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Provider status legislation introduced in House, Senate
DIANA YAP
The Pharmacy and Medically Underserved Areas Enhancement Act (H.R. 592/S. 314) has been introduced in the House and Senate.
If enacted, the legislation would enable patient access to, and coverage of, Medicare Part B services by pharmacists in medically
underserved communities. The legislation would improve patient access to health care through pharmacists and their patient care services.
H.R. 592 was introduced by Reps. Brett Guthrie (R-KY) and G.K. Butterfield (D-NC), both House Energy & Commerce Committee
Members, and Reps. Todd Young (R-IN) and Ron Kind (D-WI), both House Ways & Means Committee Members, on January 28, 2015.
S. 314 was introduced by Sens. Chuck Grassley (R-IA), Robert Casey (D-PA), Mark Kirk (R-IL), and Sherrod Brown (D-OH) on January
29, 2015. Grassley and Brown are Members of the Senate Finance Committee; Casey is a Member of both the Senate Finance and
Senate Health, Education, Labor, and Pensions (HELP) Committees; and Kirk is a Member of the Senate HELP Committee. (See page 69
for more information on Grassley.)
Patient access to pharmacists’ services
In most states, pharmacists provide services such as immunizations, diabetes management, blood pressure screenings, and routine
checks; yet despite the ability to perform such services, no mechanism currently exists for pharmacists to be reimbursed for these services
by Medicare, according to a news release from Guthrie’s office.
The House Energy & Commerce and Ways & Means Committees, and the Senate Finance and HELP Committees, are key to
successful passage because these committees first consider the legislation before deliberation by the full House and full Senate,
respectively.
As Pharmacy Today went to press, H.R. 592 had 41 cosponsors, and S. 314 had 5 cosponsors.
Pharmacy groups back bills
APhA was thrilled to see the reintroduction of the legislation in the House, which received bipartisan support from 123 House cosponsors in
the last Congress, and the introduction of companion legislation in the Senate.
“APhA and the pharmacy profession stand ready to build on the success achieved last year on this issue on Capitol Hill,” APhA
Executive Vice President and CEO Thomas E. Menighan, BSPharm, MBA, ScD (Hon), FAPhA, said in a statement.
The Association was grateful to the sponsors of both bills and is ready to work with Members of Congress to pass the legislation.
“Although my patients and their physicians recognize and value my role on their health care team, federal law does not. By recognizing
pharmacists’ patient care services under Medicare, this new legislation creates better access to health care for medically underserved
patients in Iowa and throughout” the United States, said Matthew C. Osterhaus, BSPharm, FASCP, FAPhA, a community pharmacy owner
in Iowa and APhA President, who has hosted Grassley in his pharmacy to showcase the importance of pharmacists in their community.
Pharmacists and student pharmacists can join APhA’s Pharmacists Provide Care campaign at www.pharmacistsprovidecare.com. On
the website, they can ask their Members of Congress for support of H.R. 592 and S. 314. (For more information, see page 14.)
Other pharmacy organizations also endorsed the bills.
“Independent community pharmacies … already play a vital role in underserved communities,” National Community Pharmacists
Association CEO B. Douglas Hoey, BSPharm, MBA, said in a statement. More than 70% of independent community pharmacies are
located in towns of 50,000 people or less, he added, and within urban areas, they “play a disproportionately large role serving patients.”
“For many patients, the lack of health care access remains a serious problem, and we appreciate the growing realization of the
opportunity to look to pharmacists as valuable members of the health care delivery team, in partnership with doctors, nurses, and others,”
National Association of Chain Drug Stores President and CEO Steven C. Anderson, IOM, CAE, said in a statement.
“Legislators on both sides of the aisle understand the benefits that would accrue to our nation’s health care system by ensuring that
patients have access to an essential member of the health care team,” American Society of Health-System Pharmacists (ASHP) CEO Paul
W. Abramowitz, PharmD, ScD (Hon), said in a statement.
Coalition effort
APhA is a member of the Patient Access to Pharmacists’ Care Coalition (PAPCC), which comprises organizations representing patients,
pharmacists, and pharmacies as well as other interested stakeholders. These organizations are devoted to expanding patient access to
pharmacist-provided patient care services in medically underserved communities consistent with state scope-of-practice law.
