The State of Provider Status: An Update for Pharmacy Students

As the pharmacy landscape shifts and evolves, pharmacists across the country continue to work toward a common and crucial goal: gaining legislative recognition as health care providers.

Gaining provider status is a complex and multifaceted objective, but at its heart is the exclusion of pharmacists from the Social Security Act (SSA). Exclusion of pharmacists from the SSA prevents many state and private health care plans from compensating pharmacists for patient care services, such as medication coordination, medication therapy management (MTM), chronic disease management, and patient education.

According to Stacie Maass, BSPharm, JD, senior vice president of pharmacy practice and government affairs for the American Pharmacists Association (APhA), the omission of pharmacists from the SSA also creates barriers for Medicare beneficiaries who seek to utilize these services in outpatient settings.

“For APhA, provider status is about promoting patient access to pharmacist services and recognizing pharmacists for their critical role in providing patient care alongside physicians and other practitioners,” Maass told Pharmacy Times. “While provider status efforts are crucial to the pharmacy profession, they’re equally important to patients.”

Gaining ground in the states

While the pursuit of provider status has not been without its challenges, a number of state laws passed in 2015 have given advocates much to celebrate.

For example, in 2015, North Dakota Governor Jack Dalrymple signed into law 4 bills that expanded the role of pharmacists in the Peace Garden State and recognized them as health care providers:

SB 2173, signed on March 18, permits pharmacists to enter into collaborative practice agreements with physicians and allows pharmacists to initiate and modify drug therapy.

SB 2104, signed on April 8, grants pharmacists limited prescriptive authority to distribute naloxone rescue kits to treat an opioid overdose and lists pharmacists as health care professionals alongside physicians, physician assistants, and advanced practice registered nurses.

SB 2320, signed on April 13, creates an MTM program for Medicaid-eligible patients in the medical and hospital benefits coverage group, and names pharmacists as providers who may offer MTM services in person or via telephone and are entitled to reimbursement.

HB 1102, signed on April 20, concerns work-related injuries and includes pharmacists as health care providers in its language.

“Having these bills pass helps promote pharmacists being active members of health care teams and opens additional doors allowing pharmacists to expand their scope of practice,” said North Dakota Pharmacists Association Executive Vice President Michael Schwab in an interview with Pharmacy Times following the signing of HB 1102.

The progress in North Dakota was followed shortly thereafter by Washington Governor Jay Inslee’s signing of SB 5557 on May 11, 2015. The first bill in the country to require the inclusion of pharmacists in health insurance provider networks, SB 5557 amends the state’s Every Category of Health Care Providers law, which obliges commercial health plans to include every category of health care provider within an individual’s participating provider network.

The passage of SB 5557 enables pharmacists in Washington state to collaborate with other providers more fully, allowing them to better contribute to services related to pain management, diabetes, mental health, and other chronic diseases.

“We are excited that pharmacists will have opportunities to increase collaboration within the health care team in patient-centered medical homes and in accountable care organizations, with the focus being on quality and safety,” Washington State Pharmacy Association CEO Jeff Rochon, PharmD, told Pharmacy Times at the time of the bill’s signing. “This is a huge development within our health care system, and we’re excited that pharmacists will finally be able to utilize all their skills to help patients.”

In addition, Oregon governor Kate Brown signed HB 2028 into law on June 18, 2015. This bill permits pharmacists to receive reimbursement for performing clinical pharmacy services, enabling them to more fully use their skills and knowledge to treat patients.

After HB 2028 was signed, Oregon State Pharmacy Association president Gary E. DeLander, PhD, RPh, explained to Pharmacy Times that this recognition of provider status also expands the way in which pharmacists can collaborate with other members of the health care team, as larger groups of pharmacists and physicians can now enter into agreements that would give patients easier access to enhanced pharmacy services, such as MTM and chronic disease management.

