Payment for pharmacists’ services is spreading quickly across the states
As a part of APhA’s commitment to serve every pharmacist and all of pharmacy, we have advocated for issues impacting you and your practice in your state. I’d like to introduce you to Dr. Michael Murphy who serves as APhA’s advisor for state government affairs. Michael has some exciting news to share about the growth of pharmacists’ services being covered by health plans. – Michael Hogue, PharmD, FAPhA, FNAP, FFIP, Executive Vice President and Chief Executive Officer of APhA
Pharmacist’s patient care services are being recognized by policymakers and payers across the country, enabling pharmacists to be paid for these services. As more states expand programs, the momentum continues to grow. The question shouldn’t be, “do pharmacists have the ability to practice and bill for pharmacist-provided patient care services?” The question instead should be, “how soon will all payers recognize pharmacists as health care providers?” If we keep up our continued momentum, I expect it will be before the end of the decade.
In the past 5 years, we have witnessed an explosion of programs covering pharmacists’ services across the states. Many of these programs are being established through state Medicaid fee-for-service and managed care plans, or by commercial health plans operating in the states. Pharmacists are being enrolled as providers in much the same way that health plans enroll physicians, nurse practitioners, and physician assistants. Pharmacists are also billing for their services in similar ways as other providers. Often, pharmacists submit the same billing codes that other health care providers submit for a comparable visit. Optimally, pharmacists are also reimbursed in parity with other providers’ rates.
Across these programs, pharmacists are working collaboratively with other health care professionals to ensure that patients are receiving the comprehensive and coordinated care they need. Through the expansion of these programs, we are seeing more pharmacists building business models to serve their communities and delivering the care they are expertly trained to provide. These practices are being established in all outpatient settings, including community pharmacies and ambulatory care clinics.
It cannot be understated that the impetus for the growth of these programs comes back to every pharmacists’ commitment to better serve their patients. However, to expand these programs, we recognize a continued need for key policy changes.
Advocacy in action
At APhA, we're working hand in hand with state pharmacy associations across the country to amplify our collective voice and advance policy changes that recognize and reimburse pharmacists for the services they provide to their patients every day. This is a key part of our state advocacy work, along with advocating to reform predatory PBM practices, increase the sustainability of drug reimbursement, and better align pharmacists’ scope of practice with their education and training.
One significant milestone in our advocacy efforts is the success we've achieved in supporting state Medicaid programs to submit state plan amendments (SPAs) under Medicaid to add pharmacists as a recognized health care provider. In the past 3 years, over 25 SPAs have been approved in 18 states expanding coverage of pharmacists’ services by the state’s Medicaid plan. By advocating for these amendments, we aim to ensure that pharmacists are formally recognized as valuable members of the health care team, and eligible to provide and bill state Medicaid programs for a wide range of patient care services.
Driving change, state by state
APhA and state pharmacy associations’ joint advocacy efforts are yielding tangible results across the country, with many states now announcing the coverage of pharmacists' patient care services. A few examples of this advocacy can be seen in Colorado, Nevada, Pennsylvania, and Virginia where APhA partnered with the Colorado Pharmacists Society (CPS), the Nevada Pharmacy Alliance (NPA), the Pennsylvania Pharmacists Association (PPA), and the Virginia Pharmacy Association (VPhA), respectively.
APhA worked closely with each state to provide feedback and guidance to state Medicaid departments through the submission of Medicaid SPAs, the Medicaid regulatory process, and the implementation of programs that cover pharmacists’ patient care services. At the time of writing, we are aware of programs in 42 states where at least one service provided by a pharmacist is covered by Medicaid or a commercial health plan.
And don’t worry. We are working on the establishment of programs in the other 8 states and the District of Columbia. We are also working to expand programs in every state so every service a pharmacist can provide, ranging from medication management services to conducting health screenings and administering immunizations, is covered and paid for by health plans and other payers.
Looking ahead
While we celebrate our successes, we recognize there's more work to be done. APhA continues to advocate every day at state and federal levels to prohibit PBM practices that undermine the sustainability of community pharmacies. If these practices can be minimized, pharmacists will increasingly be able to participate in expanded service programs and work toward new sustainable revenue models. As advocates for the pharmacy profession and expanding access to patient care, APhA remains committed to driving forward our advocacy efforts, forging partnerships, and championing policies that recognize and support pharmacists as essential health care providers.
At APhA, we're proud to stand at the forefront of this movement, advocating tirelessly to elevate the role of pharmacists in health care and improve patient outcomes nationwide. Join us, and your state pharmacy associations, as we work toward a future where pharmacists are fully recognized, reimbursed, and empowered to optimize patient care.
Guest authored by: E. Michael Murphy, PharmD, MBA