American College of Clinical Pharmacy
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ACCP Report - January 2018

President's Column: Provider Status — Still Relevant in Value-Based Care?

Written by Jill M. Kolesar, Pharm.D., M.S., FCCP, BCPS


Many state and national pharmacy organizations are pursuing legislative initiatives designed to advance pharmacist practice and improve the health of patients. Among the most prominent of these initiatives are disease state management protocols, comprehensive medication management (CMM), and provider status. Given the time and resources required to achieve legislative and regulatory change, organizations like ACCP must be selective about which initiatives they pursue, prioritizing those they believe will have the most impact.

Kentucky recently joined California and a few other states in expanding the pharmacist scope of practice to make pharmacists active participants in the care of their patients. New regulations now allow pharmacists to prescribe in collaboration with physicians using approved protocols for patients with a wide range of conditions, including acute infections, tobacco cessation, and opioid use disorder.

Extending beyond these disease state management protocols, CMM provides direct patient care services focused on addressing medication-related issues. When provided by qualified clinical pharmacists working as members of the patient's health care team, CMM can improve patient outcomes through medication optimization. ACCP believes that to deliver better care, reduce cost, and achieve healthier people and communities, it is vital to establish a truly team-based, patient-centered approach in delivering CMM within evolving delivery and payment models.

ACCP is currently engaged in many efforts to advance CMM, including an initiative advocating amendment of Medicare Part B to cover CMM (https://www.accp.com/govt/medicare.aspx), an ongoing College-funded study led by ACCP members Drs. Mary Roth McClurg and Todd Sorensen to enhance primary care medical practice through CMM (see https://www.accp.com/report/index.aspx?iss=1217&art=4), and an educational forum during next month's ACCP Updates in Therapeutics® meeting in Jacksonville, Florida. The forum (ACCP's Patient-Centered Team-Based Practice Forum) will allow attendees to identify how the CMM patient care process can be applied in different clinical settings and how various CMM practice management components can guide clinical pharmacy practice growth and improvement. For further information and registration details, visit https://www.accp.com/UT18PF.

In the past decade, the pharmacy profession has pursued "provider status" for pharmacists - seeking to include pharmacists in the Social Security Act as a "provider" and permitting pharmacists to bill for allowable services provided under Medicare Part B. However, although provider status would allow pharmacists to bill Medicare, it would still not authorize them to manage a patient's medication therapy or provide CMM. This begs the question of whether pharmacists' ability to bill Medicare for services they can't necessarily perform in many states would really advance the profession and benefit patients.

Like all health care professionals, pharmacists need to be compensated for the work they perform, and provider status could allow for fee-for-service billing to Medicare Part B. However, fee-for-service billing is becoming less and less relevant. For example, under bundled payment arrangements, health systems do not bill for individual provider services. Thus, even with provider status, pharmacist-provided care might not be billable. As health care financing continues to move toward paying for value instead of paying for volume (e.g., as occurs in an ACO model), the more efficiently care is provided, the more successful health systems will be in achieving their desired outcomes. Hence, regardless of whether pharmacists can bill as "providers," their contributions in today's patient-centered, team-based settings are essential to optimizing patients' medication-related outcomes.

Thus, it's time to stop expending time and resources on increasingly irrelevant "provider status"; instead, we must focus on regulatory and policy changes that will allow us to contribute maximal value to contemporary, team-based practices - settings that are increasingly subject to emerging alternative payment models. Accordingly, we must expand our professional scope of practice commensurate with our education, training, and documented competence; focus our efforts on providing medication optimization services rather than just "billing for services"; and recognize that medication optimization is the value proposition that we bring to the health care system as we seek to transform the health of our patients.