The Daniel K. Inouye College of Pharmacy Scripts

Background

Pharmacists are authorized to enter into collaborative practice agreements with physician providers in 47 states and the District of Columbia.¹ Such agreements expand conventional pharmacy services to provide pharmacists with the ability to initiate, monitor, and modify patients' chronic drug therapies. Of these, 31 states allow pharmacists to order and interpret lab tests. Models of care include pharmacists' involvement within a team care approach with patient care rounds prior to and during a patient's visit, with follow up directed to each discipline's area for separate patient follow up if needed.

Hawai‘i is one state that authorizes collaborative practice agreements between pharmacists and physician providers. The current collaborative practice agreement between the Daniel K. Inouye College of Pharmacy (DKICP) University of Hawai‘i at Hilo and several ambulatory clinics such as Hawai'i Island Family Health Clinic (HIFHC), Bay Clinic (Keeau, Hawai‘i), Lau Ola Clinic (John A. Burns School of Medicine [JABSOM], Dept. of Native Hawaiian Health, Honolulu, HI), and Mililani Physicians Clinic, (JABSOM, Dept. of Family Medicine, Mililani, Hawai‘i) allows clinical pharmacy faculty to work in tandem with other providers, including physicians, medical residents, psychologists, and nurse practitioners. This team approach provides health care education to each discipline's learners as well as direct patient care. Under this agreement, the clinical pharmacist manages a patient panel and is able to manage ongoing medication management associated with chronic conditions, in particular, diabetes, hypertension, hyperlipidemia, heart failure, depression, and anticoagulation. Common pharmacotherapeutic interventions would include initiating, titrating or discontinuing medications, ordering monitoring labs, suggesting appropriate referrals, and conducting physical assessment as necessary.^2–4

All parties involved in the collaborative practice agreement benefit. Patients continue to be cared for, often allowing for greater time spent on medication issues; the students are educated; and the team works in unison allowing physicians more time to focus on important acute patient concerns and ailments. Dr. Kristine McCoy, Program Director for the Hawai‘i Island Family Medicine Residency at HIFHC states, “I've had the benefit of practicing alongside pharmacist clinicians for the past eight years. Through this collaboration, my patients have received expert and detailed care in the areas of anticoagulation and management of their chronic metabolic conditions. As a result, my patients have better understood not just their medications, but their underlying conditions and how medicines, diet, and lifestyle interventions can improve and lengthen their lives. The other benefit to my patients is the opening up of my clinical schedule to address other medical problems. Without the partnership, my schedule would be bogged down with chronic disease management and my patients would likely have to go to Urgent Care for acute issues. In my previous practice in New Mexico, this collaboration was sustainable.”

Although this appears to be a strong model for optimizing patient care, there remains the issue of reimbursement for the pharmacists' services. Pharmacy appointments are usually 40 minutes with significant time devoted to patient education and medication reconciliation, services that are reimbursed, on average, $21/visit from Medicare by billing under the procedural terminology code (CPT) 99211; a level-I established patient encounter.⁵ When assessing national estimates by occupation, the usual hourly rate of pharmacists averages $57/hour; regardless of time spent with the patient or level of skill or knowledge required during the encounter.⁶ As a result of these reimbursement rates by insurance companies in this setting, it is difficult for many physician practices to budget a pharmacy position despite the positive patient-related outcomes and cost-savings demonstrated. According to Dr. McCoy, “As billable providers, my pharmacist colleagues earn their keep financially and not just in terms of patient outcomes. In Hawai‘i, we have been subsidizing our partnership as an academic enterprise, but unfortunately the model is not available to those in commercial practice. Provider status with concurrent reimbursement for ambulatory care pharmacists will change this, opening up the benefits to patients across the state, and helping to make primary care a more attractive career option for physicians and other health professionals who value an interdisciplinary approach.”

Why Pharmacists have not been Recognized as Providers

The problem lies within the Social Security Act (SSA) wherein all healthcare providers including physicians, physician assistants, nurse practitioners, psychologists, clinical social workers, nurse midwives, nurse anesthetists, and dieticians are considered “providers” of medical care, with the exception of pharmacists. Due to this omission from the SSA, Medicare does not pay for services rendered by clinical pharmacists. The exception to this is when pharmacists conduct specific services such as medication therapy management as part of Part D benefits to patients or provide services as a certified diabetes educator within accredited diabetes education programs. However, this service is not relegated by third party payers as pharmacist-specific; technically any qualified health care provider may fulfill these services. Concurrently, private and state insurers including those in Hawai‘i, like the Hawai‘i Medical Service Association (HMSA), University Health Alliance (UHA), and Hawai‘i Medical Assurance Association (HMAA), have followed suit, citing omission of Medicare Part B as a reason of lack of compensation for those pharmacists providing patient-centered care.⁷

Changes on the Way: Leading the Way in Other States and a National Bill

Pharmacist provider status is currently maintained at the state level within the scope of pharmacy practice law. In 2013, California passed SB 493, declaring pharmacists health care providers who have authority to provide health care services.⁸ This law authorizes all licensed pharmacists in California to administer medications when ordered by a prescriber, provide consultation, training, and education on drug therapy, disease state management, and disease prevention, participate in multidisciplinary review of patient progress with appropriate access to medical records, provide self-administered hormonal contraceptives, travel medications not requiring a diagnosis, and prescription nicotine replacement products for smoking cessation. Pharmacists in California may also independently initiate and administer immunizations to patients three years of age and older and interpret tests to monitor and manage efficacy and toxicity of drug therapies in conjunction with the patient's prescriber.

