Recognizing pharmacists as healthcare providers-a solution for the Patient Protection and Affordable Care Act roll-out

It is estimated that 30 million people will gain access to medical care beginning in 2014, with implementation of the Patient Protection and Affordable Care Act (ACA). Administratively, the federal government and most states have not worked out the details of how patients will gain access to the healthcare system, let alone receive care. Primary care providers (PCPs) are ill-prepared to accept this enormous influx of new patients, which will place an even greater strain on the already strapped primary care workforce. Estimates are that an additional 17,000 PCPs are currently needed, and another 40,000 PCPs may be needed by 2025 to care for the nation’s aging population.¹ How best to handle this large influx of patients into the healthcare system is at issue.

As described in the ACA, one of its key benefits is the increased availability of preventive care services. These services range from immunizations to wellness visits for Medicaid and Medicare patients. Expansion of these services will put an increased workload on already time-strapped healthcare providers. In addition, patients in rural or medically underserved areas may not receive access to these benefits because of severely limited access to providers. The average American lives within 5 miles or less of the nearest community pharmacy. And that puts community pharmacy in a unique position to help America close the gap on patient access, and bring greater affordability to healthcare costs.

A significant amount of time (estimated at 37%) within a primary care physician’s daily activities is related to chronic care management, ³ which often includes managing complex medication regimens. In many instances, these are not sufficiently reviewed during brief and episodic medical office visits. Appropriate management of such chronic conditions requires patient-specific data that should be obtained from patients’ medication histories for prescription, over-the-counter, and nutritional supplements. These should be supplied by the healthcare provider who has the most direct contact with medication-related decisions-the pharmacist. 

The best-performing primary care teams should include other healthcare practitioners, including pharmacists, who have skills complementing those of the physician to achieve improvements in quality and to increase physician productivity.⁴ While the pharmacist workforce is well-trained and highly accessible, these widely distributed community-based healthcare professionals are underutilized.⁵

As pointed out in a New York Times article, “When the Doctor Is Not Needed,” pharmacists are capable of adjusting medications, ordering and interpreting laboratory tests, and coordinating follow-up care, but state and federal laws complicate this even though patients prefer the convenience of dealing with pharmacists.⁶

Pharmacists represent the third-highest number of licensed healthcare providers in the United States (about 300,000), trailing only nurses and physicians in number. Unfortunately, many other healthcare providers, policy-makers, and payers fail to recognize that pharmacists presently are not recognized as non-physician healthcare providers under the Social Security Act (Section 1861 for Medicare), thus diminishing their ability to contribute to improved patient outcomes. The following non-physician providers, however, are recognized in the Social Security Act: Audiologists, certified nurse midwives, certified registered nurse practitioners, certified registered nurse anesthetists, physician assistants, licensed clinical psychologists, licensed clinical social workers, physical and occupational therapists, and registered dieticians/nutrition professionals.⁷

Interestingly, the education and training requirements to become a pharmacist include as much, and sometimes more, training as several of the presently recognized healthcare providers. As of 2004, all graduates of accredited academic pharmacy programs in the United States who earn the doctor of pharmacy degree (PharmD) have prescribed internship requirements and various licensure requirements at both the federal and state levels.

This exclusion of the pharmacy profession appears incongruent with legislative changes and policy initiatives observed over the years in the United States. There are multiple models of care where pharmacists are practicing within the full scope of their licensure, and when these practitioners (ie, pharmacists) are included as members of the healthcare team, patient outcomes improve.

The Veterans Administration (VA), Indian Health Service (IHS), and Department of Defense have recognized the unique and valuable contributions that pharmacists can provide to beneficiaries for the past 30 years. In many cases, pharmacists have equal credentials to nurse practitioners and physician assistants in the inpatient setting and outpatient clinics of the VA, after an appropriate credentialing processes. The IHS Pharmacy Standards of Practice includes a standard specifically on pharmacists’ ability to “manage therapy/care for selected patients in whom drugs are the principal method of treatment,” now commonly referred to as medication therapy management (MTM).⁸ Medicare Part D recognized the value of MTM services, by requiring all providers of the prescription benefit to offer such services to Medicare Part D beneficiaries, most often provided by pharmacists.⁹

The Public Health Service of the US Department of Health and Human Services (HHS) has deployed pharmacists as clinical pharmacy specialists for many years. In 1996, pharmacists were authorized to have prescriptive authority as PCPs within the IHS. Such recognition of pharmacists as PCPs allowed them to have medication prescribing authority and deliver primary care to eligible beneficiaries.¹⁰

