NASPA finds state-level provider status is widespread, but not necessarily linked to payment
Hub on Policy and Advocacy
Thirty-four states recognized pharmacists as providers or practitioners in at least one section of their state statute or in their state Medicaid program, according to a recent analysis conducted by the National Alliance of State Pharmacy Associations (NASPA). But little correlation existed between the recognition of pharmacists as providers within state law or the Medicaid program, and payment for pharmacists’ patient care services.
The actual framework and positioning of the language in state law varied greatly from state to state, as did the payment implications of having provider status.
“The large number of states who already have recognized pharmacists as providers or practitioners is both exciting and sobering news,” Rebecca P. Snead, BSPharm, NASPA Executive Vice President and CEO, told Pharmacy Today. “It’s exciting because it shows us that there are fewer statutory barriers to payment for pharmacists’ patient care services, but also is a reminder that there is much work to be done beyond legislative advocacy.”
Overview of results
To determine which states have designated pharmacists as providers or practitioners, NASPA staff looked at state statutes, specifically the insurance code, the business and professional codes, and the pharmacy practice act; looked at the Medicaid provider manuals; and surveyed the state pharmacy association executives.
NASPA staff also collected information on states where pharmacists are being paid for the patient care services they are providing. The analysis included the collection of information on payment for pharmacists’ patient care services from Medicaid, state employee benefits, and network contracts with private payers; instances of network contracting opportunities were captured from a survey of state pharmacy association executives. The analysis didn’t include contracts between a single payer and a single provider, incident-to billing, and facility fee billing.
Of the 34 states that recognized pharmacists as providers or practitioners, the majority do so through state statute, but a handful also recognize pharmacists within their state Medicaid provider manuals. In a couple of cases, pharmacists are recognized in their Medicaid provider manual but not within state law.
In at least 28 states, pharmacists’ patient care services (other than immunization administration) are covered by either the state or private payers. Included in the 28 were 15 states where pharmacists can be paid for services by their Medicaid program for at least one specified service, and 6 states with a state employee MTM benefit.
In at least six states, pharmacists are not formally recognized as providers in the state’s statute or Medicaid provider manual, but are compensated for providing targeted patient care services.
One of the reasons for the lack of correlation between payment and a state’s designation of pharmacists as providers or practitioners is likely due to pharmacists not being federally recognized as providers. Because Medicaid and private payers often follow precedents set by Medicare, federal provider status for pharmacists within the Social Security Act would likely make coverage for pharmacists’ patient care services easier and more widespread.
See the map on the previous page for more information on pharmacist recognition as providers in the United States.
State pathways to provider status
A state can take various pathways to designate pharmacists as providers.
Insurance code. The insurance code is one of the most common places within state statutes for pharmacists to be formally recognized as providers. The insurance code is the set of laws with which insurance companies in the state must comply. But because state insurance laws do not apply to publicly funded programs (Medicare, Medicaid, state employee plans) or to plans for self-funded employers, the insurance code affects only a small portion of the insurance market—so changes to these laws may have less impact.
Although some states have seen positive effects from recognizing pharmacists as providers under the insurance code, others have seen little change. For example, pharmacists in Virginia have been recognized as practitioners in the insurance code for more than a decade but have not seen scalable payment from private insurers for their services.
Other sections in state codes. In a handful of states, pharmacists are recognized as providers in the pharmacy practice act. With this approach, the statute may include in the definition of the word “pharmacist” a provider designation. Such is the case with Connecticut and Tennessee, which also both recognize pharmacists as health care providers in the insurance code.
Some states, such as California and Nevada, define pharmacists as health care providers in their business, professional, or occupation codes. A handful of states, such as Minnesota and Michigan, recognize pharmacists in their public health provisions; Minnesota also recognizes pharmacists as providers in the insurance code.
Recognition by Medicaid. At least nine states recognize pharmacists as providers in the state Medicaid provider manual, including two states where pharmacists are not recognized in statute. Although recognition as providers in Medicaid doesn’t always result in payment for the provision of patient care services, it does help to remove a barrier to implementing new programs that include pharmacists.
Recognition by private payers. Because the end goal of achieving provider status is to provide patients with access to coverage for pharmacists’ patient care services, another approach is to work directly with private payers. This approach has been used in states such as New Mexico, where pharmacists are recognized by many of the health maintenance organizations and health plans, and in Tennessee, where pharmacists are recognized and being paid as providers of patient care services through a program developed by the Blue Cross Health Foundation and the Tennessee Pharmacists Research and Education Foundation.
Every pharmacist can make an impact
The NASPA analysis showed that legislative changes are not the only way—and never the final step—to effect change in the pharmacy practice model. Practicing pharmacists collectively can make a huge impact on the national and state level provider status initiatives by doing what they do best: taking care of their patients. Pharmacists need to share their impact on patients’ health outcomes and costs. As public demand increases for pharmacists’ patient care services, there will be more pressure on payers to cover them. Pharmacists should continue to support APhA and other national and state pharmacy associations to ensure the success of provider status initiatives.
Call to action
Please note that it was not possible for the National Alliance of State Pharmacy Associations (NASPA) to do a comprehensive analysis of all potential contracts between pharmacists and payers for the provision of patient care services. If you are a pharmacist who is currently participating in such a contract, APhA and NASPA want to hear about it! Please send information about your program to Michael Ghobrial, PharmD, JD, APhA Associate Director of Health Policy, at email@example.com.