Provider Status Profile
Sonya Collins
“Arlene” had diabetes for about a year when she went to see Patricia Lambro, PharmD, at Peninsula Community Health Services in Bremerton, WA. Though her A1C remained high, she was having glucose lows almost every day. Her doctor, unable to identify the problem in the time allotted with the patient, referred her to Lambro.
During a 45-minute visit with Arlene, Lambro asked question after question and listened until she understood the problem. Arlene didn’t know that she was supposed to administer mealtime insulin with food. Instead, the 71-year-old simply injected the medication every time she checked her blood glucose.
Alleviating a patient’s fears
“Because she was always having these lows, she ended up scared to use her insulin. She was afraid something bad would happen and thought that it would be better not to use it at all,” Lambro said.
Lambro spent the rest of the visit explaining the difference in the insulins, how they work, and when and how to use them. “The patient stopped having the lows, and she wasn’t as afraid of her medications anymore,” Lambro recalled. “She got her blood sugar stabilized and close to goal.”
Lambro’s encounter with Arlene was several years ago. Peninsula Community Health Services, a federally qualified health center, most likely did not receive reimbursement for the visit. The state of Washington, which administers Medicaid and regulates private insurance, is one of 37 states that recognize pharmacists as health care providers—though whether provider status is tied to reimbursement varies by state.
Even within a state, reimbursement is not black and white. In Washington, Medicaid managed care and most state commercial health plans reimburse pharmacists, but Medicaid fee-for-service plans do not.
As for the federal government, which administers Medicare and subsidizes the clinic, it does not recognize pharmacists as providers. Unlike physicians, nurses, and most other health professionals, pharmacists had to lobby to be recognized as health care providers in each state where they have won the title.
‘We are not recognized as providers at the federal level’
But without federal recognition, Lambro said, “In a way, we are still fighting for all the same things pharmacists in every state are fighting for.” That is, consistent reimbursement for the clinical care that pharmacists are qualified to provide.
Practicing without provider recognition creates a host of problems for pharmacists, the clinics where they practice, and the would-be patients who could benefit from their services.
The federal government sets an encounter rate that each provider in a federally qualified health center can bill for a patient visit, but “we can’t bill at that rate because we are not recognized as providers at the federal level.”
Pharmacists at Peninsula Community Health instead bill at the substantially lower Medicaid fee-for-service rate when patients have insurance that has pharmacists in their network. For dual-eligible Medicare patients, there is no reimbursement for pharmacist-provided care, unless a quality-based or capitated payment is in place.
“We always see the patient because it’s the right thing to do,” Lambro said, “and provider status allows us to get some visits reimbursed, but not all of them.”
Because of the uncertainty of reimbursement, state-level provider status isn’t enough for many clinics to justify keeping a pharmacist on staff. That leads to inconsistencies for patients. Some learn to manage their diabetes in a 45-minute visit with a pharmacist—others in a rushed visit with their doctor.
“Pharmacists could provide education, help uncover medication problems, and alleviate fears about self-injection, but a lot of clinics can’t invest in that if the pharmacists aren’t getting reimbursed.”
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.