US Pharm. 2023;48(10):39-42.
ABSTRACT: As the essential roles of pharmacists in providing healthcare to patients continue to expand, obtaining provider status nationwide continues to be a hot topic and of paramount importance for many pharmacy organizations. Various ongoing efforts are focused on supporting the acknowledgment of pharmacists as federally recognized healthcare providers under Medicare Part B in the Social Security Act, which would allow pharmacist reimbursements for healthcare services provided by these valuable healthcare team members in their daily clinical duties.
In their day-to-day practices, pharmacists across all spectrums of practice are integral members of the healthcare team. The pharmacist’s multifaceted roles as a clinician, patient educator, and patient advocate go well beyond dispensing medications. The roles of pharmacists continue to expand, such as the delivery of vaccinations, patient counseling, medication therapy management (MTM), and optimizing the safe and effective use of pharmacological therapies. Furthermore, the dedicated efforts of pharmacists to maintain the delivery of medications and other essential healthcare services, such as COVID-19 testing and vaccines during the pandemic, further illustrated their valuable roles as healthcare providers (HCPs). An abundance of evidence reveals that pharmacists’ interventions are associated with improved health and economic benefits, improved patient compliance and patient satisfaction, and reduced medication errors and adverse effects.
Defining Provider Status
Provider status is defined as the legal recognition of a healthcare professional eligible for patient care (cognitive) service reimbursement through Medicare Part B.1 In a recent publication in the Journal of the American Pharmacists Association, the authors noted that the term healthcare providers recognized in the Social Security Act currently includes physicians, physician assistants, nurse practitioners, certified nurse midwives, nurse anesthetists, clinical psychologists, physical and occupational therapists, registered dieticians/nutritionists, and social workers; however, pharmacists are not federally recognized HCPs, and consequently, pharmacists are not entitled to service reimbursements.1-3
Literature indicates that pharmacists are providers under Medicare Part D, permitting reimbursement when dispensing medications or providing MTM services, but not Part B.1 Additionally confusing the issue, state-level “provider status” has different implications from federal-level “provider status.”1 Literature also indicates that if federal provider status is approved for pharmacists, more patients will have access to essential healthcare services, resulting in decreased economic health burdens, and due to their drug expertise, pharmacists can make patient-centered clinical recommendations for physician-led care teams.1-3 As a result, reimbursement would offer more healthcare resources, which would expand access to provide essential healthcare in underserved patient populations.1-3
The federal Public Readiness and Emergency Preparedness (PREP) Act requested that pharmacists and pharmacy technicians be recognized as a component of the COVID-19 pandemic solution, even permitting pharmacists to prescribe approved COVID-19 therapeutics; however, federal reimbursement was only permissible for the dispensing of COVID-19 drugs and not for the clinical evaluation of ascertaining which patients met criteria for these therapies.1,4 Additionally, during the COVID-19 pandemic, the PREP Act clearly illustrated the positive impact of pharmacist involvement in patient care and their efforts in sustaining the delivery of quality patient care and improving clinical outcomes.1
While many states identify pharmacists as HCPs, pharmacists are not yet recognized as providers at the federal level, which thwarts reimbursements for pharmacists even though pharmacists provide numerous and essential direct-care patient services.1,2 Currently in the United States, nearly one-half of all the states legally acknowledge pharmacists as HCPs but not all allow for reimbursement.1
Many healthcare organizations, including the Academy of Managed Care Pharmacy (AMCP), the American Society of Health-System Pharmacists (ASHP), the American Pharmacists Association (APhA), and various state pharmacy organizations across the nation are working to support provider status for pharmacists.
