By: Mah Noor, PharmD Candidate c/o 2021

             Over the past decade, pharmacists across the nation have joined in a number of grassroots efforts to gain legislative recognition as health care providers. As of 2019, thirty-four states have recognized pharmacists as providers in at least one section of their state statute or in their state Medicaid program. In at least six states, pharmacists are not recognized as providers in their statute or Medicaid program, but are compensated for providing targeted patient care services. ¹ The lack of correlation between payment and recognition of provider status is likely due to pharmacists not being recognized as providers by the federal government. However, states that have implemented changes in the pharmacy practice model have allowed pharmacists to broaden their scope of practice. Allowing them to provide patients with valuable care in line with their training.

New York State (NYS) is one of the states that does not recognize pharmacists as providers or provide compensation for their medical services. On March 7th, 2020, Governor Andrew Cuomo of New York issued an Executive Order No. 202.24 allowing pharmacists to test for COVID-19, but it did not mention pharmacists being compensated for testing. ² This is not the first time pharmacists have not been adequately and fairly compensated for their services which includes patient care services such as medication coordination, medication therapy management, chronic disease management, and patient education. Allowing pharmacists to conduct COVID19 testing is a short-term fix, they should be allowed to fully use their skills and expertise. Pharmacists aren’t just dispensers but play a crucial role on a healthcare team as seen with Collaborative Drug Therapy Management (CDTM), which has shown to improve health outcomes, provide higher quality of care, and reduce cost. Pharmacists have the ability to prescribe or modify medications under CDTM but they cannot bill for the service. NYS was the 41st state to allow CDTM in 2011. ³ Currently, pharmacists can administer any Centers for Disease Control and Prevention (CDC)-recommended vaccines in 47 states plus Puerto Rico except New York. ⁴ In New York pharmacists cannot administer Hepatitis A and B, varicella, human papilloma virus and measles, mumps, and rubella. NYS is the only state which does not allow pharmacists to administer Hepatitis A and Hepatitis B.  ⁵ Dozens of states have expanded the role of pharmacists in providing patient care but NYS is behind. NYS was the 48th state to allow pharmacy interns to immunize in late 2018, 46th state to allow pharmacy technician certification and registration, and 44th state to allow pharmacists to give the influenza vaccine in pediatric patients in 2018. ⁷  53 out of 62 counties in NY are medically underserved areas and there are over 19,500 pharmacists in NYS who have the skills to provide high-quality patient-centered care. ⁷

In 1979, Washington State legislature dramatically expanded pharmacist scope of practice by allowing for collaborative practice agreements (CPAs). This paved the way for other states to allow a pharmacist-prescriber collaboration practice which has shown to increase the efficiency and coordination of care, and leverage pharmacists’ medication expertise. ⁸  In 2015, private insurers were required to include pharmacists in their provider networks. Thus, a medical service must be covered if provided by a pharmacist as long it is within the pharmacy scope of practice. Now ambulatory care pharmacists are routinely paid for services, pharmacists in primary care are also billing successfully for office visits, and more community pharmacies are billing for medical claims. ⁸  Even though NYS allows CDTM, similar to CPA, the authority to engage in CDTM is set to sunset by July 2022. Every two years, pharmacists have to advocate for the renewal of CDTM thus New York State Council of Health-system Pharmacists has been pushing and advocating for bill A3048 (Seawright) “Collaborative Drug Therapy Management – Expansion and Elimination of Sunset”. ³  In Idaho, pharmacists are allowed to administer walk-in immunizations, point-of-care diagnostic tests, and independent prescribing of medications for common illnesses such as the flu, urinary tract infections, and smoking cessation. ⁹  How does it work? The patient presents to the pharmacy with acute symptoms and completes forms on medical history and the symptoms. The pharmacist conducts a physical assessment of vital signs and based on the screening forms he/she decides whether the patient is a candidate for independent prescribing in the pharmacy or should be referred to a primary care provider. If the patient qualifies for independent prescribing and meets the criteria for treatment, the pharmacist can write the prescription and dispense it. The pharmacist must notify the patient’s PCP within 24 hours and document follow-up with the patient. ¹⁰ Four states have created advanced practice pharmacist designations in state law: advanced practice pharmacist (California), clinical pharmacist practitioner (Montana and North Carolina), and pharmacist clinician (New Mexico). Under these designations, pharmacists can order and interpret drug therapy-related tests, and initiate or adjust/modify medications under CPA. ¹¹ Eleven States (California, Colorado, Hawaii, Maryland, New Hampshire, New Mexico, Oregon, Tennessee, Utah, Washington, and West Virginia) allow pharmacists to provide and dispense self-administered contraceptives without a prescription under requirements set by individual state laws. Only in Oregon, pharmacists can also prescribe and administer injectable contraceptives. ¹²

