In recent years, our nation has seen pharmacist provider status legislation take off like a wildfire. Pharmacist providers are more ready than ever to make use of their advanced clinical training and patient relationships.
Currently over half of the states have active Medicaid payment parity laws and about a third require provider status and/or payment by Commercial Insurance. Scope enables collaborative practice agreements and prescribing services in all states. Recognizing the growing shortages in the primary care sector, pharmacists are perfectly situated in the community to effectively manage chronic diseases and address acute needs. Why, then, are pharmacists still not commonplace as in-network providers with medical plans in our healthcare system?
There are many factors that contribute to this discrepancy. Community pharmacists, unlike other healthcare provider types, have competing alternative routes for receiving payment which pose fewer barriers. Additionally, workflow in a community pharmacy is “retail” oriented. Spending extended time beyond a transaction-based encounter requires planning, modifications and sometimes even changes to the physical layout of a pharmacy. Perhaps one of the biggest barriers is awareness. Collaborating providers, health plans, patients and even our own pharmacy community are often unaware of the patient care services pharmacists already provide and can receive reimbursement for.
Despite these challenges, I envision pharmacist credentialing with medical plans as the first of many steps required to generate a long-term shift in our profession. A necessary shift towards reimbursement for products AND cognitive services. I have been fortunate to have had enough conversations with a myriad of payors to know that this is something payors have a vested interest in supporting. This holds true even in states that do not yet mandate pharmacists to be credentialed and enrolled to be reimbursed for services.
Let's embark on this journey as a unified profession, combining efforts of advocacy, expertise, and outcomes to transform together! Here are some valuable lessons I've gathered along the way:
- Advocacy: This falls first alphabetically, but it’s also the highest priority. Even in states with payment parity and commitment from plans and payors to pay pharmacist providers, credentialing can hit roadblocks with "false" denials. This is commonly due to system configurations blocking our taxonomy codes or not being built to accept the pharmacist provider type in the first place. In addition, there often is a lack of awareness about the nuanced exceptions for pharmacist providers within the health plan. I have seen tremendous value of pharmacist leaders combining forces with application and credentialing coordinators to connect the final dots and create a credentialing pathway for pharmacist providers that actually works!
- Expertise: Our profession is navigating the complexities of credentialing. A few short years ago, I spent DAYS trying to gather materials, figure out how to answer application questions, determine what the application process included and uncover what was required for each health plan. Even determining which medical plans were in my area was challenging. Collecting all of the necessary details and information can be challenging enough. Beyond that, I found that letting credentialing specialists handle obtaining the application requirements, submission and follow up made a huge difference. Instead of investing time in learning an entirely new process, I could concentrate on preparing the pharmacy, teams and patients for practice transformation and delivery of patient care. Just as health systems and clinics benefit from support teams handling all credentialing and enrollment tasks, it's high time community pharmacies had the same infrastructure support.
- Outcomes: Our impact is the ultimate measure of success. We must provide quality programs that lower the total cost of care. Identifying patients within our workflow and pharmacy panel who need clinical programs and medication interventions is key. Then we must create meaningful quality interventions (acute and chronic) and address public health needs. As a profession of participating providers, submitting quality interventions on patient panels gives us a greater voice for alternative payment models. Bottom line – we must start seeing patients!
My lessons learned are immense and it has become a passion of mine to share with the profession. I hope you found this inspirational and are ready to get started exploring clinical programs and provider credentialing with medical plans today. There are various pathways to contribute to revolutionizing pharmacy practice in your state. One of my favorite TED talks is “How To Start a Movement” by Derek Sivers. Let’s do this! Let’s come together as pharmacists. Let’s all be those first followers. With determination, we can pave the way for the pharmacy profession. We as community pharmacists can finally bill as medical clinics, ultimately improving changing the delivery model of patient care!