APhA and PAPCC led a campaign backing last year’s bill—H.R. 4190.
Diana Yap, Editorial Director
Pharmacy champions in Congress: Sen. Chuck Grassley (R-IA)
This profile of Sen. Chuck Grassley (R-IA) is part of an occasional series in Pharmacy Today on Members of Congress who are
champions of pharmacy. Grassley, along with Sens. Robert Casey (D-PA), Mark Kirk (R-IL), and Sherrod Brown (D-OH), introduced the
Pharmacy and Medically Underserved Areas Enhancement Act (S. 314) on January 29. The bipartisan legislation is a companion bill to
H.R. 592, introduced on January 28. (For more information, see page 68.)
Grassley serves on several Senate committees, including the Finance Committee, which has jurisdiction over health care, Social
Security, Medicare, Medicaid, and more. In 2003, Grassley steered through Congress the legislation that established Medicare Part D.
Following are Today’s questions and his responses from a recent e-mail interview:
Where does your appreciation for pharmacists and pharmacy come from?
Several areas. A lot of Iowans live in small towns, where there might be a pharmacist in town but no doctor. Sometimes there’s no doctor
for several towns. Iowans are used to driving long distances for the doctor while having easier access to a pharmacist. It becomes
ingrained to ask the pharmacist for all kinds of advice on medical topics, not just on how to take prescription drugs but maybe when a
condition warrants a doctor’s visit or when a drugstore product might help.
At one point, the health policy director on my staff was a trained pharmacist, originally from a small town, so he brought a pharmacist’s
perspective to my policy work.
And for nearly a decade, after passage of the Combat Methamphetamine Epidemic Act, while drugstores are being targeted for the
pseudoephedrine used in cold medicine to make methamphetamine, pharmacists have played and continue to play a vital role in
preventing the spread of methamphetamine labs by tracking the sale of pseudoephedrine. This is meaningful to me as a senator from a
state with a methamphetamine problem and as the Chairman of the Judiciary Committee and the Caucus on International Narcotics
Control.
What do you find most compelling about S. 314 that prompted you to introduce it?
Medicare has been in place for almost 50 years, and Congress has to make sure to tweak it as needed to keep up with the practice of
modern medicine. We don’t always keep up, but we have to try our best. It makes sense to me to update Medicare to reflect the way
pharmacists are already fulfilling their role in the health care system. Pharmacists are already providing tremendous value to Medicare
beneficiaries on health care matters, and Medicare policy should reflect what’s happening in the field.
Why is S. 314 good for rural seniors, taxpayers, and pharmacists?
A Medicare beneficiary who lives many miles away from a doctor in a rural area can’t always get to the doctor easily. Maybe the
person no longer drives, and there’s no other means of getting to the doctor. But the individual might be able to get a ride from a
neighbor to stop by the town pharmacy a few miles away. While there, the individual is able to pick up a prescription and talk with the
pharmacist about managing blood sugar in diabetes or another medical condition. Maybe the individual discusses whether to get a flu
shot and even gets the shot right there at the pharmacy. These are valuable interactions that are helpful for the individual’s well-being.
Compensating pharmacists for their time and expertise encourages more such interactions. And it’s less expensive than if the
beneficiary were to visit a doctor for the same consultation.
Could you comment on your longstanding interest in access to medications and medication safety?
The role of pharmaceuticals in medicine has grown exponentially since the creation of Medicare. Congress recognized that and, in 2003,
created the Part D benefit so that seniors would have access to lower cost drugs. It was called the Medicare Modernization Act for good
reason. That law was written to make sure rural pharmacies had a fair playing field to protect access for rural seniors. As we have seen
weaknesses in that fairness, we have worked with CMS to improve matters. When new drugs come on the market, the FDA needs to do a
better job of following them through postmarketing surveillance and labeling standards to protect the public.