Single provider identification

In 2004, the Centers for Medicare and Medicaid Services issued a directive based on a Final Rule from the HHS for the establishment of the National Provider Identification (NPI) as the single provider identification for healthcare providers. The directive stated, “The Health Insurance Portability and Accountability Act (HIPAA) of 1996 requires the adoption of a standard unique identifier for healthcare providers identifies as . . .  All healthcare providers who are HIPAA-covered entities, whether they are individuals (such as physicians, nurses, dentists, chiropractors, physical therapists, or pharmacists) or organizations (such as hospitals, home health agencies, clinics, nursing homes, residential treatment centers, laboratories, ambulance companies, group practices, HMOs, suppliers of durable medical equipment, pharmacies, etc.) must obtain an NPI to identify themselves in HIPAA standard transactions.”¹¹ This action by the HHS further demonstrates the incongruence of one agency in government requiring pharmacists to obtain an identification as a healthcare provider, yet not recognized by another group within the same organizational unit (ie, Medicare).

A recent report from the office of the Surgeon General provides an evidence-based discussion of the impact of pharmacist-provided patient care on healthcare quality, safety, and costs. The report outlines current barriers such as lack of healthcare provider status for pharmacists in national healthcare policy and lack of compensation models for cognitive (eg, nondispensing) pharmacist services.¹² Multiple emerging care delivery models (eg, patient-centered medical homes and accountable care organizations) promote interdisciplinary collaboration and communication as well as care coordination across multiple providers and settings, including pharmacists. With respect to patient acceptance of this role of the pharmacist, there are multiple studies in which patients report higher rates of satisfaction. In addition, overall healthcare costs are reduced.¹³

Not recognizing pharmacists as healthcare providers could have other significant unintended consequences. For example, this could reduce the profession’s access to healthcare information technology that is vital to ensure appropriate medication use and outcomes in patients cared for by pharmacists. Limiting pharmacists’ ability to access and submit clinical information obtained at the point of care (often taking place in community pharmacies) through electronic health records would severely diminish the delivery of effective and efficient care. Continued exclusion of pharmacists from provider status recognition could negatively impact patient outcomes and result in unnecessary health-related costs, as the third largest healthcare provider is unable to communicate with other healthcare team members and patients alike.

Medications continue to rank as the primary intervention in healthcare. Four of 5 patients who visit a medical provider leave with at least 1 prescription, resulting in 3.5 billion prescriptions written annually and accounting for $310 billion in US pharmaceutical sales.¹⁴ Medication-related problems cost approximately $300 billion annually.¹⁵ Thus, total spending related to medication use may more accurately approximate $600 billion annually. How this monumental healthcare spending and workload for all healthcare providers has been ignored for this many decades is hard to continue to justify.  Yet the pharmacy profession clearly is one of the most logical health disciplines to lead interventions to curtail such inefficiencies, costs, and harmful effects as they relate to the entire medication use system.

The Institute of Medicine and other groups such as the Patient-Centered Primary Care Collaborative recognize that assuring the optimal use of all medications (prescribed and over-the-counter) through various monitoring and counseling services in an interdisciplinary fashion is essential to ensure that the intended patient outcomes are achieved.¹⁶ A recent study of private insurance beneficiaries demonstrated that every dollar invested in the delivery of MTM services by community pharmacists saved $12 in total annual health expenditures.¹⁷ Another way to look at this would be if an organization (inpatient or ambulatory) invested in the salary of a pharmacist at $100,000 annually to provide MTM services (not associated with product distribution), the organization could realize $1.2 million in related healthcare savings.

Pharmacists are readily accessible within their communities and patients often interact with them more than with their PCPs. Such access to highly educated and trained practitioners is evident in that more than 200 million Americans visit a community pharmacy within a 6-month period each year.¹⁸ Convenience is exemplified when consumers can make their own healthcare choices. For example, in 2010, 18.4% of adults received vaccinations at a pharmacy (39.8% in the doctor’s office, and 17.4% at the workplace).¹⁹ Patients also appear to value pharmacist services-pharmacists continue to earn high marks for being respected and trusted by consumers, rating at the top of the Gallup Poll for professional ethics and honesty over the past 20 years.²⁰

Patients value an accessible healthcare practitioner who is knowledgeable about multiple conditions and treatments, and provides timely and professional advice. With respect to access in the community, possibly, having pharmacies as the initial intake of new patients seeking care resulting from the ACA would be a logical consideration given the accessibility and convenience of pharmacists in most communities. When Medicare Part D was implemented in 2006, the pharmacy profession played a significant role in the education and uptake of this benefit to Medicare beneficiaries.