“Pharmacists in Oregon have had the ability to participate in these opportunities, but their ability to do so has been restricted, with only smaller agreements between a single pharmacist and a sole physician allowed,” Dr. DeLander said. “Now, it’s been opened up so that if a payor wants Oregon pharmacists to provide a particular service, that payor can create a protocol and allow pharmacists to participate.”

Dr. DeLander also expressed hope that achieving provider status would empower pharmacists to use their expertise in providing clinical services. “Pharmacists have consistently demonstrated the value of their service, and it’s important that they now use their status as full members of the health care team to deliver enhanced care,” he added.

Reflecting on the many state laws signed within the past year, Maass suggested that the growing exposure to provider status issues among practitioners and policymakers is an equally noteworthy accomplishment. “There is no question that decision makers now have a much better understanding of what pharmacists are able to do,” she said.

Entering the federal arena

Although these state-level successes are no small achievements, federal recognition remains the primary goal for many proponents of provider status. Fortunately, a proposed bill has given advocates hope that such a victory is well within reach.

Introduced on January 28, 2015, by Representatives Brett Guthrie (R-KY), Todd C. Young (R-IN), G.K. Butterfield (D-NC), and Ron Kind (D-WI), the Pharmacy and Medically Underserved Areas Enhancement Act (HR 592) would amend the SSA to cover pharmacists’ services under Medicare Part B, but only if these services 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. Companion legislation (S 314) was introduced the following day by Senators Charles Grassley (R-IA), Sherrod Brown (D-OH), Mark Kirk (R-IL), and Bob Casey (D-PA).

The bill is awaiting approval in both chambers of Congress as of press time, but it has garnered considerable bipartisan support since its introduction, with the House version crossing the majority threshold in October. At the time of writing, HR 592 has 245 cosponsors, while S 314 has 37.

Maass clarified that the bill is relatively limited in its effects, but added that it would nevertheless have a significant impact on the profession. “The federal legislation would only affect pharmacists who are treating patients in underserved areas, and it wouldn’t change these pharmacists’ scope of practice, as that can only be determined by each individual state,” she explained. “However, the bill is still a crucial first step toward the legal recognition of pharmacists as health care providers at a national level, and it’s very encouraging to see the support it has gotten from lawmakers on both sides of the aisle.”

Taking action

The advances made by the provider status movement have been due in no small part to the work of pharmacists and pharmacy students across the country.

Throughout the past year, pharmacists participated in a number of grassroots efforts to promote provider status, including visits to congressional offices and letter-writing campaigns. In one such campaign organized by the APhA, pharmacists sent over 20,000 letters to congressional lawmakers asking for their support of the Pharmacy and Medically Underserved Areas Enhancement Act. The effort, named the Pharmacists Provide Care campaign, was the largest grassroots advocacy operation in the history of the APhA.

“The support our profession is receiving from state and federal policymakers is remarkable,” said APhA Executive Vice President and CEO Thomas E. Menighan, BSPharm, MBA, ScD, FAPhA, in a press release. “We owe that growing recognition not only to the advocacy efforts by pharmacists across the country but due to the quality care they provide. Getting involved in the Pharmacists Provide Care campaign and reaching out to members of Congress to explain how this legislation will make a critical difference in your community should be a priority for all of us.”

Menighan also praised pharmacy students for the role they played in the campaign’s success, singling out the pharmacy schools at Samford University, University of Maryland Eastern Shore, Wilkes University, Presbyterian College, and the University of Puerto Rico for their high rates of student participation.

Crystal Atwell, PharmD, associate director of student development at APhA, suggested several ways for pharmacy students to get involved with the provider status movement. In addition to recommending that they write letters and make phone calls to their senators and representatives, Dr. Atwell encouraged them to organize visits to legislators’ offices or, better yet, invite lawmakers to campus to witness firsthand the services that pharmacists can provide.

“Pharmacy students are the future of the profession and, as such, they will be the ones most impacted by provider status,” Maass concluded. “Earning legislative recognition as health care providers will ensure that the next generation of pharmacists is able to treat patients to the full extent of their knowledge and abilities.”