February 10, 2016
Subject: Call To Action to have Pharmacists Recognized for Patient Care
WSPA Members – your help is needed!
The US Department of Health and Human Services Health Resources and Services Administration
released The Special Report to the Senate Appropriations Committee on Advancing Clinical Pharmacy
Services in Programs funded by HRSA and its Safety net Partners. This report summarizes clinical
pharmacy services within HRSA programs, and is another collection of the outstanding work of
pharmacists to improve patient outcomes and reduce health care costs. This report was issued in
response to the Senate Appropriations Committee’s statement that “strongly encourages HRSA to
continue to develop and implement cost-effective clinical pharmacy programs in all of the various
safety-net provider settings.”
WSPA, Pharmacists across the state and other health professionals understand the need to have
pharmacists recognized and compensated through the medical benefit for the care they provide to
patients. Compensation mechanisms to support pharmacists working at the full extent of their licensure
in every setting are critical to expand access to primary care in our state. As noted by RADM Scott
Giberson in the 2011 Report to the US Surgeon General, pharmacists are currently the most
underutilized professional in the health care team.
WSPA is actively working to utilize Washington State’s Every Category of Health Care Provider Law (WAC
284-43-205) which states insurance companies cannot categorically deny classes of providers, such as
pharmacists, from their networks. Our Every Category of Health Care Provider law is a unique way that
we lead the country once again in pharmacist provided patient care. WSPA’s vision includes
reinforcement of pharmacist inclusion in the Every Category of Health Care Provider law. Pharmacists
will be able to partner with other health care professionals to manage medications, increase
compliance, provide education and improve health outcomes in all settings. No matter what happens
with elections, or the evolution of health care we need to ensure that there is recognition of
pharmacists as providers of patient care and compensation to support this provision. Our practices
should be flexible to adapt to any model such as fee-for-service, pay-for-performance, accountable care
organizations or health homes.
Your help is needed to explain to state and national policy makers, insurance companies and state
officials how recognition of you as an individual provider and compensation for your care of patients can
make a difference! Please draft a letter To Whom It May Concern, with thoughts on how you work hand
in hand to increase access to care, manage chronic illness and/or reduce health care costs. Please invite
other colleagues, medical directors, physicians and patients to also contribute a letter. Your stories,
studies and practice models are the best way of painting a picture for change.
Please send WSPA your letters of support!
1. Address the letters to “To Whom it May Concern” so that they can be utilized to educate
multiple individuals.
2. Include examples of how compensation for your time spent with a patient would increase
overall access to primary care, better control chronic illness, or reduce health care costs.
Stories, practice specific data, and models of care are all importance. The letters do not have to
be long, or filled with data to make an impact.
3. Send your letters to Jenny Arnold, 411 Williams Ave S, Renton, WA 98057 or to
jarnold@wsparx.org.
4. WSPA will use these letters as examples to educate state and federal policy makers, insurance
companies and state officials.
Questions and Answers:
Q: Isn’t the health care setting moving toward Health Homes, Accountable Care Organizations and
capitated payment structures, where pharmacist fee-for-service billing will be outdated?
A: Yes, there are significant projects testing these models. In ACO models pharmacists still should be
listed as providers in the health care team. We do not know how long this model will take to evolve,
and to be a part of the process, we need to be players at the table. Recognition as providers and
contracts to provider care will help pharmacists to ensure this.
Q: Pharmacists in anticoagulation clinics and other settings are able to bill for seeing patients. How is
this different?
A: Currently, pharmacists in these clinics bill either a facility fee or 99211 CPT code known as “incident
to” billing. This is also an example of fee-for-service models. These mechanisms are billed under
another physician or ARNP’s NPI number, and do not permit billing higher levels of care. If a physician
or ARNP are not present in the clinic, the visit cannot be billed. If other providers, such as an ARNP
completed the anticoagulation or other visit instead of the pharmacist they can bill under their own
provider NPI number, and can bill at a much higher rate for complex patients. New healthcare payment
models will go away from fee-for-service compensation models, and pharmacists should be involved in
the development of new systems.
Q: Pharmacists are paid for providing MTM to Medicare Part D participants. Is this payment considered
an example of compensated patient care?
A: Pharmacists were first recognized federally for their ability to improve outcomes and reduce health
care costs in the Medicare Modernization Act, which specified the need to cover Medication Therapy
Management for certain Medicare Part D participants. These MTM visits are often completed by
insurance company employed nurses and pharmacists, but sometimes community pharmacists are
compensated for providing these consultations. Compensation comes from the Medicare Part D plan.
The goal of this WSPA push is to have pharmacists covered for providing covered care through the
medical benefit, the same mechanism as physicians, ARNPs, chiropractors, massage practitioners. MTM
as we know it may not be a covered medical benefit, but medication reviews in conjunction with the
management of chronic illnesses are covered, so pharmacists may have to evolve the way
comprehensive therapy reviews are provided and documented if they bill to the medical benefit.
Q: In April 2012 CMS issued 42 CFR Parts 482 and 485 which stated that hospitals may include
pharmacists as part of the medical staff. Is this recognition of pharmacists as providers of patient care?
A: The WSPA and other pharmacy associations are not sure what changes will come from this
statement. We believe that until more is known about the impact of the April 2012 statement and
expansion to include pharmacists in every setting, it is important to continue to push for full recognition
and compensation at the state level.