What can our readers do to assist you in passing this legislation?
Please contact your Members of Congress, both in the Senate and the House of Representatives, about how this legislation would make
a difference for you and the Medicare beneficiaries you serve. There’s no substitute for hearing from the grassroots about how a policy
under consideration in Washington, DC, would help the people outside the Beltway.
Photo Caption: APhA President Matthew C. Osterhaus, BSPharm, FASCP, FAPhA, explained the role of the pharmacist in patient care to Sen. Chuck Grassley (R-IA) in 2012.
MTM expansion cited as savings in Minnesota budget proposal
DIANA YAP
Gov. Mark Dayton of Minnesota proposed expanding access to medication therapy management (MTM) services within Medicaid, and
the state’s Department of Human Services cited the expansion as a savings within the governor’s budget for the years ahead.
Effective July 1, 2015, the governor recommended expanding eligibility for MTM to all beneficiaries taking medications to treat or
prevent a chronic disease and allowing for interactive video MTM to be performed in patient homes in select circumstances.
According to state Department of Human Services data, 1,085 medical assistance beneficiaries used MTM in fiscal year (FY) 2015.
Expanding MTM to all beneficiaries with a chronic condition should reach an additional 1,350 beneficiaries in FY 2016. The proposal would
have a savings to the state’s General Fund of $41,000 in the FY 2016–17 biennium and $78,000 in the FY 2018–19 biennium.
The governor’s recommendation and the Department of Human Services’ data can be read starting on page 128 of the state of
Minnesota’s proposed 2016–17 biennial budget.
State-level advocacy, budget rationale
“The Minnesota Pharmacists Associ-ation supports the governor’s proposal, as this would expand the number of patients eligible to receive
valuable pharmacists’ services as well as make it easier for pharmacists to identify eligible participants,” said Michelle Aytay, BSPharm,
CDE, Public Affairs Co-Chair for the Minnesota Pharmacists Association.
“Expanding the services that pharmacists can provide, such as immunization expansion—which is a high priority this legislative
session—and medication therapy management directly aligns with our mission of supporting Minnesota pharmacists to advance patient
care.”
“The proposed expansion of Minnesota Medicaid’s MTM benefit is a direct reflection of the Minnesota Pharmacists Association’s long
history of advocacy for improving patient care through pharmacists and a perfect demonstration of the value that pharmacists bring to
patients and the health care system,” said Krystalyn Weaver, PharmD, National Alliance of State Pharmacy Associations Director of Policy
and State Relations.
“Minnesota’s example is sure to be noticed by other states and will help to build momentum towards increased utilization of
pharmacists’ education and training to improve health.”
Before the 2011 legislative session, pharmacist-provided MTM was available only to individuals taking four or more medications to treat
two or more chronic diseases. In 2011, the definition was changed to allow individuals taking three or more medications with one or more
chronic diseases to qualify for MTM.
“Agency staff and stakeholders are concerned that the current language in state statute would preclude individuals who are receiving
just one prescription drug for a complicated disease state,” such as sofosbuvir (Sovaldi—Gilead) for hepatitis C, from receiving MTM in
many cases, according to the proposal, which was informed by stakeholder focus groups held by the Department of Human Services’
Pharmacy Unit in the summer of 2013.
Proud history
The proposal continues in the state of Minnesota’s proud history of coverage of pharmacists’ services for state employees and in Medicaid.
The June 2013 issue of Pharmacy Today reported that pharmacists are paid for performance in an MTM diabetes program under a
contract negotiated between Minnesota’s State Employee Group Insurance Plan (SEGIP) and a statewide MTM provider network run by
the University of Minnesota College of Pharmacy. Pharmacists in the network, it was reported, are compensated through billing for services
using CPT codes; under the contract, bonuses are on the table.
