Provider Status and Practice Innovation

It has always been my opinion that laws should follow the ways innovators practice rather than interfere with their practice. Of course, this means that pharmacy practice innovators must be competent, do no harm, and promote positive clinical outcomes. Unfortunately, laws can get in the way of practice innovations. Let me share a North Carolina experience that illustrates the problem and suggests why it is essential that pharmacists receive provider status under the Social Security Act.

North Carolina passed the Clinical Pharmacist Practitioner Act in 2000. The law was modeled on the legislation that gave physician assistants (PAs) recognition as providers in North Carolina. This was our state’s approach to implementing collaborative practice using selected pharmacists who worked under a supervising physician following approved protocols. These pharmacists were licensed by both the Board of Pharmacy and the Board of Medicine. The law was written so that most pharmacists could become eligible to apply to become a clinical pharmacist practitioner (CPP). A few innovative pharmacists used this new law to implement disease management practices within a medical practice. The Medicare fiscal intermediary was approached to allow these pharmacists to bill for Medicare patients at the midlevel practitioner rate. The medical director at the time agreed, reasoning that since CPPs came along after PAs but were similar to PAs, they should be considered the same and could bill at that same rate. These new practices based on a CPP model grew as a result.

Unfortunately, in 2004, a new medical director joined the fiscal intermediary staff, and in reviewing the previous position, he determined that pharmacists could not bill at this rate since they were not recognized providers. The result was that many of these innovative practices had to close because they were not financially viable at the new payment rate. Some CPPs continued to practice because they were able to bill other payers or the patient for services, suggesting that the lack of Medicare recognition of pharmacists as providers still allows some pharmacists to be innovators in a financially viable manner, especially when the pharmacist is an employee in a bundled payment environment. However, provider status for pharmacists, at least from a North Carolina perspective, would have allowed more pharmacists to flourish as practice innovators sooner, and more patients would have benefitted from their services.

Mr. Eckel is a professor emeritus at the Eshelman School of Pharmacy, University of North Carolina at Chapel Hill. He is emeritus executive director of the North Carolina Association of Pharmacists. A lifelong advocate for the profession of pharmacy, Mr. Eckel has lectured on pharmacy issues and trends in all 50 states and has traveled to 6 continents to promote, and educate audiences on, the role of the pharmacist.