PHARMACISTS IN CALIFORNIA have been on the cutting edge of practice for more than 20 years. Through collaborative practice agreements and progressive employment contracts, they have provided direct patient care and counseling, managed multi-drug medication regimens, participated in discharge planning and follow-up, and become integral members of multidisciplinary care teams.
In essence, they have been health care providers in all but official status. Now, with the October passage of S.B. 493, pharmacists have won legal, if long-overdue, recognition as health care providers. The legislation, authored by state Sen. Ed Hernandez, also provides for the creation of a new category of pharmacists in California, the Advanced Practice Pharmacist (APP), and expands authority for pharmacists in several areas crucial to public health.
“The idea behind this legislation is that pharmacists are perfectly educated and trained to provide [direct patient care] services. Until now the law did not keep pace with the changing nature of the profession,” said Jonathan Nelson, government affairs and special projects manager at the California Society of Health-System Pharmacists (CSHP). The ASHP state affiliate partnered with the California Pharmacists’ Association to lead a grassroots effort in support of the law.
By recognizing pharmacists as providers, the new law allows payers such as Medi-Cal (California’s Medicaid program) and private insurance companies to compensate pharmacists for their services. Although compensation is not mandatory, the legislation removes the barrier presented by a lack of official status.
“Basically, we’re not prohibited from billing anymore,” said Candis M. Morello, Pharm.D., CDE, FCSHP, FASHP, associate professor of clinical pharmacy and associate dean for student affairs at the University of California, San Diego, Skaggs School of Pharmacy and Pharmaceutical Sciences.
“This is a gigantic step for us,” she said. “Medicare doesn’t identify us as providers. Insurers, who want to pay the least amount they can, fell back on that. But now we have a platform to say we’ve been recognized and that these are the expanded skills we can provide.”
Morello added that there is plenty of evidence in the literature to demonstrate the positive impact pharmacists have on outcomes, and, therefore, justify compensation. Indeed, that evidence was instrumental in garnering support for the bill in the legislature and deflating counterarguments from groups such as the California Medical Association (CMA), which initially opposed the bill.
“Physicians expressed concern about patient safety since providers would not be supervised by physicians. But when we pointed out that pharmacists were already doing [patient care] activities, the CMA stopped outwardly opposing this legislation,” said Dawn Benton, MBA, CSHP’s executive vice president and chief executive officer.
Benton added that timing was everything, given that roughly 7 million Californians are about to enter the health system as a result of the Affordable Care Act, and service is already stretched thin by a shortage of primary care physicians. Other physicians’ organizations, such as the California Association of Physician Groups, were on board from the start, recognizing that pharmacists could help alleviate the upcoming care crunch.
The legislation grants all pharmacists in California with relevant training the authority to furnish hormonal contraceptives, prescription nicotine replacement products, and, following guidelines by the Centers for Disease Control and Prevention, travel medications. Pharmacists may also order tests related to managing a patient’s medication regimen. However, pharmacists are not required to provide these services.
“This increased scope of care is permissive, but not mandatory,” said Steven Gray, Pharm.D., president of CSHP. “Pharmacists do not have to offer these services if they don’t feel qualified.”
The new law also provides for the establishment of the APP designation. Pharmacists who seek recognition as an APP will have to meet two of three criteria: certification in an area of clinical practice (ambulatory care, critical care, oncology, etc.), completion of a pharmacy residency where at least 50 percent of the experience includes providing direct patient care, and one year of providing clinical services to patients under a collaborative practice agreement or protocol.
These pharmacists will be able to perform physical assessments; order and interpret tests related to drug therapy; refer patients to other health care providers; initiate, adjust, and discontinue drug therapies; and evaluate and manage diseases and health conditions in collaboration with other care providers.
Provider status, expanded authorities, and the APP designation will combine to offer pharmacists in California a plethora of opportunities, said Gray. “They will be able to work in different environments, including private practice in the medical home, ambulatory care, and collaborative group practices with other clinicians.”
Pharmacists who stay in the hospital or health-system setting will see changes to their practice as well. For example, at Kaiser Permanente, dispensing pharmacists will be able to take a more active role in medication management. “If they think there is a problem with adherence, they will be able to order tests to monitor medication therapy, then recommend adjustments based on the results,” said Gray, who is also a pharmacy professional affairs leader for Kaiser.
“The new legislation could also drive up demand for pharmacy specialties,” added Nelson, noting that certification in a specialty is one of the three criteria pharmacists may meet for the APP designation.
Ryan J. Gates, Pharm.D., CGP, CDE, residency coordinator and senior clinical pharmacist at Kern Medical Center and adjunct assistant professor of pharmacy practice at the University of Southern California and the University of the Pacific, said the legislation will enable pharmacists to partner with managed care companies for the betterment of public health.
“We’ll be able to provide medication therapy management services, transitions of care, geriatric care, pediatric care, and so on. We can partner with companies that are struggling to meet the demands for care, such as immunizations for children.”
A Plan for the Future
California is the third state to establish an advanced practice designation, behind New Mexico and North Carolina. Montana and Washington State also recognize pharmacists as health care providers. California is also the largest state, by far, to recognize pharmacists as providers.
“This shows other states that this is not an insurmountable issue,” said Nicholas Gentile, ASHP’s director of state grassroots advocacy and political action. “California can serve as a model for other states in terms of moving provider status forward. They’re really given new life to these efforts across the U.S.”
Brian Meyer, ASHP’s director of government affairs, noted that the legislation was passed within a year of being introduced.
“This was pretty fast-tracked. Every state has its own dynamic process and timetable, so our recommendation to members is to not get discouraged,” he said, adding that “a lot was done behind the scenes to educate other clinicians and providers and help make it happen.”
Gates offered tips for pharmacists in other states. “The state pharmacy organizations need to identify pharmacists who are practicing in their state as providers, usually in managed care systems or Veterans Affairs systems, and start promoting them. Get them some awards and build awareness of what they do as providers,” he said. “Start the dialog in the public sector as much as possible so that when it comes up in the legislature, it’s not coming from Mars.”
He added that the need for pharmacists to collaborate with other clinicians and legislators could not be overstated. “Find physicians who can testify before your state senate and assembly, and get behind candidates and representatives who would be favorable to sponsoring a bill,” Gates said.
ASHP is currently developing provider status toolkits for other states, said Gentile. “The toolkits will provide what they need to do and what good legislation looks like.”
From there, the goal is federal recognition as Medicare Part B providers under the Social Security Act, Gentile said. “Efforts by the states will serve as great models and strong evidence of the need for provider status at the federal level.”
—By Terri D’Arrigo