative practice but has yet to promulgate rules.
Source: National Association of Boards of Pharmacy

Pharmacists have been making some inroads with Medicare payments, most notably reimbursement for administering immunizations, said Winckler. She noted that current rules do not prohibit payments to R.Ph.s but don't require reimbursement either. Pointing to Medicare payment for diabetes education, she added, "Although the rules are not fabulous for pharmacy, I think they'll expand Medicare payments to pharmacies that have a certified diabetes educator and a dietitian. There have been incremental gains in securing Medicare payment, and we must continue to build on that."

Half the legislative battle may be educating Congress and the Bush Administration about the expanding role pharmacists play in today's health-care system. Raising the consciousness of government officials is the centerpiece of the drive to win provider status. In April, representatives from nine pharmacy organizations had a face-to-face discussion with HHS secretary Tommy Thompson. On the top of their list was the addition of a prescription drug benefit to Medicare. Presenting a united front, the association representatives stressed the pharmacist's role in ensuring that patients use their medications safely and appropriately. They also emphasized the need for a new Medicare reimbursement system that would pay R.Ph.s not just for dispensing drugs, but also for providing drug therapy management services.

"I think we're seeing a change, certainly at the federal level in Congress," said APhA's Winckler. "The idea that you need some oversight for these medications is getting a lot more play. Even the bill that passed the House last year, which APhA and other pharmacy groups vigorously opposed, had a portion that said pharmacists should be paid for some of their services. There is some recognition that this has to happen. We're getting there."

State pharmacy boards are doing their part in nudging pharmacist provider status forward, said Carmen Catizone, executive director, National Association of Boards of Pharmacy. Thirty states have implemented laws, regulations, or rules permitting pharmacists to enter collaborative drug therapy management agreements with prescribers. Louisiana's board has statutory authority to allow collaborative practice but has not yet promulgated the actual rules.

"The sentiment I have is that state pharmacy boards are very supportive of provider status, expansion of the pharmacist's role, and collaborative practice," Catizone told Drug Topics. "The states have not been involved in any reimbursement issues, but I think there's almost 100% support that if there's a Medicare drug benefit, the pharmacist should be recognized as a practitioner and those benefits should extend beyond just the medication. I think the states are willing to change their practice acts or do whatever they need to make sure that happens legally."

A potential Medicare prescription drug benefit was an issue that brought about a position statement in August 1999 from the 10 national pharmacy associations that make up the Joint Commission of Pharmacy Practitioners. JCPP took the position that any Medicare prescription drug benefit must extend beyond just the medications to include payment for the pharmacist's drug therapy management services.

"The profession is absolutely united on this issue," said Winckler. "I'm not sure the details are all together, but we're all working on that too. The most valuable tool the profession has to advance this agenda is pharmacists themselves, pharmacists providing these services."

Capitol Hill being what it is, odds of the ASHP-ACCP legislation winning passage may be slim, but the Pharmacist Provider Coalition won't back away from the fight, according to Webb. "It will be an uphill battle," he said. "As the chances of a Medicare prescription drug benefit decline, it gets to be a tougher sell. We have no illusions that it will be an easy thing, but we will work on it until we win."

Carol Ukens

Carol Ukens. Will pharmacists win provider status?.

Drug Topics

2001;10:33.