Transcript Pharmacists as Medical Providers

Pharmacists as
Medical Providers
DON DOWNING
CLINICAL PROFESSOR, UNIV. OF WA SCHOOL OF PHARMACY
SEATTLE, WA
[email protected]
Conflicts of Interest

I have no commercial conflicts of interest and I am not being
compensated for this webinar

I am not a consultant or advisor for Wolters Kluwer Clinical Drug
Information
Objectives
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Understanding the difference between pharmacist provider status &
pharmacist medical provider status
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Creating provider leverage from existing state laws
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Establishing professional guidelines when both prescribing & selling
prescription medications
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Unbundling pharmacy location licenses from pharmacist medical
provider practice
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Establishing sustainable & responsible professional practices that
improve patient outcomes
What is Provider Status?
Provider Status
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What is it that pharmacists are seeking? Is it…
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Professional, patient & legislative recognition of our clinical skills & services?
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A scope of practice expansion, incl. prescribing medications?
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Elimination of dependence on selling medications for income?
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A new revenue stream that compensates & sustains professional practice?
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“Full” membership on healthcare teams / medical boards?
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Getting out of the “drug benefit” wedge?
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A legislative acknowledgement that says pharmacists are providers?
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Ability to practice at the top of our license
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To be able to help patients in ways we struggle to provide right now
Pharmacist provider status
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State legislative recognition in name only
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No Federal recognition other than low-level MTM billings by
pharmacies (but not pharmacists)
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Payment of some services through NDC#-based claims submissions
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Payment of some services through “incident-to” medical billings
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Facility fee payments for health system clinical care services
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But: mostly provision of valuable clinical services without sustainable
compensation due to rejection of pharmacists as contracted,
credentialed providers in health plan networks
Pharmacist medical provider status
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State and commercial health plans recognize pharmacists as
contracted and credentialed medical providers (Feds soon…?)
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Major medical CPT and ICD-10 codes used for provider claims
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Incident-to billing the exception rather than the rule
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Pharmacists making decisions not just taking orders
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Collaborative agreements are not direct supervision by physicians –
they are coordination of care / expansion of care partnerships
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No PBM involvement
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Allows clinics, hospitals and community pharmacies to hire
pharmacists as medical providers – not pharmacist providers
Getting there: Where is the
Leverage?
Creating leverage for pharmacist
medical provider status
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Searching state laws
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Every Category of Provider Laws (not the same as Any Willing Provider Laws)
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Anti-discrimination laws
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These laws may make it illegal for health plans and Insurance Commissioners
to deny pharmacists from contracting as medical providers
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May need to get a State Attorney General’s opinion to prove your point
Patient advocacy organizations
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They are struggling to find patient access to care
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They speak with a larger and louder voice than pharmacists
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They need and want pharmacists to help their clients
Engaging the “Treating” docs more than “Meeting” docs
Conflicts of Interest
Conflicts of Interest Guidelines

A common pushback for pharmacist medical provider status for
ambulatory care and community pharmacists is the perceived or
real conflicts of interest involved when a pharmacist both makes the
therapeutic drug choices and also dispenses these medications.
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Case: Pharmacist in community pharmacy is providing lipid
management services and commonly treats patients with an
inexpensive generic statin. Pressure comes from pharmacy
management to improve prescription profits by asking clinical
pharmacist to move these patients to another statin than has a
larger profit margin.
Conflicts of Interest Guidelines
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Issues:
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Pharmacy has argued that physicians should not sell the Rxs they prescribe
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A pharmacist medical provider is subject to pressure that may not be in their
patients’ best interest
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Urgent prevention-based pharmacist prescribing may not fall under the
same conflict of interest (i.e. naloxone, ella™, epinephrine, vaccines, etc.)
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You do not want to defend yourself in front of a news camera when a
reporter asks you if you are prescribing in the full interest of a patient or in the
interest of your pharmacy prescription business.
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Is there a need for a state conflict of interest guideline? Pharmacy should
own that guideline before they are forced to defend their dual role of
prescribing and dispensing.
Pharmacy Location Licensure
Mandated Pharmacy Location
licensure
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Most states have laws/rules that require pharmacists to practice in a
licensed pharmacy
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Should a pharmacist medical provider who is not dispensing
medications be required to get a pharmacy location license?
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If you are seeking pharmacist medical provider status, consider
amending your state pharmacy regulations or get a legal opinion
regarding the need for a location license as soon as possible.
A Brave New World
Pharmacist medical provider:
Rules of the road
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Issues to ponder:
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Are you’re a specialist, a primary care provider or both in health plan
networks?
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Does your compensation reasonably match the value you provide and
your ability to provide sustainable clinical services?
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When do your clinical services need a prior referral or other similar
mechanism in order to meet quality assurance requirements to:
coordinate care, to not duplicate care, & to provide medically
necessary services?
Rules of the Road
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Who will credential you with employers and health plans?
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Does your employer have a “delegated credentialing” contract with
health plans?
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What is your scope of practice and how is that decided?
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What CPT/ICD-10 billing codes will you insist be appropriate for your
services?
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Are you measuring outcomes?
Rules of the Road: Collaborative
Agreements
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It’s time to look at your collaborative drug therapy management
agreement (CDTA) regulations:
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Do CDTA regulations only allow pharmacists to implement, modify or
discontinue drug therapy when the authorizing physician has a
legitimate physician-patient relationship?
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What about patients who don’t have a physician provider? Shouldn’t
you as a “medical provider” be their initial provider?
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Can only physicians sign CDTAs?
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Are CDTA relationships with physicians a direct supervisory relationship?
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Are pharmacists writing prescriptions or furnishing /dispensing
prescriptions under protocol?
Pharmacist medical provider status
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Will your state pharmacist association, your state medical association,
your state legislature, or your state’s health plans decide that
pharmacist medical providers need to achieve a higher pharmacy
practice status in order to provide and be compensated for pharmacist
medical provider services?
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Is a pharmacy degree adequate?
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Do you need to complete a residency?
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Do you need Board Certification?
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Are these requirements barriers to patient access to care?
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Can schools of pharmacy graduate students who are prequalified to be
pharmacist medical providers?
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States are answering these questions differently. Carefully consider the
consequences.
Questions?