EXPERT BLOG: Provider status for pharmacists — one way or another

You may have heard the good news: through proactive involvement from pharmacists all across the state, California recently passed a law (SB 493 in October, 2013) declaring that pharmacists are healthcare providers who have the authority to provide healthcare services within the state. The law creates a new category of pharmacists by statute, for those who meet the criteria, and as a result creates new opportunities for pharmacists to engage with others more traditionally understood as healthcare providers (physicians, hospitals, clinics and health plans) to assist patients in managing chronic conditions. For more information on the statute and the expected impact of the change, click on the following link provided by the California Pharmacists Association.

All of us understand at some level the significance of what happened in California. But as is often the case, such a law creates a new series of questions. Will this action in California springboard other states to pass similar laws in 2014 and beyond? When will reimbursement opportunities for pharmacists as providers follow the statutes defining them as such? Will the Office of the National Coordinator (ONC) follow suit in later stages of Meaningful Use and recognize pharmacists with provider status? And will reimbursement opportunities follow in later stages of Meaningful Use for pharmacists as a result? These questions are difficult to answer and certainly more difficult to put a timeline on as to when they may happen.

Even if we don’t have the answers to the questions above right now, are there other ways in which we can see pharmacists gaining a greater foothold with provider status across the country? What about seeing examples of reimbursement model changes for pharmacists acting as providers?

As we know, health reform’s “grand experiment” is underway as a result of passage of the Affordable Care Act. And although pharmacists aren’t mentioned specifically as a provider participant within many of the Pioneer ACO models today, this doesn’t mean pharmacists won’t be permitted to integrate in the future or to create a plan for participation in these ACO models. Moreover, this doesn’t preclude pharmacists from the opportunity to be involved with other care coordination models sponsored by the CMS Innovation Center Award Program.

For example, there is a specific model in Hawaii that by design integrates outpatient pharmacists with the inpatient healthcare team (including hospital pharmacists). The model is titled, “Pharm2Pharm” and provides a new context for the community pharmacist to participate as a provider. The goal of the project is to reduce annual medication-related hospitalizations and emergency department visit rates and total cost of care among the elderly and others at risk in rural Hawaii.

This model works by creating a formal hospital pharmacist-to-community pharmacist collaboration. It is designed to address gaps in care among patients at risk as they transition from a hospital to a community setting. In other words, the patient is formally “handed off” to the certified community pharmacist by the hospital pharmacist at discharge to perform similar services in the outpatient setting (medication reconciliation, patient counseling, proactive PCP collaboration) as were performed in the hospital setting. According to information provided by the program, Pharm2Pharm pays community pharmacists $695 per patient enrolled per year on the assumption that there will be ROI to CMS (the award also funds the hospital pharmacists). For further information on Pharm2Pharm, please click here, here, and here.

It seems the industry as whole will likely continue pushing for formal pharmacist provider status changes at the federal and state level via statute. We all know healthcare is changing.  It makes financial sense for all the providers across the spectrum to continue experimenting with ways in which they may work together to help improve patient outcomes and reduce costs.  Ignoring any provider in the new healthcare continuum may ultimately be counterproductive in obtaining the ultimate trifecta: better outcomes, reduced costs and increased reimbursements.

As Director of Business Development with Pharmacy Services for Emdeon, Nathan Ludvigson directs policy and business development for Pharmacy Services related to electronic prescribing, Health Information Exchange (HIE), Medication Therapy Management (MTM), Prescription Monitoring Programs (PMP), Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS), and other pharmacy services areas. Nathan also identifies, analyzes and makes recommendations regarding key legislative issues and regulatory matters impacting the pharmacy industry as needed with the pharmacy services executive team. Nathan combines extensive pharmacy industry experience with legislative policy experience in both the U.S. Congress and Texas Senate. Nathan earned his Bachelor of Science degree in Political Science from Texas Christian University and a Master’s Degree in Public Administration from the University of Houston.