According to a current SEGIP webpage, the Diabetes MTM and Lifestyle Program is a partnership among the employee, their
physician, and a chosen clinical pharmacist. Administration of the program is a partnership among Navitus, the health plan administrators,
StayWell, and the University of Minnesota College of Pharmacy.
Diana Yap, Editorial Director
Provider status would increase pharmacists’ impact on outcomes
SONYA COLLINS
On a recent home visit, Tanya Dougherty, PharmD, BCPS, asked “Jeff” to bring out all his medications. He dumped more than a
thousand dollars’ worth of prescriptions—in the form of dozens of bottles—onto the coffee table in his living room.
“So, which ones are you taking?” Dougherty asked Jeff.
“None,” he said.
Jeff had just been discharged from the hospital—for the third time in 3 months—with severe sleep apnea, shortness of breath, heart failure,
and cognitive impairment. During the home visit, he told Dougherty that his shortness of breath was as bad as it had ever been. After some
probing, Dougherty learned that Jeff wasn’t taking his medications because he didn’t know how to read.
“I don’t know what to take, so I’m not taking any of it—because I’m scared,” Dougherty recalled the patient saying. Dougherty then created a
chart for Jeff that used only pictures and symbols to denote which medications he should take when.
Substantial time, probing
This was just one of many patient encounters in which it took Dougherty substantial time and probing to understand the patient’s barriers to
adherence and to help him overcome them. As other stories in this series show, if pharmacists could bill insurance for providing direct patient
care in the outpatient setting, pharmacists like Dougherty could help more patients manage their complex medication regimens.
As director of the pharmacy residency program at Penn Presbyterian Medical Center, Dougherty’s direct patient care time is rolled into her
many other teaching and administrative responsibilities. “Reimbursement for our services would justify additional direct patient
management opportunities in the outpatient setting,” she said.
Health care providers can bill insurance for their services through “provider status,” a classification given them by CMS. Unlike virtually all
other health professionals, pharmacists do not have provider status. To be compensated for patient care, pharmacists might build clinic time
into larger job descriptions, such as professor of pharmacy, or they might see patients alongside another health care provider who can bill.
Some pharmacists see only those eligible for medication therapy management under their Medicare Part D plan. Others might see only the
patients who can afford to pay them out of pocket. These models limit the impact pharmacists can make.
Primary care physician shortage
Provider status, Dougherty said, would significantly increase the number of patients pharmacists can see and have far-reaching effects on
health care workforce demands and patient outcomes.
“The physician shortage in primary care is a prime opportunity for pharmacists to take the lead in providing primary care to patients who
otherwise would not have it,” Dougherty said. “Especially in underserved areas and rural areas, pharmacists could certainly fill in gaps in care
for patients.”
For primary care physicians to treat chronic disease according to current guidelines, they would need to work more than 10.5 hours per day,
according to a study in Annals of Family Medicine. This is where pharmacists could step in, Dougherty said. “After a patient has been
diagnosed, if medication management is necessary, that’s where a pharmacist fits in.”
But until insurance reimburses for pharmacists’ services, primary care practices will be unlikely to hire pharmacists to manage their chronic
patients. “It’s very difficult for clinics to justify a salary for a pharmacist who isn’t able to bill for their services,” Dougherty said.
Pharmacists’ unique expertise
With provider status, pharmacists could also expand beneficial, but time-consuming, models of care, such as home visits for postdischarge
patients. Multiple studies have shown that pharmacist-led home visits improve quality of care and patient outcomes. “But it takes a lot of time to
do a home visit,” Dougherty said. “If pharmacists could bill for services, though, they could run home-visit programs.”
The way Dougherty sees it, each member of the health care team—physicians, physician assistants, nurse practitioners—has unique
expertise. But until pharmacists have provider status, patients are not getting the full benefit of their unique expertise.
“Pharmacists receive over 2 years of training and education in therapeutic and medication-specific information. Our training positions us to
care for patients with complex and chronic medical conditions, monitoring their medications for safety and efficacy.”
Sonya Collins, MA, MFA, contributing writer
Photo Caption:
Tanya Dougherty