The AMCP indicates that it “supports the recognition of pharmacists as providers under the Social Security Act. When pharmacists are recognized as provider members of the healthcare team, patient outcomes improve, and patients report higher rates of satisfaction while overall healthcare costs are reduced.”3 The AMCP notes that if pharmacists obtained provider status, this acknowledgment would enable them to be reimbursed under the Medicare Part B benefit for delivering essential healthcare services to patients.3 It indicates that identifying pharmacists as providers is past due and that obtaining provider status would permit pharmacists to effectively work with physicians and other HCPs to optimize medication therapy and deliver patient-centered care.3 Additionally, the AMCP states that through the delivery of direct patient-care services, pharmacists—in partnership with other HCPs—can offer continuing, comprehensive assessment and management of drug therapy that is individualized to the needs of the patient while also enhancing the quality of healthcare, improving patient access to care, yielding optimal clinical outcomes, and diminishing both patient and health system costs.3
According to the APhA, there is ample evidence that interventions and care from pharmacists are often associated with improved patient clinical outcomes and decreased healthcare costs and that obtaining provider status for pharmacists would expand access to healthcare for many underserved patient populations in need of healthcare.5
The ASHP also has ongoing efforts to support and advance provider status recognition for pharmacists under Medicare Part B.6 The ASHP indicates that provider status would provide Medicare patients with expanded access to healthcare services delivered by pharmacists, including testing for infectious diseases, ordering products employed for smoking cessation, and providing comprehensive medication management (CMM) services.6
Literature reveals that obtaining provider status for pharmacists on a federal level will necessitate a multifaceted effort from individuals and local, state, and national pharmacy organizations.1,7,8
Legislative Changes
On July 26, 2023, the Equitable Community Access to Pharmacist Services Act (S. 2477) was introduced and aims to establish Medicare Part B reimbursements for pharmacist-provided services, including testing for COVID-19, influenza, respiratory syncytial virus, and strep throat; the treatment of COVID-19, influenza, and strep throat; and administering vaccinations for COVID-19 and influenza.9
In May 2023, the ASHP and the APhA announced the Pharmacy and Medically Underserved Areas Enhancement Act (H.R. 2759/S. 1362). The bill seeks to enhance health outcomes and lower healthcare expenditures by giving Medicare beneficiaries living in medically underserved communities access to patient care services from their state-licensed pharmacist.10,11 The bill would enable pharmacists to deliver Medicare Part B services that are already authorized by their respective state laws. These services may include MTM, management of chronic conditions (including type 2 diabetes mellitus, hypertension, and related medications), testing for hyperlipidemia, point-of-care testing (e.g., COVID-19, strep, and influenza), immunization screening and administration not currently covered by Medicare Parts B and D, tobacco-cessation services, and transitions-of-care services.10,11
The following announcements regarding reimbursements for healthcare services provided by pharmacists were recently published on the ASHP website:
• On February 27, 2023, Wyoming Senate File 0009 was signed into law, authorizing reimbursement for services provided by pharmacists under Medicaid within their scope of practice, effective July 1, 2023.
• On March 23, 2023, Virginia Senate Bill (SB) 1538 was passed by the Virginia legislature and signed into law requiring Virginia Medicaid to reimburse pharmacists for any covered service provided under a collaborative agreement or statewide protocol.
• On March 29, 2023, the Maryland General Assembly passed SB 678—Reimbursement for Services Rendered by a Pharmacist. SB 678 requires both Medicaid and state-regulated commercial insurance plans to recognize pharmacists as providers and reimburse for all covered services within their scope of practice effective January 1, 2024. The governor signed it into law on May 3, 2023.
• Effective April 1, 2023, MO HealthNet—Missouri’s Medicaid program—allows pharmacists to receive reimbursement for any covered service that falls within their scope of practice. Pharmacist providers will apply the same billing codes and receive the same reimbursement as other practitioners.
• In April 2023, North Dakota passed House Bill 1095, which requires coverage for licensed pharmacists to provide CMM services. ASHP worked with the Get the Medications Right Institute (GTMRx) and the North Dakota Society of Health-System Pharmacists to testify in support of the legislation, which would ensure that patients have access to critical CMM.12
More information on these updates can be found on the ASHP website: https://news.ashp.org/news/ashp-news/2023/04/06/states-expand-pharmacist-provider-status-cmm.
In a recent publication, the authors indicated that the introduction of the Pharmacy and Medically Underserved Areas Enhancement Act (H.R. 2759 and S. 1362), if passed, would enable pharmacists to address the current primary care physician shortages and expand access to care and essential healthcare services to those in underserved areas.13
Preceding the extension amendment signed by the Secretary of the Department of Health and Human Services, the PREP Act was set to expire in May 2023, threatening the termination of many added pharmacist functions and, consequently, long-term sustainability for these pharmacy-led services; the PREP Act is now projected to expire in December 2024.1,14
According to the National Alliance of State Pharmacy Associations (NASPA), as of December 22, 2022, 178 bills pertaining to pharmacist scope of practice, payment for pharmacist-provided patient-care services, and/or the designation of pharmacists as providers were introduced in 38 states in the 2022 state legislative sessions.15 More information per state can be found on the NASPA website: https://naspa.us/resource/2022-provider-status-legislative-update/.
