Hub on policy and advocacy, May 2013

NASPA conducted survey of state execs; how provider status and payment have played out in several states

State-level lessons on provider status

A survey of state pharmacy association executives conducted by the National Alliance of State Pharmacy Associations (NASPA) showed that attaining payment for services and thus a viable and sustainable business model, is related to, but not the same as, legislative recognition of pharmacists as providers.

Currently, less than half of states recognize pharmacists as “providers” in state law, according to the NASPA survey; this recognition usually appears in the state insurance code but sometimes can be found elsewhere, such as in general laws or the health professional practice code. Not being recognized in statute does not exclude pharmacists from receiving payment in that state. Many states and the District of Columbia pay pharmacists for at least one professional service—though many offer very limited services such as only immunization administration. 

Few states pay for their Medicaid enrollees to have access to medication therapy management (MTM); even fewer states pay for other services such as smoking cessation services, and only one state pays for comprehensive pharmacists’ services. For more information on the NASPA survey, contact Rebecca P. Snead, BSPharm, NASPA Executive Vice President and CEO, at rsnead@naspa.us.

High variability, limited access

Without “provider status” at the national level in Medicare Part B of the Social Security Act, state pharmacy associations and state legislators—who have seen the value of pharmacists’ services for their constituencies—have provided a means for patient access to pharmacists’ patient care services in a small number of states. This access was accomplished through intensive and innovative approaches and outreach efforts.

The high variability in state-level legislative provider status and state-based payment for pharmacists’ services, according to the NASPA survey, has resulted in limited public access across the country to these valuable services. For pharmacists to be used effectively to improve health outcomes and lower overall health care costs, a national solution is needed for patients and the health care team to have consistent, reliable access to pharmacists’ services.

Top priority

The profession’s vision for pharmacists is articulated in the Joint Commission of Pharmacy Practitioners (JCPP) 2015 Vision of Pharmacy Practice: “Pharmacists will be the health care professionals responsible for providing patient care that ensures optimal medication therapy outcomes.” One of the barriers to achieving the JCPP vision is the lack of a widespread, viable, and sustainable business model. Recognition of pharmacists as nonphysician providers within the Social Security Act would be an important step toward access for patients and the health care team to pharmacist-provided patient care.

APhA, hand in hand with other national and state pharmacy associations, is actively working to gain recognition and coverage for pharmacists’ patient care services delivered in collaboration with other health care providers. For more information, visit www.pharmacist.com/providerstatusrecognition.

Here’s a look at how provider status and payment have played out in several states.

MTM in Minnesota

Minnesota has what is probably the most robust state-based MTM program. The Medicaid program in Minnesota includes MTM for patients taking four or more medications to treat or prevent two or more chronic medical conditions, or for patients referred by a physician. Enacted in 2005, the Minnesota MTM Care Law defines the MTM component of pharmaceutical care services and recognizes qualified pharmacists as providers, according to a 2007 final report evaluating the effectiveness of the Minnesota MTM Care Program.

Minnesota Medicaid has a statewide network of pharmacists, “so there’s pharmacists around the state who have taken it up” in all types of practices—chain, independent, clinic, hospital, and so on, said former APhA President Lowell J. Anderson, DSc, FAPhA, FFIP, Professor at the University of Minnesota College of Pharmacy. The fee schedule is “pretty reasonable,” based on the CPT code system, and billed electronically on a CMS medical form.

When the MTM program “went through the legislature, it had a negative budget impact,” Anderson told Pharmacy Today. “Which means in Minnesota that if they were to cut the program, they would have to add money to the budget because this was anticipated to save money for the state. Which in fact it has. So that was kind of key, and it is almost an insurance policy that that program will stay in place.” 

Tying the Minnesota experience to the national push for provider status, Anderson cited an argument made in the 2011 U.S. Public Health Service pharmacy report to the U.S. Surgeon General that there are numerous studies to document the value of pharmacists. “We don’t need another study,” he said. “We need people going out and taking the studies and going to the policy people. That’s what we did in Minnesota.”

Limited payment in Montana

Under the Montana PharmAssist Program, $6,000 was initially allocated this fiscal year to cover comprehensive medication management services provided by pharmacists. When that amount was exhausted within 6 months, the funding was increased to $12,000. That funding was established through a bill in a legislative session in 2005 and is paid for through tobacco tax revenue. The PharmAssist program is not through Medicaid; it is a standalone program.