Acknowledging (and then supporting legislatively) that pharmacists be recognized as non-physician providers in the Social Security Act will allow licensed pharmacists to work collaboratively with physicians and other providers to optimize medication therapy in patients and deliver patient-centered care. Having all practitioners, including pharmacists, practicing at the top of their licensed scope of practice and recognized for this, will allow providers in their respective disciplines to deliver care that produces desired patient outcomes in a coordinated and collaborative manner across multiple healthcare systems and settings. ■

REFERENCES

1. Smith M. Pharmacists and the primary care workforce. Ann Pharmacother. 2012;46:1568–1571.

2. DrugstoreNews.com. What pharmacy can do to plug the gaps in healthcare. (March 2012) http://www.nacds.org/pdfs/pr/2012/rximpact-0312.pdf. Accessed May 28, 2013.

3. Ghorob A, Bodenheimer T. Sharing the care to improve access to primary care. N Engl J Med. 2012;366:1955–1957.

4. Grumbach K, Bodenheimer T. Can health care teams improve primary care practice? JAMA. 2004;291:1246–1251.

5. Smith M, Bates DW, Bodenheimer T, Cleary PD. Why pharmacists belong in the medical home. Health Aff (Millwood). 2010;29:906–913.

6. New York Times. When the doctor is not needed.  December 15, 2012.

7. Social Security Act.  Available at: http://www.ssa.gov/OP_Home/ssact/title18/1861.htm. Accessed May 28, 2013.

8. US Department of Health and Human Services, Indian Health Service. Indian Health Manual, Part 3, Chapter 7. Manual Appendix A: IHS Pharmacy Standards of Practice. Available at:    http://www.ihs.gov/IHM/index.cfm?module=dsp_ihm_pc_p3c7_ap_a. Accessed May 28, 2013.

9. Centers for Medicare and Medicaid Services. Medication therapy management.

http://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovContra/MTM.html. Accessed May 28, 2013.

10. US Department of Health and Human Services. Indian Health Service. Designation of pharmacists as primary care providers with prescriptive authority. October 18, 1996. Available at: http://www.ihs.gov/ihm/index.cfm?module=dsp_ihm_sgm_main&sgm=ihm_sgm_9602 . Accessed May 28, 2013.

11. The National Provider Identifier (NPI).  Centers for Medicare and Medicaid Services.

http://www.cms.gov/Regulations-and-Guidance/HIPAA-Administrative-Simplification/NationalProvIdentStand/downloads/npi_fs_geninfo_010906.pdf. Accessed May 28, 2013.

12. Giberson S, Yoder S, Lee MP. Improving patient and health system outcomes through advanced pharmacy practice.  A report to the U.S. Surgeon General. Office of the Chief Pharmacist. U.S. Public Health Service. December 2011. http://www.usphs.gov/corpslinks/pharmacy/documents/2011AdvancedPharmacyPracticeReporttotheUSSG.pdf. Accessed May 28, 2013.

13. Isetts B, Schondelmeyer SW, Heaton AH, et al. Effects of collaborative drug therapy management of patients’ perceptions of care and health-related quality of life. Res Social Adm Pharm. 2006;2:129–142. 

14. Institute for Healthcare Informatics. The use of medicines in the United States: review of 2011. April 2012. Available at: http://www.imshealth.com/ims/Global/Content/Insights/IMS%20Institute%20for%20Healthcare%20Informatics/IHII_Medicines_in_U.S_Report_2011.pdf. Accessed May 28, 2013

15. New England Healthcare Institute (NEHI). NEHI research shows patient medication nonadherence costs health care system $290 billion annually. August 11, 2009. Available at: http://www.nehi.net/news/press_releases/110/nehi_research_shows_patient_medication_nonadherence_costs_health_care_system_290_billion_annually  Accessed May 28, 2013

16. Patient-Centered Primary Care Collaborative. Integrating comprehensive medication management to optimize patient outcomes. Available at:

 Accessed May 28, 2013

17. Isetts B, Schondelmeyer SW, Artz MB, et al. Clinical and economic outcomes of medication therapy management services: the Minnesota experience. J Am Pharm Assoc. 2008;48:203–214. doi:10.1331/JAPhA.2008.07108.

18. Doucette WR, McDonough RP. Beyond the 4Ps: using relationship marketing to build value and demand for pharmacy services. J Am Pharm Assoc. 2002;42:183–193.

19. Centers for Disease Control and Prevention. March flu vaccination coverage: United States, 2011-12 influenza season. Available at: http://www.cdc.gov/flu/professionals/vaccination/nfs-survey-march2012.htm#place. Accessed May 28, 2013

20. Gallup. Honesty/ethics in professions. November 26–29, 2012. Available at: http://www.gallup.com/poll/1654/honesty-ethics-professions.aspx. Accessed May 28, 2013

Dr MacKinnon is founding dean and professor of the College of Pharmacy, vice provost for Health Sciences, Roosevelt University, Chicago, and also serves as an editorial advisor to Formulary.