Recent Study and Survey Results
In a cross-sectional study published in the Journal of the American Medical Association Network Open involving Medicare beneficiaries who actively access healthcare services, researchers sought to assess the number of patient visits to community pharmacies and the number of visits with primary care physicians.16 The researchers discovered that patients are nearly twice as likely to visit pharmacists than their primary healthcare provider. As a result, the authors noted that pharmacists and primary care physicians should collaborate as multidisciplinary primary care teams to prevent and manage chronic disease.16
In a survey conducted in August 2022 by CVS Health/Morning Consult, findings revealed that among 2,210 adults, an estimated 61% of individuals surveyed would favor obtaining a wider range of healthcare services at their local pharmacy, and 74% of those surveyed stated that they trust their local pharmacist and agree that pharmacists should be able to step in when primary care is not accessible. An estimated 69% feel that pharmacists’ services should be covered by insurance companies, like other providers’ services.17
A Wolters Kluwer commissioned survey entitled “Pharmacy Next: Health Consumer Medication Trends” revealed that of the participants surveyed, 61% believe that pharmacies, retail clinics, or pharmacy clinics will provide most primary care in the next 5 years, and approximately 56% of participants would trust a pharmacist to prescribe them medications if it meant lower costs.18
In a 2023 report conducted by PioneerRx, a survey was conducted to obtain opinions about pharmacy professionals with regard to provider status. Findings revealed that 60% of pharmacists are “somewhat confident” they will receive provider status; 100% of pharmacists are comfortable with patient counseling and immunizations; 97% believe they are equipped for MTM and point-of-care testing; 95% feel equipped to prescribe medications; and 30% feel equipped to provide other healthcare services.19 Several additional findings are indicated in FIGURE 1.
In a 2022 poll by the National Association of Chain Drug Stores, 70% of those surveyed support extending policies that permit pharmacists to continue to provide clinical services allowed under the PREP Act, and 68% support making these policies permanent.20 Additionally, among those participants who received COVID-19 vaccines, including boosters from a local pharmacy, 85% and 84% support extending policies and making these policies permanent for pharmacist-provided clinical services, respectively.20 Poll participants also indicated that the extension of pharmacy-provided services would contribute to the following benefits: decreasing COVID-19 hospitalization rates and related deaths, health equity by expanding access to care, the convenience of routine vaccinations and testing, and providing patients with convenient access to other essential healthcare services.20
Conclusion
The valuable roles of the pharmacist in patient care cannot be overstated and continue to evolve across various spectrums of practice. The ACMP indicates that published literature provides noteworthy evidence of the clinical benefits gained when pharmacists are allowed to fully employ their drug expertise skills within clinical settings as part of the healthcare team and that pharmacists are integral in the delivery of patient education for the proper use of medications, disease management, and preventative care.3 Many organizations believe that granting pharmacists provider status will optimize patient care and enable them to work collaboratively with prescribers and other HCPs, while also providing patients with convenient access to essential healthcare services, including MTM, immunizations, patient counseling, and point-of-care testing for infectious diseases including COVID, influenza, and strep throat, which in turn may result in improving patient outcomes and reducing healthcare costs. Ongoing efforts to grant provider status on a federal level for pharmacists continue to be a top priority for many pharmacists and pharmacy organizations, and hopefully, these efforts will soon come to fruition so that patients across the nation will benefit from the indispensable healthcare services provided by pharmacists every day.
REFERENCES
1. Ali US, Hale GM, Santibañez M, et al. Is now our time? History to provider status for allied health professions and the path for pharmacists. J Am Pharm Assoc. 2023;21:S1544-3191(23)00246-7.
2. Evans A. Yes, pharmacists are healthcare providers. GoodRx. August 16, 2022. www.goodrx.com/hcp/providers/yes-pharmacists-are-healthcare-providers. Accessed July 25, 2023.
3. Academy of Managed Care Pharmacy. Provider status for pharmacists. February 2022. www.amcp.org/policy-advocacy/policy-advocacy-focus-areas/where-we-stand-position-statements/provider-status-for-pharmacists. Accessed September 11, 2023.
