Provider Status Profile
Sonya Collins
When “Sam” came into Blount Discount Pharmacy in Blount County, TN, for diabetes education, his A1C was over 11%, and his blood glucose consistently ran in the 350s. The retired paralegal was at a loss as to how to control his type 2 diabetes. Blount Discount Pharmacy was the only location for miles that offered diabetes education in the form of diabetes self-management training (DSMT). But Sam almost wasn’t able to take advantage of it.
‘I’ve tried to get in’
Blount Discount Pharmacy is currently accredited and recognized as a DSMT provider in the traditional Medicare program, but not Sam’s Medicare Advantage (MA) plan. “I’ve tried to get in network with his MA insurance company, but they won’t let me in,” said Hamilton Borden, PharmD, the diabetes educator at Blount Discount Pharmacy. “So, I had to get a prior authorization and do all kinds of extra paperwork before he could come into the program.” And while recognition of the pharmacy for DSMT in one segment of Medicare is a positive step, provider status for individual pharmacists to be credentialed and contracted as medical providers would be instrumental in broadly leveraging pharmacists’ contributions to the health care system.
The 2017 Tennessee Pharmacists as Providers Law was an important step in recognizing pharmacists as health care providers with whom payers can contract. But, 3 years later, challenges remain because pharmacists lack recognition as providers at the federal level. The 2017 law has resulted in many of the state’s private insurance plans incorporating individual pharmacists into their medical provider networks, but others, especially those exclusively focused on Medicare, have not.
The discrepancies that Borden sees in his state may continue unresolved until pharmacists have national recognition as health care providers. Unlike physicians, nurses, physician assistants, and most other health professionals, CMS does not recognize pharmacists’ services for payment. As a result, these clinicians cannot bill Medicare for patient care services. Typically, private payers tend to follow Medicare, so if Medicare doesn’t cover a service or a type of provider, private payers often don’t, either.
Fortunately for Sam, his MA plan authorized the diabetes program. It changed Sam’s life. In the 10-hour program, Sam learned about intermittent fasting and decided to try it. Because the strategy had him eating far less each day, he was motivated to choose foods that would give him more bang for his nutrition buck. He steered away from empty calories and toward more nutrient-dense foods, including those high in fiber and low in fat.
The program also taught him about the important role of exercise in diabetes control. The once-sedentary retiree than made a commitment to join a gym and go every day. Since starting diabetes education at Blount Discount Pharmacy, Sam’s A1C has dropped to 5.1, and his blood glucose holds steady in the 120s.
“And all that happened without adding any drugs,” said Borden. “It was just through learning what he could do to control his condition.”
Given the burden of type 2 diabetes in the South, Borden knows there are many more people like Sam who could benefit from diabetes education at Blount Discount Pharmacy. Patients who complete the program tend to see their A1C drop by about 2%, which reduces risk for stroke, heart attack, amputation, and dialysis exponentially.
When insurance companies refuse to pay for diabetes education at a pharmacy, they pay later, Borden said. “As pharmacists, we can’t change lives if we can’t partner with the insurance companies on a variety of services.
“Diabetes education saves health care dollars. Lowering A1C keeps people out of the hospital and off medications. The patient is healthier, and the payer saves money. It’s the ultimate win-win situation. How much more evidence do they need?”
Provider status stories
Pharmacists are health care providers. In a series of profiles appearing in Pharmacy Today and on pharmacist.com, pharmacists explain how their patients would benefit from provider status. And as part of our campaign for provider status, APhA has asked pharmacists to share their story of how they provide care to their patients and how provider status will improve health care. These stories are collected on the APhA YouTube channel at https://www.youtube.com/user/aphapharmacists/playlists. If you would like to share your story, please visit PharmacistsProvideCare.com.