Population Health Management and Provider Status

Stephen F. Eckel, PharmD, MHA, BCPS, FASHP, FAPhA, FCCP
Published Online: Tuesday, May 13, 2014
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Pharmacists gaining provider status is a major legislative push among the various professional pharmacy associations, national employers, and trade groups. Most have partnered to form a coalition and together develop a strategy that will amend the Social Security Act to recognize pharmacists as providers. This status will allow Medicare beneficiaries to gain access to pharmacist-provided ambulatory-based patient care services. While I believe this is a laudable goal and one I hope is ultimately achieved, I want to make sure we do not put all of our energy into 1 item and miss out on emerging practice models that might ultimately impact a greater number of patients.

In a broad sense, the current health care reform that is under way impacts both delivery and financing. While acute care services will never go away or lose their importance, the ultimate goal is to keep patients healthy and minimize the use of these expensive services. In addition, a growing realization of the importance of incentivizing health care providers to keep their patients healthy will occur. If pharmacists are successful in getting provider status, the result will be individual pharmacists having appointments with patients and billing for their time in managing their medication needs. With more patients having insurance and a growing focus on prevention, this has to be positive.

Yet while it is a good thing, a few assumptions need to be met for pharmacists to take advantage of the legislation:
  • Ambulatory care services will have to operate as fee-for-service for business models to be sustainable.
  • Employers will have to value a pharmacist involved in medication management as opposed to another mid-level practitioner
  • The reimbursement rates that arise after provider status is achieved will have to be sufficient to financially support pharmacist services.
If these assumptions do not become reality, then pharmacy might get provider status but the business model to support it will not exist. Because of this, pharmacy needs to be active in supporting other roles of pharmacists in emerging models of health care delivery.

One area that is starting to be talked about more is population health management. What this term encompasses is taking a holistic view of all patients in a clinic and targeting any outliers. As opposed to being referred a single patient from a provider for chronic disease management, the pharmacist has a panel of patients and follows them collectively.

For example, a clinic might have hundreds of diabetic patients who are in need of cardiovascular risk reduction. An insurance company might incentivize this clinic with improved reimbursement rates if a certain percentage have their glycated hemoglobin at a certain goal, are taking an aspirin for cardiovascular risk reduction, and keep their lipids within an appropriate range. The provider responsible for this initiative would determine all the patients in this group to be at risk, contact them through different means, and then implement strategies to improve compliance. While the visits could be appointments that allow one to bill for the encounter, much of it would be done through group visits, telephone follow-up, or even tele-health interactions. Gaining provider status might not have much impact here.

I believe population health management will continue to increase in importance, especially as accountable care organizations and health systems predominate. Not only do we need to train our future practitioners on how to see patients in this manner, but we have to be considered as the health care professionals to lead it in the clinic setting. If not, someone else will and it will be a lost opportunity for pharmacy.

My concern is that if we only focus on provider status, we could miss out on other emerging roles that will be a part of future health care delivery reform. I hope we do not miss out on the forest for the trees.

Do you have insights on the future of pharmacy activities in the ambulatory care setting? Just let me know.


Stephen F. Eckel, PharmD, MHA, BCPS, FASHP, FAPhA, FCCP, is associate director of pharmacy, University of North Carolina Hospitals, and clinical associate professor and director of graduate studies at the University of North Carolina Eshelman School of Pharmacy.


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