4. U.S. Department of Health & Human Services. Public Readiness and Emergency Preparedness (PREP) Act. https://aspr.hhs.gov/legal/PREPact/Pages/default.aspx. Accessed July 31, 2023.
5. American Pharmacists Association. Pharmacy’s top priority: Medicare provider status recognition. www.pharmacist.com/Advocacy/Issues/Medicare-Provider-Status-Recognition. Accessed September 11, 2023.
6. American Society of Health-System Pharmacists. Provider status. www.ashp.org/advocacy-and-issues/provider-status. Accessed September 11, 2023.
7. Abramowitz PW. Achieving provider status for pharmacists. Am J Health Syst Pharm. 2013;70(3):184.
8. O’Brien JM. How nurse practitioners obtained provider status: lessons for pharmacists. Am J Health Syst Pharm. 2003;60(22):2301-2307.
9. American Society of Health-System Pharmacists. ASHP applauds senate introduction of equitable community access to Pharmacist Services Act. July 26, 2023. https://news.ashp.org/News/ashp-news/2023/07/26/ASHP-Applauds-Senate-Introduction-of-Equitable-Community-Access-to-Pharmacist-Services-Act. Accessed July 31, 2023.
10. American Pharmacists Association. The Pharmacy and Medically Underserved Areas Enhancement Act, H.R. 2759/S. 1362. https://www.pharmacist.com/Advocacy/Issues/Medicare-Provider-Status-Recognition/Medicare-Provider-Status-Recognition-Fast-Facts. Accessed September 11, 2023.
11. American Society of Health-System Pharmacists. Pharmacist groups applaud introduction of bill expanding Medicare patients’ access to pharmacist services. May 11, 2023. https://news.ashp.org/news/ashp-news/2023/05/10/pharmacist-groups-applaud-bill-expanding-medicare-patients-access-to-pharmacist-services. Accessed June 27, 2023.
12. American Society of Health-System Pharmacists. States expand pharmacist provider status CMM. April 6, 2023. https://news.ashp.org/news/ashp-news/2023/04/06/states-expand-pharmacist-provider-status-cmm. Accessed July 31, 2023.
13. Perez K. Provider status would enable retail clinics to help fill the void in seniors’ access to patient care. EnlivenHealth. www.enlivenhealth.co/blog/provider-status-would-enable-retail-clinics-to-help-fill-the-void-in-seniors-access-to-patient-care/. Accessed September 11, 2023.
14. U.S. Department of Health and Human Services. Public Readiness and Emergency Preparedness (PREP) Act. May 9, 2023. https://aspr.hhs.gov/legal/PREPact/Pages/default.aspx. Accessed July 27, 2023.
15. National Alliance of State Pharmacy Associations. 2022 Provider status end-of-year legislative update. December 22, 2022. www.naspa.us/resource/2022-provider-status-legislative-update/. Accessed July 31, 2023.
16. Berenbrok LA, Gabriel N, Coley KC, et al. Evaluation of frequency of encounters with primary care physicians vs visits to community pharmacies among Medicare beneficiaries. JAMA Netw Open. 2020;3(7):e209132.
17. Minemyer P. 2023 Forecast: pharmacists push to take on a greater role in patient care. Fierce Healthcare. December 21, 2022. www.fiercehealthcare.com/retail/2023-forecast-pharmacists-push-take-greater-role-patient-care. Accessed July 28, 2023.
18. McCoy S. Safety, access, and affordability: how the pharmacist role is shifting. Wolters Kluwer. February 16, 2023. www.wolterskluwer.com/en/expert-insights/safety-access-and-affordability-how-the-pharmacist-role-is-shifting. Accessed July 31, 2023.
19. PioneerRx. Should pharmacists get provider status? [2023 Report]. January 3, 2023. www.pioneerrx.com/blog/should-pharmacists-get-provider-status-2023-report. Accessed July 31, 2023.
20. National Association of Chain Drug Stores. NACDS releases poll: 70% of adults back extension of policies giving access to pharmacies’ pandemic services. March 11, 2022. www.nacds.org/news/nacds-releases-poll-70-of-adults-back-extension-of-policies-giving-access-to-pharmacies-pandemic-services/. Accessed July 27, 2023.
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