Understanding the Pharmacist as a Provider


Q&A: What passed and pending legislation means for the future of pharmacy.

In this question-and-answer session, Peter Kounelis, Senior Director of Provider Network Business Development, shares insights on the impact of approved and pending legislation that establishes the pharmacist as a provider.

Let's start with the basics. What is provider status legislation?
The patient care services that pharmacists provide have not historically been included in key sections of the Social Security Act (SSA), which determines eligibility for healthcare programs such as Medicare Part B. As such, this exclusion limits access to pharmacists' services for Medicare beneficiaries and impacts both quality care in communities and how Medicare pays pharmacists for what they do.

According to the American Pharmacists' Association (APhA), "studies and practice-based experience have shown that when pharmacists are involved as members of the healthcare team, patient outcomes improve, patients report higher rates of satisfaction and overall health care costs are reduced."1 In fact, medication therapy management (MTM) services provided by pharmacists can reduce costs to the healthcare system by chipping away at the nearly $300 billion non-adherence costs the system annually2.

Why is now the right time for provider status?
Recognizing pharmacists as healthcare providers acknowledges the value of pharmacists' services in the healthcare "triad," which consists of the patient, physician and pharmacy. And now, the Affordable Care Act (ACA) has birthed value-based payment models that highlight the importance of continuity of care. These present opportunities for pharmacists to receive reimbursements from Medicare that can be up to 85 percent of physician fee schedule reimbursements. In addition, we are seeing a combination of issues that highlight the importance of the pharmacist's involvement in care, from physician shortages and ACA coverage expansion that put pressure on the healthcare system to the emergence of specialty therapies in oral form that lend themselves to increased pharmacist clinical involvement. So not only is it the right time in terms of the need for adherence-related cost reductions across the continuum and the value of quality care in the community, but also the ACA has shed new light on the role of the pharmacist.

Has pharmacist as provider legislation passed?
At the state level, in California, yes. California approved S.B. 493 in October 2013, and many other states are considering the legislation. As for Federal legislation, things are looking very good. H.R. 4190 was introduced to the House of Representatives in March 2014. This resolution seeks to modify Title XVIII of SSA and recognize pharmacists as providers with a couple of important caveats: reimbursement is limited to "medically underserved" communities, and provider status is subject to state scope-of-practice laws and licensure/certifications. In addition, a survey conducted by the American Pharmacists Association recently indicated that 83 percent of voters agree that pharmacists have the education and training to do more than just fill prescriptions3, which is very promising for this piece of legislation.

What are the barriers associated with passing this legislation?
There are a few reasons H.R. 4190 may not pass. First, U.S. financial pressures mean Congress is focused on legislation that saves money. Making matters a bit more confusing is the fact that members of Congress often equate provider status with the "fee-for-service" payment model - a model the healthcare system is shifting away from as more and more payers focus on quality outcomes. And then there's the opposition from other providers who fear the legislation will cut into what they do. So there's a very real need for pharmacists and their advocates to demonstrate the true value of pharmacy services such as MTM and chronic disease management.

What can pharmacists do to help passage?
A number of groups within the healthcare space are advocating this important legislation. The American Society of Health System Pharmacists, the APhA and the National Community Pharmacy Association, for example, continually provide educational materials and resources that prove the value of this evolutionary role for pharmacists. All of these groups encourage pharmacists to contact their state representatives to advocate for themselves and have their voices heard. Collaborative practice agreements (CPAs) are also a great way for pharmacists to demonstrate value in the community with immunization programs.

In closing, is there anything additional pharmacists should know?
Independent community pharmacies really need to recognize that this legislation presents a critical diversification opportunity, meaning that while prescription drug reimbursements are a source of frustration that is not likely to go away, recognizing pharmacists as providers means opportunities to bill for in-scope services and realize additional revenue. It all goes back to capitalizing on that personal, patient-centered focus that is the independent's stock and trade.


1 American Pharmacists Association. Improving Patient Care. Available online at Accessed 19 December 2014.
2 New England Healthcare Institute. Thinking Outside the Pillbox: A system-wide approach to improving patient medication adherence for chronic disease. August 2009. Available online at Accessed 9 January 2015.
3 American Pharmacists Association. What Voters Are Saying. Available online at Accessed 19 December 2014.


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