Why is it important to advocate for Pharmacist Provider Status? Pharmacists are one of the most underutilized health care professionals. They are on the front-line dispensing medications, counseling patients, and providing direct patient care in hospitals or ambulatory clinics. By 2025, the U.S. could see a shortage of as many as 31,100 primary care physicians. Even if nurse practitioners and physician assistants are fully utilized, patient needs will not be fully met.¹³ We have pharmacists who can manage chronic diseases, including high blood pressure, diabetes and high cholesterol. Yet due to limitations on both federal and state levels, as seen in New York, scope of practice is being restricted and no reimbursement for services are being provided. CPAs have been shown to improve outcomes in patients with hypertension, diabetes, clotting disorders and high cholesterol while lowering adverse drug reactions and costs.  ¹⁴ Immunization rates across the U.S. have continued to increase since pharmacists began vaccinating. ¹⁵ Any advancements that have been made thus far on state levels has been due to the advocacy work of pharmacists and pharmacy students across the country. A small proportion of our legislators have a medical background; even fewer have a pharmacy background. It is our job to educate lawmakers on pharmacy thus future pharmacists can treat patients to the full extent of their knowledge and abilities.

Rebecca P. Snead, BSPharm, NASPA Executive Vice President and CEO stated, “The large number of states who already have recognized pharmacists as providers or practitioners is both exciting and sobering news, It’s exciting because it shows us that there are fewer statutory barriers to payment for pharmacists’ patient care services, but also is a reminder that there is much work to be done beyond legislative advocacy.” ¹

Sources

1. Weaver, K. NASPA finds state-level provider status is widespread, but not necessarily linked to payment. National Alliance of State Pharmacy Associations. Published February 02, 2014. Assessed September 27, 2020. https://www.pharmacytoday.org/article/S1042-0991(15)30990-7/pdf 
2. Cuomo, A. No. 202.24: Continuing Temporary Suspension and Modification of Laws Relating to the Disaster Emergency. (n.d.). New York State. Published March 07, 2020. Assessed September 27, 2020. https://www.governor.ny.gov/news/no-20224-continuing-temporary-suspension-and-modification-laws-relating-disaster-emergency 
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12. States Authorize Pharmacists to Prescribe and Dispense Contraceptives. (n.d.). Association of State and Territorial Health Officials. Assessed September 27, 2020.  https://www.astho.org/StatePublicHealth/States-Authorize-Pharmacists-to-Prescribe-Dispense-Contraceptives/06-06-19/ 
13. The Complexities of Physician Supply and Demand: Projections from 2013 to 2025. Association of American Medical Colleges. Assessed September 27, 2020. https://www.aamc.org/download/426248/data/thecomplexitiesofphysiciansupplyanddemandprojectionsfrom2013to2.pdf.
14. APhA. (n.d.). Expanding Patient Access to Care: Pharmacist Provider Status Supportive Data. Pharmacists Provide Care. Assessed September 27, 2020. https://pharmacistsprovidecare.com/sites/default/files/files/Provider-Status-Supportive-Data.pdf 
15. CDC. Flu Vaccination Coverage, United States, 2014-15 Influenza Season. Figure 1. Centers for Disease Control and Prevention.  Assessed September 27, 2020. https://www.cdc.gov/flu/fluvaxview/coverage-1415estimates.htm. Accessed 8/15/18.

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