Sonya Collins
Alis Volat Propriis—“She flies with her own wings”—is Oregon’s state motto. The government first adopted the slogan in 1854 as a hat tip to the independent spirit of the pioneers who formed Oregon’s first government. The slogan was replaced by others over the years until lawmakers brought it back in 1987—arguing that it still reflected Oregon’s traditions of independence and innovation.
Oregon pharmacists have come to embody those traditions. The state has recognized pharmacists as providers since 2009. But, as pharmacists in many other states know, provider status alone does not always give pharmacists the authority to exercise their full scope of practice or the autonomy to bill for the services. Laws enacted in Oregon since 2009 have further empowered pharmacists to use their expertise to provide the best care for their patients. Fair reimbursement for this care by both public and private payers has made clinical pharmacy services a sustainable part of the offerings at clinics across the state.
“It’s exciting to be in a place where you’re able to do more for your patients,” said Ucheoma Nwizu, PharmD, clinical pharmacist at Neighborhood Health Center in Portland.
Laws on their side
In 2003, legislators passed a bill that allowed pharmacists to bill for clozapine monitoring. In 2005, the legislature expanded pharmacists’ billing authority to other drugs that required monitoring beyond clozapine. By 2009, they could bill for medication therapy management services. Then, in 2015, a landmark law required payers to cover any clinical pharmacist services in the profession’s state scope of practice.
“These laws paved the way for pharmacists to start building their practices and bill like any other provider,” said Andrew Hibbard, PharmD, ambulatory care clinical coordinator at CareOregon, a state coordinated care organization.
Laws on the books in Oregon also prohibit payers from discriminating against a provider on the basis of profession. Discriminatory pay is prohibited, too. Payers must reimburse pharmacists at the same rate that any other clinicians get for that same service.
Some plans reimburse pharmacist clinical services as a specialist visit. Others reimburse the visit as they would another primary care provider.
The laws of the last decade have brought other measures of increased autonomy for pharmacists, too. For example, the clinicians may now recommend clinical services, such as medication therapy management, directly to a patient. They do not have to rely on referrals from physicians or other providers.
Care coordinators
After laws go into effect to expand pharmacists’ practice or billing authority, it can take years for clinics to catch up and for payers to catch on.
“Provider status is really an unknown thing for many pharmacists,” Hibbard said. “They don’t always understand it.”
Many payers are no different.
When Neighborhood Health Clinic began working with embedded pharmacists and billing for their services, they sent out credentialing requests to their payers. “Some of them said no or got back to us with ‘We’ve never done this before. Let’s think about it’ or ‘Let’s talk about it.’ Some of them were on board, and some never got back to us,” said Zach Rosko, PharmD, director of pharmacy care and teams at Neighborhood Health Center in Portland.
But, Rosko added, “It was shocking how many people right off the bat just said, ‘Yes, absolutely, we’ll reimburse pharmacists,’ and I’m talking commercial plans.”
CareOregon has stepped in to bridge the knowledge gaps among both pharmacists and payers when it comes to billing for clinical care. Through the organization’s Pharmacists Collaborative, which Hibbard runs, CareOregon has helped embed 125 credentialed and contracted pharmacists in clinics across the state.
“There’s still a lot of room to grow in areas of our network that don’t have access to clinical pharmacy services to manage complex diseases, such as diabetes and heart failure,” Hibbard said.
And there’s good reason to push for more access to these services for patients, Hibbard said. CareOregon’s extensive internal research shows that patients with type 2 diabetes, as well as patients who use polypharmacy, get better outcomes in clinic systems that employ a pharmacist.
Disease state specialists
At many clinics in Oregon, pharmacists are the chronic disease specialists.
“Here, other providers rely on pharmacists for recommendations and defer to our expertise on many conditions,” said Vivian Ton, PharmD, lead pharmacist at Central City Concern, a federally qualified health center in downtown Portland. Through collaborative drug therapy management, pharmacists at Central City also manage anticoagulation therapy, hepatitis C, hypertension, dyslipidemia, COPD, asthma, clozapine therapy, and pre-exposure prophylaxis for HIV.
Among Ton’s patients is a man with type 1 diabetes who had already had one leg and the toes of the other foot amputated before becoming her patient. The man struggles with keeping his blood glucose levels regulated because he lives in fear of hypoglycemia. It has taken a lot of education to make him comfortable with keeping his blood glucose at the right level. After a year, Ton and her patient have made substantial progress.
“In the middle of our last visit, he broke down when he saw his A1C and said he wouldn’t be here if it weren’t for me,” Ton said.
The patient noted that his visits with his physicians were more like check-ins, whereas in his longer and more frequent appointments with Ton, he learned how to manage his disease.
“Our practice model allows us to provide more one-on-one care to our patients,” Ton said.
At Neighborhood Health Center, the care model also gives pharmacists the time to unravel the distinct problems of each patient, such as the young woman cared for by clinical pharmacist Nwizu. In her mid-20s, the woman was in the emergency department frequently for A1Cs as high as 15%.
At their first meeting, Nwizu read in the patient’s chart that both she and her mother, who was her caregiver, had intellectual disabilities. But a talk with them made it clear that was not the case.
“They just had poor health literacy,” said Hibbard, who was co-resident with Nwizu at that time. “They needed a little bit more attention than you would get in a typical primary care provider visit.”
Over the next 12 months, under Nwizu’s care, the young woman’s A1C fell from 15% to 6.2%. The pharmacist also streamlined her medication regimen from about 18 medications from six prescribers at four pharmacies to 9 medications from three prescribers at one pharmacy.
“Pharmacists don’t just come in and wave a magic wand,” Nwizu said. “It was very rewarding to get the patient to goal, but it took a lot of hard work.”
Both patients needed the time and attention that only pharmacists were able to give.
The meaning of accessibility
In a state where pharmacists must be treated and paid like any other provider, will availability and accessibility continue to be their strengths? Or will their days, too, fill up with hurried, back-to-back 15-minute visits?
Ton, of Central City Concern, said that’s not how pharmacy visits work.
“Disease state management is a targeted approach,” she said. “We are able to do problem-solving and motivational interviewing around that one condition, while primary care providers are bombarded with three or four different things in a 20-minute visit.”
Because patients come to the pharmacist after they have undergone a work-up and received a diagnosis, the pharmacist can cover a lot more ground in the allotted time. It’s like a relay in which the diagnosing provider has already sprinted the baton far down the track. Then pharmacists can go the remaining—often long—distance to get patients to the finish line.
“This is teamwork,” Nwizu said, “and it makes care pretty seamless.”