National attention in the pharmacy press has focused recently on pharmacists being recognized as providers under federal health programs such as the Medication Modernization Act.
National attention in the pharmacy press has focused recently on pharmacists being recognized as providers under federal health programs such as the Medication Modernization Act. After years of political activity by several national pharmacy associations, to date, 145 legislators have cosigned HR 592, the Pharmacy and Medically Underserved Areas Enhancement Act, which appears to be gaining the momentum needed to pass both houses of Congress. The passage of such a bill, however, does not necessarily ensure pharmacist recognition, nor does it guarantee compensation for services in the private sector.
Meanwhile, pharmacists in Washington state took a different path to achieving the goal of compensation for pharmacists’ services from third-party payers. A recently passed law, the first of its kind in the United States, ensures pharmacists are included in health insurance provider networks. SB 5557, signed into law by Governor Jay Inslee this past June, explicitly provides this much-needed recognition for pharmacists. The law asserts that pharmacists must be included in insurance provider networks and cannot be denied compensation by third-party payers for nondispensing services. This law was supported by major pharmacy groups in the state with partnership by the Washington State Medical Association, Washington State Hospital Association, and patient advocacy groups. It was passed with overwhelming bipartisan support.
The Washington State Pharmacy Association (WSPA) noted in its press release, “Until now, health insurance carriers only recognized pharmacists for dispensing medications. This restriction blocked patients from receiving medical care from pharmacists practicing within their scope of practice. ESSB 5557 requires health insurance carriers to recognize pharmacists in the same way as other providers. Working collaboratively with other providers, pharmacists will effectively be able to provide a broad spectrum of patient care services that prevent patient harm and reduce emergency department visits and hospital readmissions.”
“Removing these barriers will allow pharmacists to directly care for patients in all practice settings,” said Jeff Rochon, CEO for WSPA, in a press release. “This common-sense solution encourages greater collaboration among health providers and brings health care to patients in our communities.
“We are excited that pharmacists will have opportunities to increase collaboration within the health care team in patient-centered medical homes and accountable care organizations, with the focus being on quality and safety,” Rochon added. “This is a huge development within our health care system, and we’re excited that pharmacists will finally be able to utilize all our skills to help patients.”
“The passage of ESSB 5557 simply means that patients will have greater access to high-quality care services. Most people only know pharmacists as their trusted prescription partner, but now pharmacists will more closely partner with each patient’s medical provider as an exquisitely trained medication specialist,” stated Don Downing, clinical professor at the University of Washington School of Pharmacy, in the WSPA press release. Downing was instrumental in securing the bill’s passage.
This legislation passed after many years of effort by the WSPA and the faculty and students of the University of Washington School of Pharmacy and the Washington State College of Pharmacy. The approach Washington state pharmacists used to pass this legislation is unique and may be instructive to pharmacists in other states.
The groundwork for SB 5557 is decades-old: in 1995, several categories of health care providers successfully lobbied for passage of RCW 48.43.045 and WAC 284-43-205, known as the “Every Category of Health Care Providers” legislation. This law stated that health insurers were prohibited from excluding any category of providers licensed in the state who provide health care services or care within the scope of their practice for services provided as “essential health benefits,” as defined in other Washington state codes. Washington’s list of essential health benefits is broad-based and includes prescription drug services and medical devices.
The law provided explicit examples of what could not be excluded from coverage. For example, as stated in the statute, “If the issuer covers outpatient treatment of lower back pain as part of the essential health benefits, any category of provider that provides cost-effective and clinically efficacious outpatient treatment for lower back pain within its scope of practice and otherwise abides by standards pursuant to RCW 48.43.045 (1)(a) must not be excluded from the network.” Elsewhere, the statute continues, “These standards may not be used in a manner designed to exclude categories of providers unreasonably. For example, issuers must not decide that a particular category of provider can never render any cost-effective or clinically efficacious services and thereby exclude that category of provider completely from health plans on that basis.”
Health plans were not prohibited, however, from placing reasonable limits on individual services rendered by specific categories of providers based on relevant information or evidence of the type usually considered and relied upon when making determinations of cost-effectiveness or clinical efficacy.
One might have thought that the passage of this law more than 15 years ago would have been sufficient to allow pharmacists to provide and bill for nondispensing services. After all, the definition of the practice of pharmacy in Washington had been revised in 1979 to include nondispensing services such as the initiation or modification of drug therapy in accordance with written guidelines or protocols, the monitoring of drug therapy and use, and participation in drug utilization reviews and drug product selection. All licensed pharmacists are eligible to perform these services with no additional training or certification required. This groundwork provided a solid basis for making the case for reimbursement. Payers, however, did not see it that way.
Washington state health plans universally refused to accept health plan credentialing applications from pharmacists, let alone pay pharmacists, for these services. Invoices for services were routinely submitted by pharmacists, but rejected. Commonly stated reasons for rejections included (1) since pharmacists were paid a dispensing fee when filling prescriptions, this constituted compliance with the “Every Category of Health Care Providers” law, and (2) billing claims could not be accepted because the billing pharmacist was not a recognized network provider for the health plan.
Numerous complaints were submitted to the Washington State Office of the Insurance Commissioner (OIC), but they went essentially unheeded for years. Getting nowhere with the OIC, Downing began working with and educating a number of assistant attorneys general and state legislators about the scope and value of pharmacy practice. Mounting political pressure resulted in a formal request for an opinion from the Washington state attorney general’s office about pharmacists’ status as health care providers, particularly with respect to this law. The state attorney general’s opinion, produced in 2013, stated in part, “Pharmacists are health care providers and must be compensated for services…within the scope of the pharmacist’s practice and if the pharmacist agrees to abide by stated standards related to cost containment, management, and clinically efficacious health services.”
With this legal opinion in hand, the OIC finally began supporting pharmacists’ right to be recognized as major network clinical providers eligible for compensation for their services, within the language of the “Every Category of Health Care Providers” law. The OIC collected evidence of insurer refusals to credential pharmacists as providers. The OIC legally challenged and threatened to fine several large commercial health plans for their ongoing failure to recognize pharmacists. Still, the plans resisted.
Downing, Rochon, and other pharmacy leaders recognized that a different strategy was needed, one that would involve sponsoring a more specific bill. A state senator who was also a pharmacist agreed to sponsor a bill, SB 5557, that amended the “Every Category of Health Care Providers” law by explicitly clarifying that (1) pharmacy contracts for filling prescriptions did not satisfy the health plan’s requirement to enroll pharmacists as major medical network providers, and (2) insurers must also compensate pharmacists if they cover and compensate physicians, nurse practitioners, or physician assistants for providing a service that was within a pharmacist’s scope of practice.
“The victory is sweet, but political skirmishes are never fun,” Downing stated in an exclusive interview with Directions in Pharmacy. “The key to victory for us was winning broad support from physicians, other health care providers, and administrators who wrote letters of support indicating they recognized and supported pharmacists’ role in optimizing drug therapy for patients.”
“The road is always toughest for the pioneer,” Downing said. “The key is to be attentive, consistent, and persistent, always focusing on what is best for patients.”
Dale Christensen, PhD, is an affiliate professor in the department of pharmacy at the University of Washington School of Pharmacy.