Provider status crucial in states with expanded Medicaid

Hub on Provider Status



Gates

After 39-year-old Raul Gonzalez had a stroke, he was temporarily blind, unable to walk, and challenged to speak clearly. His glycosylated hemoglobin (A1C) was more than 13%. When his diabetes was later diagnosed, Gonzalez required four insulin injections per day. Over the next 5 months, Ryan Gates, PharmD, CGP, CDE, met with Gonzalez monthly at California’s Kern Medical Center. During visits of sometimes an hour or longer, Gates taught Gonzalez about diabetes management through medication, diet, and exercise.

“He was the first doctor that ever made me feel he was concerned about my well-being,” Gonzalez said. “I wanted to give up, but he always said, ‘Come on. I know you’ve got some fight in you.’”

Medicaid covers care by providers

Gates, however, couldn’t have continued to see Gonzalez if it weren’t for SB 493, which granted provider status to all licensed pharmacists in California when it passed in 2013.

In community pharmacies, lack of provider status can incentivize pharmacists—like others profiled in this series—to prioritize dispensing pills over providing medication therapy management, medication reconciliation, and in-depth counseling. In health systems, pharmacists provide this type of care as long as hospitals have the means to pay them.

Gates’ means of getting paid, however, was about to come to an end. Before the Affordable Care Act (ACA) permitted states to expand Medicaid coverage, Kern Medical Center paid for its pharmacist services with safety-net funds. This allowed pharmacists to extend care in diabetes, anticoagulation and hypertension, among other disease states. Now that Medi-Cal, California’s state Medicaid, has absorbed most safety-net patients, Kern no longer receives these funds. But Medicaid will only reimburse for care provided by professionals that it deems health care providers.

“Clinical pharmacy services in the state of California live and die by Senate Bill 493,” Gates said. “In order for us, in this new environment without the safety-net funds, to continue with our services to our patients who were now enrolled in Medi-Cal, we had to be providers under Medi-Cal and be able to bill as providers for those services.”

Clinical pharmacists’ role in diabetes care

Fortunately for patients like Gonzalez, Gates and his California colleagues won recognition as providers. Today Gonzalez reports better vision than before his stroke. He walks and talks with ease, works, and rides a bike. His only diabetes medication is metformin. But Gonzalez isn’t the only one who could’ve gone without much-needed care if it weren’t for SB 493.

“Kern is a very sick county. We rank among the worst in California in deaths due to diabetes and cardiovascular disease,” Gates said. The county’s health ranking is 54 out of 57, according to the Robert Wood Johnson Foundation. Among the largest counties in the United States, Kern has three endocrinologists—and none of them takes Medicaid.

“Historically, clinical pharmacists have played a huge role in expanding access to diabetes care for these patients,” he said.

Not unique to California

Gates does not describe a problem that is unique to California. Since the passage of ACA, 26 states and Washington, DC, have expanded Medicaid, and 3 others continue to debate the issue. All of this unfolded in the face of a longstanding, nationwide physician shortage.

“In my county, we’re about 87% below the federal benchmark of physician to patient ratio,” Gates said. “There’s a huge physician shortage here, and we are taking that as an opportunity to enter in and expand access where there is none.”

This is among the reasons many pharmacists hope that provider status will eventually become the law of the land. “The kingpin is federal provider status,” Gates said. “We have to get Medicare Part B provider status before we can fully realize the potential of pharmacists.”

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. If you would like to share your story, please visit PharmacistsProvideCare.com.