Overview Recognizing Pharmacists as Background and History on Provider Status Providers Public Health Need and Public Policy Fulfilling an Unmet Patient Need Solution Patient Access to Pharmacists’ Care NMSHP 2014 Balloon Fiesta Symposium Coalition October 5, 2014 Brian M. Meyer, M.B.A. Current Legislative Proposal Director, Government Affairs ASHP Individual and Collective Actions Background and History Background and History Medicare enacted in 1965 — no prescription 2003 Medicare Modernization Act provides drug benefit for Part D prescription drug coverage and Part A: Hospital insurance medication therapy management services Part B: Physician outpatient services 2010 Affordable Care Act expands coverage Pharmacists not recognized as “non -physician and establishes: practitioner” Accountable Care Organizations 1977- 97 Nurse Practitioners and Physician Patient Centered Medical Homes Assistants slowly and incrementally gain Pay for Performance with quality and outcomes provider status measures required for hospitals Projected Change in Medicare Enrollment, 2000-2050 Public Health Policy Problem Medicare Enrollment Average Annual (in millions) Growth in Enrollment Unmet Need: 100 10% 92.4 Access to Primary Health Care 88.9 90 9% 81.5 80 8% 64.3 Growing number of Medicare beneficiaries 70 7% 60 6% Increasing patients with 1+ chronic conditions 47.7 50 5% 39.7 Newly covered patients via Affordable Care Act 40 4% 3.0% Projected Physician Shortage 30 3% 2.4% 1.9% 20 2% 0.9% 10 1% 0.4% 0 0% 2000 2010 2020 2030 2040 2050 SOURCE: 2013 Annual Report of the Boards of Trustees of the Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds. 1
Percentage of Medicare Fee for Service Beneficiaries by Number of Chronic Conditions Source: AAMC Center for Workforce Studies, June 2010 Analysis Centers for Medicare and Medicaid Services. Chronic Conditions among Medicare Beneficiaries, Chartbook, 2012 Edition. Baltimore, MD. 2012. Public Policy Solution: Provider Status is About Patients Provider Status Pharmacists collaborate to play greater role Provide patients’ access within state scope of practice Health and wellness testing Achieving provider status is about giving patients Managing chronic diseases access to care that improves: Performing medication management Patient safety Administering immunizations Healthcare quality Transitions across the care continuum to reduce Outcomes emergency department visits and readmissions Decreases costs What is Provider Status? Who Has Provider Status? Physicians Certified nurse Being listed in section 1842 or 1861 of the Social anesthetists Nurse practitioners Security Act as a supplier of medical and other health services. Speech-language Physician assistants pathologists Becoming a “provider” in the Social Security Act Certified nurse means: Audiologists midwives Pharmacists can participate in Part B of the Registered dietitians Psychologists Medicare program and bill Medicare for services Physical therapists Clinical social workers that are within their state scope of practice to perform. 2
Why is provider status important for What is H.R. 4190? pharmacists? Pharmacists are not recognized under the A bipartisan bill that will amend the Social Security Act to recognize pharmacists as Medicare Part B Social Security Act as health care providers providers in medically underserved communities Introduced by Representatives Guthrie New payment systems emphasize quality (R-KY), Butterfield (D-NC) and Young (R- IN) in the House of Representatives on and outcomes March 11, 2014 Nearly 100 bipartisan cosponsors include two physicians: Reps. Roe (R- Accountable Care Organizations TN) and Bera (D-CA). Applies to licensed pharmacists Medical Homes working within their state’s scope of practice laws Social Security Act determines eligibility Establishes a mechanism of pay for pharmacist provider services under Medicare H.R. 4190 Why does H.R. 4190 only cover medically Specifics underserved communities? Amends Section 1861(s)(2) of the Social Security Act to include: Help meet unmet health care needs Pharmacists services furnished by a pharmacist licensed by State Increase access law Improve quality Which the pharmacist is legally authorized to perform in the Decrease costs State Follow similar successful paths taken by In setting located in/for and defined in federal law: other health care professionals to gain Medically underserved area provider status Medically underserved population Health professional shortage area What are medically underserved Patient Access to Pharmacists’ Care Coalition communities? (PAPCC) Formed January 2014 Medically Group of more than 20 organizations Underserved Areas representing patients, pharmacists, Medically pharmacies and other interested stakeholders Underserved Populations Drafted H.R. 4190 to expand medically- Health Professional underserved patients’ access to pharmacist Shortage Areas services consistent with state scope of practice 3
Patient Access to Pharmacists’ Care Coalition Why Do Pharmacists Want Provider Status When Fee-For- Service is Going Away? (PAPCC) Over the next 5 or more years traditional fee-for-service will be phased out and Current Members Current Members replaced with new payment systems that emphasize quality, outcomes, and team- based patient care. ASHP Albertson's APhA Amerisource Bergen Pharmacists recognize that traditional fee-for-service is not the model of the future, Bi-Lo Pharmacy AACP and we view ourselves as members of interprofessional teams collaborating with Cardinal Health physicians, nurses, and others throughout the continuum of care. ASCP CVS Caremark Food Marketing Institute NCPA However, the Social Security Act (SSA) remains the reference point for which Fred's Pharmacy NACDS practitioners are eligible to participate in current, new, and emerging delivery Fruth Pharmacy systems and payment models (see ACO example). NASPA Rite Aid Safeway Inc. IACP Therefore, for pharmacists to fully participate in current and emerging delivery and SuperValu Pharmacies Walgreens payment systems, pharmacists need to be listed in the SSA along with other Thrifty White Pharmacy providers. Winn-Dixie. Why isn’t ASHP calling for credentialing Does H.R. 4190 require pharmacists to be residency requirements given that ASHP started pharmacy trained, Board certified, or possess other credentials? residencies and supports Board certification? A: No, just like other health care professionals who are recognized as providers, H.R. 4190 requires pharmacists to A: ASHP supports these concepts, but they do be licensed by a state, and the state legislature and board not belong in federal law. of pharmacy, health care organizations, and private health plans determine what credentials are required to perform certain services (e.g., CA: “Advanced Practice Pharmacist” Instead, credentialing and privileging NM: “Pharmacist Clinician”). requirements are for states and organizations to decide through state pharmacy practice acts, Most hospitals and health systems have a process to private health plan requirements, and credential and privilege pharmacists based on the type and credentialing and privileging requirements by level of patient care services they provide. hospitals and health systems. What will a pharmacist provider be referred Why only medically underserved and not to when H.R. 4190 is signed into law? broader? A: Fulfills an unmet need; provides a foot in A: A pharmacist. the door. There is no need to create a new category of Other health professionals have taken a pharmacist in federal law. One group has similar initial approach (e.g., Nurse suggested that a new pharmacist category — Practitioners and Physician Assistants). ”Qualified Clinical Pharmacist”— be codified in federal law and therefore distinguished from all Also limits opposition and brings down the other pharmacists. States and health care cost of the legislation. organizations may do such things, but it is Will likely expand in the future. inadvisable to do so at the federal level. 4
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