Speakers at AMCP 2022 shared updates on current legislative efforts related to pharmacist provider status implementation, including how reimbursing pharmacists could drive improvements in both quality and clinical outcomes.

The session began with Stuart Beatty, PharmD, BCACP, FAPhA, director of strategy and practice transformation, Ohio Pharmacists Association, polling attendees on their current knowledge of provider status for pharmacists.

“There are 2 different kinds of pathways for payment, the pharmacy side and the medical side,” Dr Beatty explained. “Provider status is the pharmacy side of the benefit.”

He went on to explain pharmacy benefit billing includes pharmacist-specific codes for medication management therapy (MTM), payment with dispensing (including drug utilization review [DUR]), and metrics related to adherence.

Medical benefit billing options include evaluation/management codes and payment is historically tied only to quantity of services provided. Associated metrics include wellness, clinical cutoffs, utilization, and costs.

“In both sides of the benefit, the metrics are moving toward value-based arrangements,” continued Dr Beatty.

Changing historical payment models requires an active congress, Dr Beatty said; however, change at the state level does not. The state of Ohio serves as an example due to high PBM scrutiny, which prompted a lot of state legislators to look closer at working with pharmacists to improve care and in turn opened the door for success.

A number of other states have provider status legislation in progress, but Ohio passed senate bill 265 in the 132nd General Assembly and signed it into law January 2019. Under this legislation, pharmacists are included in language as providers, permitted insurer coverage, and are able to launch pilot programs without a mandate.

A number of organizations in Ohio implemented provider status already, including UnitedHealthcare Community Plan, Buckeye Health Plan, CareSource, and Molina Healthcare.

Under the pharmacist provider status rule in Ohio, pharmacists can:

• sign up for Medicaid ID number;
• enroll with Medicaid and MyCare plans; and
• bill for services provided all rules are met.

Nicholas Trego, PharmD, associate vice president of Ohio pharmacy market, Caresource, Meera Patel-Zook, PharmD, vice president, pharmacy operations, Buckeye Health Plan/Centene Corporation, and Kimberly Broyles-Kpogli, PharmD, director of pharmacy, Molina, continued the session by walking through a roadmap for implementing pharmacist provider status and sharing successes from their respective pilot programs.

Among the first steps is identifying the key stakeholders involved in the process which includes the health plan, health system, pharmacies, and pharmacists. Next, the speakers underscored the need to establish collaborative practice agreements between pharmacists and providers and outlining the scope of services pharmacists can provide. Dr Trego emphasized the importance of credentialing—which can be a slow, lengthy process.

Dr Broyles-Kpogli discussed the need to determine appropriate reimbursement based on Medicaid/Medicare fee schedules.

Lastly, before engaging with providers and implementing the program, the speakers noted the need to leverage NCQA HEDIS measures, medication reviews, medication adherence, readmission rates, and more.

A Look at Pilot Programs

Dr Patel-Zook shared insight from the pilot program launched with Buckeye Health Plan—which has worked extensively with Ohio health systems and retail pharmacies. Buckeye includes 2 federally qualified health centers (NEON and Primary Health), 1 hospital system (The Christ Hospital), 10 independent pharmacies, and 1 chain pharmacy.

The pilot program with Buckeye focused on holistic disease state management, reducing health care spending, improving member experience, and enhancing provider partnerships.

Buckeye’s pilot program demonstrated a number of successful outcomes, including directly improving the health of members. Speakers shared feedback from a patient with diabetes who said, “Just want you to know that being my ‘accountability partner’ has really helped me to stay on the straight and narrow as far as my medication compliance is concerned. My numbers haven't looked this great in years.”

Dr Patel-Zook went on to say that they have several examples of concrete improvements in patient outcomes related to the pilot program. Under the program, pharmacists can go above and beyond connecting with patients to learn more about social determinants of health or other factors that are affecting care and outcomes. One pharmacist had a 45-minute conversation with a member and discovered transport and financial problems that were preventing the member from seeking necessary care. The pilot program helped make that connection and improve access.

Dr Trego of Careport spoke further about how pilot programs were designed at two participating locations, Camden Village Pharmacy in Camden, OH, and ZIKS Family Pharmacy in Dayton, OH. These two pilots focused on 4 disease states: smoking cessation, naloxone therapy, diabetes care, and asthma care.

These two pilots of pharmacist interventions were able to fill gaps in care and make significant improvements. Dr Trego highlighted the following top successful interventions:

• ​​​​80% of patients had an increase in asthma control test scores
• 75% of patients saw a reduction in blood glucose
• 50% of patients reduced tobacco usage
• 80% of patients began tobacco cessation medications

He noted naloxone therapy did not see significant uptick, but 3 patients were counseled and provided care. The program also created more opportunity to connect with patients and he’s hopeful it could improve further.

Other significant outcomes related to pharmacist interventions included avoided emergency department visits, additional diet counseling, and a foot ulcer diagnosis that might have otherwise been missed.

Molina Healthcare implemented targeted interventions at 10 independent pharmacies across Ohio based on patient populations.

One of the most successful interventions, Dr Broyles-Kpogli explained, were the initiatives related to addressing depression and anxiety conditions.

Under this program, “Pharmacists administer PHQ9 or GAD7 tests to patients who are regularly filling antidepressants or antianxiety medications. Based off these scores, the pharmacist can make interventions to help patients maximize their therapy and improve their scores and wellbeing.”

Through the intervention, pharmacists educated members on their medications and offered counsel to optimize therapy effectiveness, as well as reached out to prescribers to recommend. Under this intervention, 73% of patients reported stable or improved PHQ9/GAD7 scores after follow up. About 27% reported worse scores but continued to receive services and support.

Overall, Dr Beatty underscored the benefits of pharmacists as accessible health care professionals and if incentives are aligned with other health care professionals, these pharmacist interventions can improve care.