Under the program, $200 per patient per year is allocated for comprehensive medication management services—a complete medication review at the initial visit and then one or two follow-up visits—and pharmacists decide how to divide that up based on a patient’s needs. “That very much limits the number of patients we can actually help,” said Carla Cobb, PharmD, BCPP—a psychiatric pharmacist at RiverStone Health Clinic in Billings, MT, and a cofounder of Merit Medication Consultants, a private practice—who has likely done more medication reviews through the PharmAssist program than any other pharmacist in the state.

“With the national push for provider status, I’m seeing a lot more pharmacists in our state energized about what they can do to get involved,” Cobb said. “I’m seeing more pharmacists who are stepping up to the plate [who] are now getting engaged in the discussions but still are limited because of limited payments,” she added, “and really are not always at the table when it comes to those discussions because of lack of provider status.”

Private payer in Tennessee

Tennessee is an example of how to advance provider status by working within the health care marketplace to gain recognition for pharmacists as providers of patient care services. The Tennessee Pharmacists Association (TPA) worked collaboratively with BlueCross BlueShield of Tennessee (BCBST) to develop a process to credential pharmacists who are compensated as health care providers through the BCBST medical payment system for the provision of immunizations to eligible beneficiaries.

Tennessee pharmacists who complete the BCBST application and credentialing process can receive reimbursement for certain vaccines and administration of those vaccines; these pharmacists are compensated for these services through the same mechanisms and at rates identical to any other health care provider, including physicians, according to TPA Executive Director Baeteena M. Black, DPh, and TPA Director of Professional Affairs Micah Cost, PharmD.

“The notion of pharmacists as providers is not a new concept. Pharmacists have provided care and services not directly related to the dispensing or delivery of a medication to their patients for decades,” Black and Cost told Today. “However, there has not been a structure and process in place to recognize this provision of care and services. It is important for pharmacists to identify and share success stories like this project here in Tennessee to help pharmacists gain national recognition.”

Provider bills in Massachusetts

Like California (see page 71 of April Today for more information), Massachusetts has introduced new legislation to recognize pharmacists as providers. Two bills, HB 2060 and SB 484, both titled “An Act Recognizing Pharmacists as Healthcare Providers,” are now working their way through the 2-year legislative session that began on January 1, said David Johnson, Executive Vice President of the Massachusetts Pharmacists Association (MPhA).

HB 2060 simply would include pharmacists in the definition of a health care provider, but wouldn’t require any public or private payer to compensate pharmacists. SB 484 also would add pharmacists to the definition of a health care provider but would require any blanket insurance plan to provide benefits for services of a registered pharmacist acting under the authority of a collaborative practice agreement. This bill was filed through the efforts of MPhA in the previous legislative session.

“Fighting for provider status in Massachusetts is also a way of contributing to the effort to recognize pharmacists as providers under the federal Social Security Act,” Johnson added. “As the ‘laboratories of democracy,’ states that have gained provider status and are climbing the mountain to secure compensation for services as providers will help convince officials at the federal level to yield to the inevitable.”

Provider status law in Virginia

Pharmacists have had provider status recognition in Virginia for about 15 years—the law defines pharmacists as practitioners—but this recognition has not really resulted in payment. Some state payers tend to list the providers eligible for payment instead of referring to the state’s practitioner definition. With Virginia Medicaid, pharmacists are almost never listed as providers, according to Timothy S. Musselman, PharmD, Executive Director of the Virginia Pharmacists Association. With the state employee plan, through a new MTM program, payments will start July 1. “It’s open to all providers,” he said. “Leaving it open and generic to all practitioners—obviously, with us [having] practitioner status—does allow us to be eligible to provide the services to state employees.”

Many payers, including Medicaid and private insurers, don’t necessarily default to the state status; they default to federal standards, Musselman told Today. “Federal listing, I think, will open it up.” But the true objective of “provider status” recognition of pharmacists will take not just listing but also action “like us getting MTM for the state employee plan; working with the Medicaid program on payment models,” he added. 

“Getting listed is an important first step,” Musselman said, “but that’s only part of the battle.”

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