By Jackie Miller
Lately, the rising cost of drug prices, the opioid crisis and the role of pharmacy benefit managers have dominated the headlines of pharmacy-related news. However, a slower moving, yet important, development is also taking place: the evolution of pharmacists’ roles and responsibilities. While the pharmacy profession is experiencing change, this is certainly not its first transformation. At the profession’s inception, pharmacists mostly focused on compounding and manufacturing medications. As these job responsibilities waned, dispensing medication emerged as pharmacists’ most prominent role; it has largely remained this way for the past couple of decades. In recent years, the occupation has begun to undergo another evolution. Pharmacists are taking on additional responsibilities, which often center on integrating into the care team. This means that pharmacists are expected to be knowledgeable about other health care products and services and about how these may interact with pharmaceuticals to advise patients given their individual situations. This shift is still in its early stages. In California, the passage of SB 493 in 2013 represented the first step in the recognition of pharmacists as integral members of the care team. The bill allowed pharmacists to prescribe and discuss certain drugs and treatment regimens, such as hormonal contraceptives and nicotine replacement therapies. It also included recognition for advanced practice pharmacists (APhs). While APh designation exists in several states, educational and professional requirements vary. To achieve APh status in California, APhs must hold appropriate pharmacy licensure and satisfy two of the following three criteria: earned certificate in a relevant area of practice, completed a postgraduate residency and/or provided direct patient care under a collaborative practice agreement for at least one year.
Even in light of their expanding scope of practice, pharmacists remain underutilized in the workforce because they are not federally recognized as providers. Physicians, physicians’ assistants, nurse practitioners and several other professions have all been granted provider status under the Social Security Act. Pharmacists’ exclusion from provider status prevents them from billing under Medicare Part B, meaning they are unable to be reimbursed for providing services to beneficiaries enrolled in the traditional Medicare program; members of the care team who have been granted provider status do not face this barrier. Other state and private insurance plans use the federal government’s omission as rationale to exclude or limit pharmacist services reimbursement under those plans. According to Lisa Kroon, PharmD, Professor & Chair of UCSF’s Department of Clinical Pharmacy, “we won’t see a huge shift [in pharmacy] until [pharmacists] get paid, just like with any other position.” Although SB 493 was instrumental in expanding pharmacists’ scope of practice in California, it did not address the crucial questions related to reimbursement of services.
Policies Affecting Pharmacists Across the US
Some state-level initiatives have expanded scope of practice and/or granted reimbursement for pharmacists’ services across the country. New Mexico and North Carolina’s pioneering models allow pharmacists to bill for services as a designated APh (note that each state uses slightly different terminology than APh: New Mexico uses pharmacist clinician, and North Carolina uses clinical pharmacist practitioner). New Mexico’s program began in 1993 and North Carolina’s began in 2000. More recently, Montana enacted legislation in 2010 that is modeled after New Mexico and North Carolina. Since 2015, North Dakota has signed four bills into law that expand non-APh designated pharmacists’ scope of practice; Washington state and Oregon followed suit by each passing their own scope of practice expansion bills soon after. North Dakota and Oregon’s bills also contained elements related to reimbursement. Although California has not yet implemented broad and sustainable reimbursement practices for pharmacist services, SB 493’s passage did expand pharmacists’ scope of practice in specific situations. Additional bills that aim to further expand scope of practice by allowing pharmacists to provide additional services are working their way through the legislature. For example, SB 1264 would include hypertension medication services as a covered pharmacist service under Medi-Cal. As of this writing, the bill had passed in the Senate and was sitting in Appropriations within the Assembly. Two additional bills introduced to the California legislature this year, both of which impact insurance coverage for services provided by the pharmacy workforce, would aim to make even broader changes to pharmacists’ scope of practice: SB 1285 would require coverage of services provided by APhs under most health insurance plans and SB 1322 would require the coverage of comprehensive medication management (CMM) for Medi-Cal (California’s Medicaid Program) beneficiaries only. Both bills aim to make pharmacists a contributing member of the care team. SB 1285 would do so by covering the services of pharmacists with specific certification only and SB 1322 by covering a service that pharmacists can provide, regardless of whether or not they have specific certifications. Both of these bills were analyzed by the California Health Benefits and Review Program (CHBRP), a University of California program which responds to requests from the California State Legislature for independent analyses of bills pertaining to health insurance benefit mandates. Based in Berkeley, CHBRP is a consortium of faculty and staff at University of California campuses who assess newly written bills’ financial, public health and medical impacts. UCSF has contributed to assessing the medical effectiveness of proposed bills since 2004. CHBRP provides independent analyses that weigh the potential benefits against the known outcomes of proposed legislation. “We’re more of a blinking yellow, rather than a red or a green light,” said CHBRP Program Director Garen Corbett. Often, an unbiased evaluation of existing evidence yields a “blinking yellow,” or proceed with caution, when deciding upon intervention implementation. The full analyses and key findings produced by CHBRP for SB 1285 and SB 1322 can be found here. In 2018, a total of 11 bills were analyzed by CHBRP. Given that two of these bills centered on reimbursement of pharmacists’ services, there is indication of a changing landscape for the pharmacy profession.
Corbett believes that the proposed bills reflect pharmacists’ desire to become more independent and are indicative of the path that people in the profession hope to take over time, as the prospective workforce modifications would create a more autonomous role for pharmacists. Support for pharmacists’ incorporation into the care team has also been echoed among legislators. On the federal level, The Pharmacy and Medically Underserved Areas Enhancement Act would allow pharmacists provider recognition and thus the ability to bill under Medicare Part B, so long as they are providing services in medically underserved communities. This Act aims to increase access to primary care through expanded scope of practice for pharmacists. Although the proposed legislation already has a sufficient amount of votes to pass both the Senate and the House, it has not yet made it to the docket. According to Marilyn Stebbins, PharmD and Professor at UCSF’s Department of Clinical Pharmacy, their passage is inevitable: “it’s not a matter of if [these bills] pass. It’s a matter of when.”
True Members of the Care Team
Pharmacists are not attempting to take anything away from physicians, nor other providers who offer primary or specialized care to patients, Dr. Kroon said. Instead, pharmacists would like to partner with physicians. “We are not a threat. We want to help – we know that there is a primary care shortage in the nation and in California. We can help address this shortage,” she said. “We are not lone rangers.” Lisa Kroon, PharmD, Professor & Chair of Clinical Pharmacy at UCSF Dr. Kroon also emphasized the importance of bringing attention to data that demonstrate pharmacists’ worth within the care team. For example, a recent study shows the effectiveness of pharmacist intervention, particularly among a population that is traditionally more difficult to reach. The “barbershop” study shows that the dual efforts of barber screening and further pharmacist intervention to treat high blood pressure among customers-turned-patients reduced blood pressure by 27 mm Hg, allowing a majority of patients to achieve “normal” blood pressure readings. Such evidence supports the potential favorable influence of pharmacists as members of the care team, as well as illuminates the potential positive effects of non-traditional methods for intervention in general. As of this writing, neither of the CHBRP analyzed bills affecting the coverage of pharmacist-provided services had been voted out of the health committee, but they had been granted reconsideration. In fact, it could take several years for the bills or other similar bills to gain momentum. Despite the slow pace of policy change, pharmacists will continue to fight for autonomy and to gain recognition as vital contributors to comprehensive patient care.
Jackie Miller is a research analyst with the Institute for Health Policy Studies and Healthforce Center. Her projects focus on a range of research including community health workers, workforce policies and workforce supply and demand.