In recent years, legislative reforms have been introduced that recognize pharmacists as reimbursement-eligible providers under government-funded health care programs. While these efforts have attracted significant media and academic attention, until recently, the provider status movement has resulted only in incremental and localized gains. Most of the new reimbursement opportunities at the state level have been fairly limited in scope, and there is significant variation among state laws. Nonetheless, significant breakthroughs in the last two years have been made with the passage of landmark provider status legislation in California, Oregon, and Washington. Industry observers are taking note of whether these developments will translate into real-world gains for the pharmacist profession that will meaningfully impact health care delivery. Success in these states could bolster the movement to promote pharmacist provider status across the remaining states and serve as the tipping point for reform at the federal level.
On January 1, 2014, groundbreaking legislation was implemented in California (SB 493) that recognizes pharmacists as providers and creates a new classification of Advanced Practice Pharmacists (“APP”) with enhanced patient care authorities.[1] While the law does not directly address payment, it fosters new reimbursement and collaborative care opportunities by expanding pharmacists’ scope of practice and permitting pharmacists to contract with health systems, third-party payers, and collaborative delivery models. Thus, the law, which is being implemented in stages through administrative and regulatory processes, establishes a framework that is designed to elevate the role of pharmacists in health care delivery. Earlier this year, the California Board of Pharmacy released a protocol outlining the parameters of pharmacists’ expanded prescriptive authorities for certain medicine types that will go into effect this fall.
Due to the size of its economy and population, California has been regarded as a model for states considering pharmacist provider status legislation. In May 2015, Washington State passed pharmacist provider status legislation (SB 5557) that closely follows and even surpasses the California precedent.[2] The new law not only designates pharmacists as reimbursement-eligible providers, but even mandates that commercial health insurance plans include a sufficient number of pharmacists in their networks of participating providers. The law was designed to facilitate coordination among pharmacists, physicians, and other providers to advance a team-based approach to patient care that is essential to collaborative care models envisioned by the Affordable Care Act. A multidisciplinary advisory group of insurers and providers is overseeing the bill’s implementation and the drafting of provider accreditation policies. These reforms, which will go into effect more broadly in 2017, will impact hospital systems and clinics as early as next year.
Following close upon the heels of its neighboring states, Oregon passed provider status legislation (HB 2028) in June 2015 that permits pharmacists to obtain reimbursement for performing clinical pharmacy services, such as chronic disease and medication therapy management.[3] Additionally, the law broadens the ability of pharmacists to participate in collaborative care arrangements, which had previously been restricted to agreements between single pharmacists and physicians. Like the California model, the Oregon law creates a framework for subsequent reforms by broadly defining the scope of “clinical pharmacy services” and permitting the state Board of Pharmacy to work with the Oregon Health Authority to establish protocols for clinical service programs that will involve pharmacist participation.
Key to the legislative success in California, Oregon, and Washington was the participation of a diverse range of stakeholders, including pharmacists, academics, patient advocates, and insurance carriers, who collaborated in drafting the bills’ language and in coordinating lobbying support. These efforts were critical to gaining support—or at least neutralizing opposition—from physician groups and cost-conscious lawmakers. As awareness of pharmacists’ cost-saving potential and role in health care delivery spreads, stakeholders are beginning to view pharmacists as critical to promoting primary care and collaborative care models.
With the growing momentum behind provider status legislation at the state level, reformers are increasingly focused upon attaining provider status under federal health care programs. Federal provider status has been a focal point of the pharmacist profession’s aspirations and is increasingly regarded as important to the success of collaborative care models. In 2014, pharmacy groups rallied behind a bipartisan bill that would grant Medicare Part B coverage for state-authorized pharmacist services performed in medically underserved areas.[4] After this initial legislation failed, in January 2015, reformers renewed their efforts by introducing companion bills in the U.S. House and Senate that would permit coverage for Medicare Part B services provided by pharmacists in medically underserved communities.[5] Although these bills have stalled in congressional committees, they have garnered unprecedented bipartisan support and media attention, which could serve as a foundation for further legislative efforts. In the meantime, industry observers are eagerly watching to see if the legislative enactments in California, Oregon, and Washington will produce real-world progress, which, in turn, will further encourage substantive reforms at the federal level.
ENDNOTES
[1] The text of SB 493 is available at http://leginfo.legislature.ca.gov/faces/billTextClient.xhtml?bill_id=201320140SB493.
[2] The text of SB 5557 is available at http://app.leg.wa.gov/billinfo/summary.aspx?bill=5557.
[3] The text of HB 2028 is available at https://olis.leg.state.or.us/liz/2015R1/Measures/Overview/HB2028.
[4] H.R. 4190, 113th Cong. (2014), available at https://www.congress.gov/bill/113th-congress/house-bill/4190.
[5] See S. 314, 114th Cong. (2015), available at https://www.congress.gov/bill/114th-congress/senate-bill/314, and H.R. 592, 114th Cong. (2015), available at https://www.congress.gov/bill/114th-congress/house-bill/592/all-info.