In addition, SB 493 also established a new “Advanced Practice Pharmacist” (APP) recognition. Those pharmacists meeting the APP designation may perform patient assessments, order and interpret drug-therapy related tests in conjunction with the patient's prescriber, refer to other healthcare providers, and initiate, adjust, and discontinue drug therapy in accordance to established protocols and pursuant to a prescriber's orders in collaboration with other health care providers. Attaining APP recognition is contingent upon earning certification in a relevant area of practice (ambulatory care, critical care, oncology pharmacy, or general pharmacotherapy), completion of a postgraduate residency program, and having provided clinical services to patients for one year under a collaborative practice agreement or protocol with a physician.

There is major movement at the federal level to secure provider status for pharmacists. The Pharmacy and Medically Underserved Areas Enhancement Act (H.R. 592/S. 314) is one such piece of legislation that has recently been introduced to increase accessibility and quality of care by enabling pharmacists to provide care consistent with their education, training, and license as governed by the state pharmacy board. If passed, this bill will amend the SSA, thus allowing pharmacist-provided services to be reimbursable under Medicare Part B in medically underserved communities.⁹ These communities meet the criteria set by the Health Resources and Services Administration (HRSA) and include regions where residents have a shortage of personal health services (medically underserved areas), groups of persons who face economic, cultural, or linguistic barriers to health care (medically underserved populations), and health professional shortage areas where there is a lack of primary care, dental, or mental health providers.¹⁰

Healthcare Benefits

The benefits of pharmacists being recognized as providers can be seen nationally as well as locally here in Hawai‘i. With the implementation of the Patient Protection and Affordable Care Act, it is projected that an extra 25 million people will enter the healthcare system annually from the years 2016 through 2024.¹¹ By 2025, it is estimated the United States will have a shortage of between 46,000–90,0000 physicians in both primary and specialty care. ¹² As the shortage widens, the need for medical care in underserved communities will also rise. H.R. 592/S. 314 addresses the provider shortages and increases accessibility to care from other types of health care professionals, namely pharmacists in these underserved areas.

All five Hawai‘i counties are considered medically underserved with a shortage of 600 physicians statewide and 174 physicians in Hawai‘i county itself.¹³ There are more than 1200 licensed pharmacists in Hawai‘i at present.¹⁴ These pharmacists could help to fill a niche to decrease the shortage of health care providers and to widen the bridge of opportunities for further reimbursement for National Committee for Quality Assurance (NCQA)-driven payments and Accountable Care Organization (ACO) changes.

Pharmacists can contribute to meeting the NCQA Patient-Centered Medical Home (PCMH) standards within this changing healthcare landscape. Involvement can be met particularly with the Healthcare Effectiveness Data and Information Set (HE-DIS); these measures are used to ensure performance of quality healthcare.15 For example, ambulatory-based pharmacists may be tasked with ensuring pharmacotherapy management of chronic obstructive pulmonary disease exacerbation, use of appropriate medications and medication management for people with asthma, initiation of beta-blocker therapy after a heart attack, chronic diabetes, hypertension and cholesterol management. As members of the healthcare team, pharmacists can meet the access-to-care measure for preventative and ambulatory care services.

Financial Benefits

By increasing access to care, the bill promotes healthcare that is cost-effective by increasing the likelihood of early interventions, preventing medication-related morbidity and mortality, improving medication adherence, and improving patient satisfaction. Pharmacists have had provider status within the federal system since 1995 under the VHA 10-95-019 directive. Since then, there have been multiple studies documenting the cost-effectiveness of the services provided by clinical pharmacists. One such study looking at the first 600 recommendations made by clinical pharmacists over one year estimated a mean total cost avoidance of $420,155.¹⁶ Furthermore, in 90% of the cases, patient harm was avoided due to pharmacist intervention. The Asheville Project, conducted over a period of six years, demonstrated both the clinical and economical benefits of pharmacists conducting medication therapy management and providing education for patients with diabetes, hypertension, dyslipidemia, and asthma by improving disease outcomes and decreasing medical costs and hospital/emergency department visits.^17–19

Under national bill H.R. 592/S. 314 pharmacist services would be reimbursed at 85% of the physician fee schedule as consistent with the precedent that is currently maintained by the SSA for nurse practitioners and physician assistants. If the pharmacist provides clinical duties under the direct supervision of a physician, the pharmacist will be reimbursed at 100% of the physician fee schedule.

Skeptics may wonder why pharmacists are concerned with provider status when fee-for-service payment models are fading away. As pharmacists, we firmly believe we are members of the multidisciplinary health care team working collaboratively for improved patient outcomes. As mentioned above, pharmacists can contribute to achieving ACO accreditation and PCMH recognition as required by NCQA, thus increasing physician pay-for-performance as aligned with quality measures. However, even as these new health care models emerge, the SSA still remains the reference point for which practitioners are eligible for compensation.

Conclusion

Although pharmacists have not been formally recognized as medical providers on the health care team, there is current legislation at the national level moving towards achieving this designation. Pharmacist's provider status will provide: (1) physicians more time to focus on patients' complex medical issues; (2) increase patients' access to care, improve quality of care, and decrease costs; and (3) decrease health care systems' long-term expenditure, while recognizing and reimbursing pharmacists working at the top of their degree.