American College of Clinical Pharmacy
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ACCP Report - July 2019

ACCP Washington Office Commentary

Coverage for Services: Why Provider Status Is Not the Solution

Written by John McGlew
Director of Government Affairs



Capitol

Historically, the pharmacy profession has sought Medicare provider status as the “holy grail” of health policy advocacy. For as long as ACCP has operated a Washington office, the omission of pharmacists from the list of “eligible providers” under Section 1861 of the Social Security Act (SSA) has been viewed by the wider pharmacy profession as the single greatest barrier to securing payment for services.

Without doubt, recognition of pharmacists as Medicare providers is a key piece of the Medicare coverage puzzle. That’s why, as far back as 2003, ACCP led efforts to “fix” Medicare Part B through the Pharmacist Provider Coalition (PPC) and the Leadership for Medication Management (LMM).

So why, then, in 2013, after a decade of advocacy work focused on provider status, did the ACCP Board of Regents launch its high-profile legislative Medicare Initiative focused on securing coverage for clinical pharmacist services for patients instead of “status” for providers?

Put simply, Medicare payment is not based on the “recognition” of certain health care professions as providers. Medicare payment policy sets out a list of covered tests, items, and services together with the qualifications required for eligibility to render these services. Therefore, ACCP’s advocacy strategy focuses on amending the list of covered services, not the list of covered providers.

Let’s look at examples of other Medicare-eligible providers. Doctors of chiropractic services are listed as Medicare providers, but from a regulatory standpoint, the process that provides their payment is linked specifically to “manual manipulation of the spine if medically necessary to correct a subluxation when provided by a chiropractor or other qualified provider.”

Perhaps more tellingly, doctors of dentistry are clearly listed as Medicare providers under the SSA, yet Medicare payment policy does not cover their services. CMS (the Centers for Medicare and Medicaid Services) specifically states that it does not cover most dental care, dental procedures, or supplies (i.e., cleanings, fillings, tooth extractions, dentures) and that “beneficiaries pay 100% for non-covered services, including most dental care.”

The significance of this to ACCP’s effort cannot be overstated – under federal law, pharmacists’ and dentists’ services are treated identically. In both cases, patients are perfectly entitled to pay out-of-pocket to access the services that pharmacists and dentists provide in accordance with state practice acts, even though dentists currently enjoy “Medicare provider status.”

That’s not to say provider status is irrelevant. Efforts at the state level to formalize pharmacists’ integration into patient care teams often require a legislative amendment to expand the statutory definition of provider. In California, defining pharmacists as providers and establishing the “advanced practice pharmacist” designation was an important step in this process. But even according to the California Pharmacists Association (CPhA), obtaining provider status and additional scope of practice was only the first step for pharmacists to contribute in broader ways to the health care team. Now CPhA’s focus has turned to ensuring that payment systems support pharmacists in these new roles.

And let’s be clear here: if successful, ACCP’s Medicare Initiative will in effect achieve “provider status” for qualified pharmacists. Our message is simple: getting the medications right is an essential objective for a modernized, cost-effective, and quality-focused Medicare program. Congress should enact legislation to reform Medicare Part B to cover CMM (comprehensive medication management) services provided by qualified clinical pharmacists, as members of the patient’s health care team. Our point is that securing coverage for services also requires provider status. But securing provider status does not require payment for services.

So What Is the Road Map?

ACCP invests significant time and resources to help policy-makers in Congress, the executive branch, and key health stakeholder organizations understand why getting the medications right is central to the “health care quadruple aim” of enhancing patient experience, improving population health, reducing costs, and enhancing provider wellness.

Consistent with this strategic outlook, MedPAC – the independent body charged with advising Congress on issues affecting administration of the Medicare program – in its March 2019 report reiterated its focus on finding ways to provide high-quality care for Medicare beneficiaries while giving providers incentives to constrain their cost growth and thus help control program spending.

Accordingly, ACCP’s advocacy continues to expand – not only targeting Congress to seek a “legislative fix” but also strengthening and expanding the efforts already under way to test innovative approaches for integrating CMM through Medicare alternative payment models and building relationships with physician groups, other provider and specialty organizations, private payers, and other key stakeholders to advance this initiative.

Realistically, in today’s political climate, a single-issue piece of legislation (e.g., focused on “pharmacist provider status”) rarely works its way through the traditional congressional committee process to be signed into law. In practice, carefully crafted, well-defined policy solutions are vetted, tested, and ultimately integrated into broader “omnibus” legislative packages that navigate from Capitol Hill to the White House. Nevertheless, although progress of ACCP’s Medicare Initiative is necessarily slow and incremental, the College remains confident that CMM coverage will successfully be integrated across a variety of health payers and structures.

The external landscape, both politically and from a clinical practice standpoint, looks very different in 2019 from when the College first opened its Washington office in 2000. Consequently, ACCP’s advocacy strategy has evolved significantly beyond the “provider status efforts” of the early 2000s.