New Legislation Aims to Reimburse Essential Pharmacist Services

By Matt Devino, MPH

The Pharmacy and Medically Underserved Areas Enhancement Act (H.R. 2759/S. 1362) was introduced in both the House and Senate in late April 2021. The legislation would give Medicare beneficiaries living in medically underserved communities access to patient care services delivered by their state-licensed pharmacists. This would be accomplished by granting pharmacists “provider status,” and allowing them to bill Medicare Part B for their services. Such services would include only those permitted by individual states’ scope of pharmacy practice and those that Medicare Part B already reimburses when they are delivered by other providers.

Given that pharmacists may be the only local healthcare providers available in some geographic regions to provide critical services, and that 90 percent of the U.S. population lives within five miles of a pharmacy, pharmacists are well-placed to make up for geographic gaps in care. The range of services pharmacists can provide is wide: They are trained and qualified to administer immunizations; measure and monitor blood pressure and cholesterol; perform foot checks for patients with diabetes; furnish smoking cessation products; screen for depression and other mental health conditions; and perform point-of-care testing for blood glucose, cholesterol, influenza, strep, COVID-19, and more. 

Below, Scott Knoer, MS, PharmD, FASHP, executive vice president and CEO of the American Pharmacists Association (APhA), explains why the Pharmacy and Medically Underserved Areas Enhancement Act is important to patients. 

ACCC: How has APhA advocated recently for Medicare provider status recognition for pharmacists? 

Dr. Knoer: Right now, pharmacists are not eligible providers under Medicare, meaning they cannot directly bill for their services provided to Medicare beneficiaries. Other clinicians, such as physicians, nurse practitioners, and physician assistants are considered eligible providers.

Recently, APhA and the American Society of Health-System Pharmacists (ASHP) came together to obtain cosponsors for a bill that gives Medicare provider status to pharmacists. Now other organizations have joined in because they realize how important this is.  

ACCC: Can you explain what is included in H.R. 2759 and S. 1362 and why they are important specifically for patients in rural and underserved areas? 

Dr. Knoer: Right now, pharmacists are providing much-needed services to patients, such as smoking cessation, point-of-care testing, and immunizations. There is also a very important discussion going on right now in healthcare about racial disparities. Many pharmacies are closing in areas where there is a poor payer mix, mostly in underserved regions. More pharmacy deserts are forming in both cities and in rural areas, where few other local healthcare services are readily available. 

Unfortunately, the payment model for pharmacies is broken. Most pharmacists see a high volume of patients now, and without a reasonable payer mix, you cannot stay in business.  

Years ago, community pharmacists had time to talk with patients about their diabetes and help them more with medication management. Because pharmacy benefit managers (PBMs) pocket much of the reimbursement for medications, the only way for pharmacies to stay in business is to fill a high volume of prescriptions, leaving pharmacists without the time to adequately help patients manage their medications. We want pharmacists to be able to use what they went to school for to improve patient care. This bill would create a new revenue stream for pharmacists, who, under the pending legislation, would be able to bill the federal government for their services. 

There are many studies that have demonstrated  how valuable oncology pharmacists are to the interdisciplinary care team. Pharmacists possess unique skills that can benefit the quality of care provided to patients. This bill would give Medicare patients with the most need access to these services.  

ACCC: How do oncology pharmacists contribute to comprehensive cancer care? 

Dr. Knoer: It is all about the team and interdisciplinary care. Everyone on the team is important. The physician is like a quarterback and needs other  disciplines such as nurses, social workers, and pharmacists on their team. Pharmacists have a unique knowledge and skill set. They are highly trained in pharmacology, more than other members of the team, and they understand the intricacies of drug management. Pharmacists can educate patients about drug interactions and side effects.  

In my previous practice as chief pharmacy officer at Cleveland Clinic, I knew whenever we increased the number of pharmacist FTEs, it improved the quality of care we provide by increasing medication compliance and reducing adverse events for patients. The oncology specialty is so complex, and the therapies can be very expensive. It is critical to make sure patients are using the right medications, correct dosing, and assessing for drug interactions. There is no room for error in many oncology drugs that are highly sensitive to treatment changes. Pharmacists are integral in every specialty, but in oncology, the opportunity for error is so small and the costs can be very high if a mistake is made.  

ACCC: Are any other legislation or advocacy efforts being headed by APhA?  

Dr. Knoer: Yes, we are very focused on looking at the currently unsustainable pharmacy reimbursement system, primarily in community pharmacies, but this can also occur in health systems. Pharmacists can bill “incident to,” but they cannot directly bill for their services. The other big problem is PBMs, who are the middlemen. They make a lot of money by taking profit out of pharmacy benefits by setting high prices on drugs. We recently joined a lawsuit with our partners at the National Community Pharmacists Association (NCPA), and we are suing the Department of Health and Human Services related to the use of indirect remuneration fees (DIR) and how they are retroactive claw backs that harm pharmacies. We are also looking at working with other pharmacist organizations, primarily NCPA, to introduce a bill to reign in DIR fees. We are always advocating, and we are not slowing down.  

Kristin Marie Ferguson, DNP, RN, OCN, is the ACCC senior director of cancer care delivery and health policy.