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Provider Status Coming to Medically Underserved Areas?

Mar 19, 2014

A BILL INTRODUCED in the House of Representatives on March 11 would allow the Medicare program to reimburse pharmacists for pharmacist services in medically underserved communities.

According to the Rural Assistance Center, medically underserved areas occur in almost every state in the country. H.R. 4190 would offer provider status in those areas and areas which experience health care provider workforce shortages.

According to the Rural Assistance Center, medically underserved areas occur in almost every state in the country. H.R. 4190 would authorize Medicare payments to pharmacists who offer pharmacists’ services in those areas.

The Medicare program, which provides health insurance for the disabled and persons 65 years of age or older, currently does not provide a mechanism to directly reimburse pharmacists for their services.

Representatives Brett Guthrie (R-Kentucky), G.K. Butterfield (D-North Carolina), and Todd Young (R-Indiana) jointly stated that their “common-sense bill” creates a means by which pharmacists can receive reimbursement for providing services permitted by state law to Medicare beneficiaries in medically underserved areas.

All three congressmen represent districts in which more than half the counties have been federally designated as medically underserved areas.

Pharmacotherapy Specialist Tim R. Brown cares for patients in a medically underserved area, Summit Service Area, commonly known as Akron, Ohio.

“This particular bill becoming a law would allow me to stand on my own as a provider—still working with that same physician and still working ‘incident to’ but being recognized as someone that’s a part of the team,” he said. “And that would be a huge step.”

Brown, who practices at Akron General Medical Center’s Center for Family Medicine, said he currently bills his chronic disease state management services under a collaborating physician’s name as incident to physician professional services in the physician’s office.

He estimated his payer mix as 60 percent Medicare and 40 percent private pay.

Ohio has allowed such pharmacist–physician–patient collaborative practice agreements since 1999.

Studies show that patients in all settings clearly benefit from the medication expertise of pharmacists.

The bill, if enacted into law, would also strengthen the health care team, Brown said.

“By giving provider status to pharmacists,” he said, “that [bill] strengthens our role as a part of the patient-centered medical home model team that many people are working within currently.”

Sandra Leal, director of clinical pharmacy at El Rio Community Health Center in Tucson, Arizona, cares for patients in the medically underserved Pima Service Area.

In fact, the health center targets the medically underserved population, she said.

Although El Rio has what Leal described as a good mix of payers, she lamented that the center does not receive compensation for some of the services the pharmacists provide patients. Or, if the center does receive compensation, the amount represents a level of service lower than what was actually provided to the patient.

For example, when Leal and other El Rio pharmacists manage the diabetes therapy of a patient with Medicare Part B coverage, “we have to override our level of care to a lower code because we’re not recognized for the full service that we provide.”

She said compensation for the actual service level the pharmacists provide would help the center’s clinical pharmacy program become more sustainable and widespread.

“There’s a significant demand for patient visits, for access,” Leal said. “We had a lot of people that joined the health care system [in 2014] with new insurance. And right now we have pharmacists at some of our sites but not all of the different satellites.”

The primary reason, she said, is lack of a means to permanently finance the full-time-equivalent positions. El Rio applies for and receives grants and funds, but those have end dates.

“I’m glad to see some new legislation out there” to recognize pharmacists as providers, Leal said.

This [bill] is a really great opportunity to give patients the access they deserve.

Although Gloria P. Sachdev, in her current position, does not work with a medically underserved population, she expressed support for the legislation.

Having “provider status” in Medicare Part B is “critically important to our sustainable business model” for clinical pharmacist services in ambulatory care settings, said Sachdev, a clinical assistant professor at the Purdue University College of Pharmacy.

“I’ll certainly be contacting my congressman and my senators . . . to support this bill,” she said, adding that she is “just waiting for someone to say, Do it” and also for the exact language of the bill to be available.

The bill by Guthrie is modeled after the concepts advocated by the Patient Access to Pharmacists’ Care Coalition, in which ASHP plays a “significant leadership role,” said Kasey K. Thompson, the Society’s vice president for policy, planning, and communications.

“This [bill] is a really great opportunity to give patients the access they deserve” to pharmacist-provided patient care services, he said.

By amending the portion of the Social Security Act concerning the Medicare program, Thompson said, the bill would allow pharmacists to bill for Medicare Part B practitioner services.

The type and scope of those services remain under the purview of the state in which a pharmacist provides them, he said.

Guthrie’s bill pertains to all state-licensed pharmacists, Thompson said, and ASHP and the coalition support that position—all pharmacists are providers.

–By Cheryl A. Thompson, reprinted with permission from the ASHP News Center (first published March 14, 2014)

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