Washington state law: Pharmacists now providers in private health plans
SB 5557 signed into law
Gov. Jay Inslee of Washington state signed legislation into law on Monday that begins the process of enrolling pharmacists in the state as network providers in all commercial health care plans.
SB 5557 requires commercial or private health care plans doing business in Washington to enroll pharmacists into their provider networks, and it mandates that these plans pay pharmacists for services they provide if they are within a pharmacist’s scope of practice.
“This is transformative in terms of what pharmacists will be able to do for patients under their covered insurance benefit,” Don Downing, BSPharm, Clinical Professor at the University of Washington School of Pharmacy, told Pharmacy Today. “Clinics and hospitals will be able to utilize more pharmacists in direct patient care to improve patient outcomes.”
Most states have some form of provider status for pharmacists written into law, thus allowing pharmacists to provide patient care services beyond dispensing of medications. What sets Washington’s law apart from other states is that the state now mandates enrollment of pharmacists in commercial health plans and payment for the services they provide. In other words, this most recent provider status win in Washington means that not only are pharmacists allowed to provide patient care services, but they must be compensated by insurance plans governed by the state for the services they provide within their scope of practice.
The state’s Medicaid managed care program is required to pay pharmacists for medication therapy management services.
Although the new law does not require the state agency that manages Washington’s Medicaid and public employee health plans to participate, Downing said the agency has already decided that it will be credentialing and privileging pharmacists along with commercial plans because they believe that patient benefits and cost savings will result from allowing pharmacists to practice at the top of their license.
“To me, this move by a public plan potentially portends the future decision by many public payers to fully recognize pharmacists as full provider status practitioners,” said Downing.
The path to now
Downing, who was instrumental in the bill’s passage, said the path getting to this point was long and hard.
He used legal maneuvering, including filing legal complaints against the Washington State Office of the Insurance Commissioner and some the largest insurers in the state. Eventually, eight legislators filed a request in 2013 for a legal opinion from the Washington State Office of the Attorney General that resulted in the opinion that pharmacists are not just providers, but they must be paid for their services. Downing said the basis for this mainly came from a 1995 law that “declared that if one category of provider was being paid for a service that another category of provider could provide, then it would be illegal to pay one and not the other.”
Washington state Sen. Linda Evans Parlette (R-12), BSPharm, said her decision to introduce the bill was also strategic. She chose to wait until this year because last year’s session was a short one.
Downing, Parlette, and other pharmacy stakeholders, including the Washington State Pharmacy Association (WSPA), also worked collaboratively with the state’s medical and hospital associations.
According to Jeff Rochon, PharmD, CEO of WSPA, they had already been in close contact with these associations over the years focusing on numerous patient care and access to care issues, including care provision by pharmacists through collaborative drug therapy agreements.
“What made a difference is that the medical directors wrote letters of support for the legislation that drove home the point that clinics and hospitals need to use pharmacists on their team,” said Rochon.
Sen. Parlette told Today that the biggest challenge was dealing with insurance carriers. At first they wanted to delay making any moves.
As a compromise, Parlette insisted on a staged adoption of credentialing, where entities in the state that have internal or delegated credentialing already in place, such as Virginia Mason Medical Center, could start credentialing in January 2016, and then a workgroup would convene to determine the next steps for community clinics and pharmacies to follow in 2017.
The large health systems that have internal credentialing will now bill for services at full evaluation and management payment codes rather than relying on incident-to billing, facility fee overhead billing, or no billing at all.
“I believe this graduated approach is the best method and also knowing who the people are on the workgroup who will come to the table in 2017 is key,” said Parlette.
The workgroup will decide which rules pharmacists need to abide by in order to be credentialed, privileged, and paid, and it will be working on issues of medical necessity, referrals from primary care providers, and other gate-keeping mechanisms, according to Downing.
“Since pharmacists have already seen over 5 million patients for clinical care services in the past 10 years, we will be looking to not create unnecessary barriers to care access,” said Downing.
He said accountable care organizations will also be hiring more pharmacists to improve patient outcomes and be able to bill private payers for the pharmacists’ services.
“Physicians, hospitals, and clinic systems have been waiting for this law for some time,” said Downing. “Hundreds of pharmacists will be hired and embedded into medical systems in the next 2 years to provide any kind of pharmacy service that is needed and within the pharmacist’s scope of practice.”
Updated May 22, 2015