Provider Status Is Finally Emerging. Now What?

Author(s)Troy Trygstad, PharmD, PhD, MBA, Pharmacy Times Editor in Chief

Pharmacists and Pharmacy Advocates Have Been Calling for Pharmacist Practitioner Scope of Practice and Reimbursement for Decades, but What Happens When We Catch the Bus?

STATE LEGISLATION HAS ACCELERATED SCOPE AND REIMBURSEMENT EXPANSION FOR PHARMACISTS

Washington, California, Oregon, Texas, Arkansas, Pennsylvania, North Dakota, and many other states have successfully adopted or are about to successfully gain access to varying opportunities for pharmacists to bill for services as practitioners. With an assist from the COVID-19 pandemic that expanded perceptions of pharmacists and pharmacies as service providers, the “provider status” ball has found the downside of the hill, and it is finally accelerating after decades of foundation building, strife, setbacks, and intractability. Although most states do not yet have a wide range of services outlined in statute to pay pharmacists as providers, all but 9 states have mandated some sort of payment for pharmacist-provided services.¹

ABSENT BLANKET AUTHORIZATIONS OR DIRECTIVES, A PATCHWORK OF OPPORTUNITY WILL PERSIST

Progress is being made at the state level, but the federal government remains sclerotic and recalcitrant, failing to provide multistate guidance, mandates, or even a door opening to Medicare or other federally funded insurance programs. Varied jurisdictional and operational needs, requirements, and clinical transformation efforts prevail thanks to the lack of federal leadership or acknowledgement the need, value, and imperative of recognizing pharmacists as cornerstones of health care access. Although the state-level opportunities offer multiple petri dishes for proving and improving these services, the resulting lack of consistency of opportunity, service availability, established means of documentation, method of billing, and contracting vehicles for pharmacist practitioners across state lines is also an impediment to scaling.

TRYING ANY MEANS POSSIBLE TO GET PHARMACISTS IN FRONT OF PATIENTS FOR SERVICES INSTEAD OF DISPENSING

Ironically, what brings all the pharmacy settings of care together is the pharmacist. The common denominator is the practitioner, and varying sites of care that involve a pharmacist have been focused on advancing their respective sites of care more than the pharmacist, as any rational actors would given the lack of progress with pharmacist provider status. Workarounds have included drug regimen review mandates for pharmacists to consult in long-term care settings, vendor- and platform-centric Part D medication therapy management as a veneer for pharmacist practitioner services in community pharmacy settings, expansion of schools and colleges of pharmacy with subsidized faculty-practitioners, use of 340B savings for subsidization of pharmacist practitioner funding within health systems, and many others. Each respective site of care has nobly tried to advance the workarounds in an effort to increase the total number of pharmacist full-time equivalencies who are engaged as well as increase funding (somehow) of nondispensing activities.

PHARMACISTS OR PHARMACIES? THE TUG OF WAR BEGINS

Questions remain about whether the pharmacist or pharmacy will be the common denominator and ultimately the fulcrum of access to services, provision, and billing. One side says, “We already have a scalable system of credentialing, interoperability, contracted networks, adjudication, auditing, and payment for pharmacies. Just apply the same to pharmacist-provided services.” The other side says, “The pharmacist should be universally credentialed, regardless of setting of care, and should bill using the same billing systems and processes as every other health care provider.” Each center of gravity is now pulling on the other, and what services pharmacists provide and how they are billed will be decided over these next few months and years.

About The Author

Troy Trygstad, PharmD, PhD, MBA, is executive director of CPESN USA, a clinically integrated network of more than 3500 participating pharmacies. He received his PharmD and MBA degrees from Drake University and a PhD in pharmaceutical outcomes and policy from the University of North Carolina. He recently served on the board of directors for the Pharmacy Quality Alliance and the American Pharmacists Association Foundation.

WHO FOOTS THE BILL AND BENEFITS: PHARMACY BENEFIT MANAGERS OR HEALTH PLANS?

Pharmacy benefit managers (PBMs) have become the dominant payer for pharmacies and have been responsible for medication therapy management to date, thanks to the Medicare Modernization Act of 2003, which neglected to name pharmacists as billable practitioners. With drug spend hovering around 10% of the entire health care dollar after all rebates and concessions,² who should pay for pharmacist practitioner services? PBMs might argue that medication-related services are logically part of the pharmacy benefit. Pharmacists not practicing in a pharmacy might argue that practitioner services are provided by individuals, each with their own National Provider Identifier number, and are not associated with a pharmacy. Additionally, many will point to the benefit of medication optimization accruing to the medical benefit, not the pharmacy benefit, with medication spend increasing with improved adherence and reductions in untreated and undertreated conditions.

CREDENTIALING IS LIKE SUCCESSFULLY REGISTERING FOR THE RACE—YOU HAVE TO RUN IT

Another consideration is the widespread lack of experience for both payers and providers of these pharmacist-provided services, both with onboarding of the individual practitioners and their often untested billing systems and lack of experience in billing for encounters. Medical providers spend much more time and resources generating practitioner claims than pharmacies do submitting drug claims, oftentimes with more personnel devoted to billing, reconciliation, rebilling, and collections than to the practitioner themselves. Additionally, there is a lag time associated with receiving payment for practitioner services typically lasting many weeks, regardless of who might administer them, creating an additional working capital requirement. Many questions remain about how to scale and optimize pharmacist-provided care, but at least we are now out of the gate and racing down the track.