I Have Been a Provider for Over 2 Decades...Haven't I?

Directions in Pharmacy, December 2014, Volume 1, Issue 6

With an expanding scope of practice, provider status could help pharmacists receive adequate compensation for services.

In an effort to expand my role as a consultant pharmacist from long-term care facilities to ambulatory care, I approached Greensboro Medical Associates to see if they would consider the integration of a pharmacist into the physician office setting. Beginning with baby steps by providing anticoagulation management services for the practice, my role quickly expanded to provider of medication management services for a variety of chronic diseases, practicing shoulder-to-shoulder with all of the other health care providers in the practice, including physicians, nurse practitioners, and physician assistants.

In 2000, North Carolina passed the Clinical Pharmacist Practitioner (CPP) Act which established a dual registration with the North Carolina Board of Pharmacy and the North Carolina Medical Board that adds to the scope of practice of pharmacy to allow for collaborative drug therapy management. For the past 2 decades, I have provided collaborative drug therapy management services for patients with such chronic diseases as diabetes, hypertension, hyperlipidemia, cardiovascular disease, and general pharmacotherapy, to name a few. My typical day usually involves 20 to 25 office visits with patients referred by their primary care physician.

With the attempt of pharmacists to gain provider status evolving over the better part of the last 15 years, I think it is important to first define “provider status.” It is best to do this through a comparison with the concept of “scope of practice.” It is well documented that the scope of practice of pharmacy has evolved from a product-centered provision of service to a patientcentered provision of service. The patient-centered expansion of clinical service fully defines the transition of the scope of practice to medication management services being provided in many areas such as community pharmacies, physician offices and clinics, hospitals, and long-term care facilities. My example of collaborative drug therapy management at Greensboro Medical Associates is but one example of the expansion of “scope of practice.”

On the other hand, and in contrast with scope of practice, provider status is a term used to define which health care practitioners may receive compensation for services provided under Part B of Medicare. In other words, provider status has traditionally been used to define those health care practitioners (physicians, nurse practitioners, physician assistants, clinical nurse specialists, clinical social workers, etc) specified by the Social Security Act who may receive compensation for their services, be it Medicare, Medicaid, or commercial insurance. While my scope of practice as a clinical pharmacist has expanded greatly over the past 15 years to be recognized as a health care practitioner whose services greatly improve the quality of care while saving health care dollars, the lack of provider status has greatly impacted my ability to gain adequate compensation for services in order to make such provision of services a viable business model. While pockets of adequate compensation for services exist, the lack of broad compensation for services greatly affects the sustainability of the business model.

Ten years ago, the CPPs in North Carolina created a bill that would provide for coverage of their services in the Social Security Act under Medicare Part B. While a bill was successfully authored and introduced in Congress, it set off a huge controversy within pharmacy. Many of the large pharmacy organizations had difficulty supporting the legislation as there was fear that it would be too narrow in focus and pertain only to those CPPs recognized in North Carolina and exclude most pharmacists nationally. Many pharmacy organizations wanted all pharmacists nationally to be recognized as health care providers under the Social Security Act. However, there was concern in Congress that such sweeping legislation would be so costly that it would not be sustainable under the current health care model and sustainable growth rate. The legislation failed to gain any momentum and simply died. Oddly enough, the legislation that is currently on the table to recognize pharmacists as health care providers specifies those services provided to patients in medically underserved communities.

As a health care practitioner who has been providing care for patients for the past 20 years, not product-centered care but patient-centered care, my perspective on provider status for pharmacists is well defined. While my scope of practice has successfully expanded to allow me to provide advanced-level care to my patients, the lack of provider status as recognized by the Social Security Act has limited and continues to limit the universal sustainability of the business model that will allow such an advanced level of care to be provided to every patient. Under the current compensation model, due to the lack of provider status, I am significantly limited on the compensation I receive for providing a level of care that is equal to that provided by my physician, nurse practitioner, and physician assistant counterparts. For the physician office setting, the only route for reimbursement is under the “incident-to” guidelines, which are very restrictive in the manner in which services can be provided and which significantly limit the compensation to the lowest level Evaluation and Management code, a 99211, which is not nearly enough compensation to cover the cost of providing the service. Additionally, under the new models of care in the Affordable Care Act, such as patient-centered medical homes and Accountable Care Organizations, pharmacists are left off the medical team due to their lack of recognition as health care providers. Another example specific to North Carolina is the lack of coverage of medications and supplies prescribed by me as a CPP under a collaborative practice agreement with a physician by some insurers due to lack of provider status under Part B of Medicare. While there are pockets of payers, such as employer groups, that will compensate for services, there is a lack of extensive, universal compensation for services due to the lack of provider status.

Do I think that gaining provider status will enhance my scope of practice? The answer is no, as that horse is long out of the barn and I have been providing an advanced level of care to my patients for years. Will it have an effect on sustainable business models, not only for myself but for pharmacists everywhere? The answer is a resounding yes, as adequate compensation will finally allow the services I have been providing my patients to not only be sustainable, but to grow exponentially.

Brian Bray, PharmD, CPP, is partner, chief operating officer, and clinical pharmacist practitioner at Medication Management, LLC, and vice president of clinical services for Piedmont Pharmaceutical Care Network, LLC. He also serves as a preceptor for an ambulatory care clerkship for the University of North Carolina at Chapel Hill School of Pharmacy. Brian earned his PharmD at the University of North Carolina at Chapel Hill.