Received: 25 April 2018 Revised: 6 June 2018 Accepted: 7 June 2018

DOI: 10.1002/jac5.1026

CLINICAL PHARMACY FORUM

Past, present, and continued need for provider status legislation:

Navigating clinical practice with significant sustainability barriers
Jennifer Bingham Pharm.D.1 | Nicole Scovis Pharm.D.2 | Ann M. Taylor MPH2 |
Sandra Leal Pharm.D., MPH1

1
SinfoníaRx, Tucson, Arizona
2 The pharmacy profession has advanced remarkably, however, pharmacists have yet to obtain pro-
University of Arizona College of Pharmacy,
Tucson, Arizona vider status at the federal level. Establishing pharmacists as providers is imperative in light of the
Correspondence growing shortage of primary care providers and need to provide care for medically underserved
Jennifer Bingham, SinfoníaRx, 100 N Stone populations. Academic reform, professional development and legislation have all contributed to the
Avenue, Tucson, AZ 85701. furtherment of provider status. Yet, the cornerstone to obtaining this status lies in imminent
Email: jmbingham@sinfoniarx.com
changes at the health care and interprofessional collegial levels in conjunction with professional
perseverance and legislative action. These actions will help ensure pharmacists as integral partners
on collaborative health care teams in clinical service provision for managing patients' chronic condi-
tions and medications, to ultimately, improve access to quality care and patient health outcomes.

KEYWORDS

patient care, pharmacy, policy

1 | I N T RO D UC T I O N Association as pharmacists.1 He further advocated that physicians prac-

While the pharmacy profession has progressed considerably over the past
two centuries, one hurdle still remains. Pharmacists have yet to obtain
provider status at the federal level and thus, must continually advocate for
this recognition. Yet, the health care system is facing multiple challenges,
evidenced by the growing shortage of primary care providers and the
need to provide care for medically underserved populations. Thus, estab-
lishing pharmacists as providers is of utmost importance and a critical step
in helping to address these challenges. To better understand the rationale
for establishing pharmacists as providers and integrating them in to the
health care team, it is important to reflect on some historical milestones
leading to the evolution of pharmacy practice including advocacy and
opposition, academic reform, professional development, legislative action,
provider status, and health care system changes.
2 | PHARMACY ADVOCACY AND
O P P OS I T I O N
ticing pharmacy should receive appropriate training from master phar-
macists. In the 20th century, Irving Rubin was a tireless campaigner for
the profession.2 His efforts led to the employment of a pharmacist in
the United States Capital, helping to advance the profession via
increased visibility and advocacy at the federal level. He also was piv-
otal in the development of the Oath of the Pharmacist.
2.2 | Tumultuous Times For The Profession
The early 20th century was a tumultuous period for pharmacists who
often faced criticism regarding their professional scope of practice. In
1915, educator Abraham Flexner, well recognized for his vital role in
higher and medical education reform, declared that “pharmacy was
not a profession. While the physician thinks; decides; and orders; the
pharmacist obeys….and does not originate.”3 Furthermore, the military
questioned whether pharmacy was an actual professional trade and
consequently refrained from commissioning pharmacy officers.4

2.1 | Pioneer pharmacy advocates 3 | ACADEMIC REFORM

In the 1800s, ethicist Edward Parrish proposed the importance of offi-
Early reform of the medical and dental curricula provided the impetus
cially recognizing apothecary members of the American Pharmaceutical
that spurred reform of the pharmaceutical curricula. Medical and dental

The copyright line for this article was changed on 23 August 2018 after original education changed as a result of the Flexner Report and Gies Report,
online publication. respectively.5 The landmark Elliott Report, officially known as the

32 © 2018 Pharmacotherapy Publications, Inc. wileyonlinelibrary.com/journal/jac5 J Am Coll Clin Pharm. 2018;1:32–37.

BINGHAM ET AL.
General Report of the Pharmaceutical Survey,5 was created in the
1940s in response to a post-war health care system. The report assem-
bled critical facts relating to then, present-day pharmaceutical educa-
tion, practices, and trade. It also sought to reform the profession by
formulating proposals designed for the progressive betterment of
pharmacy—a profession steadily striving to establish and maintain a dis-
tinctive place among the recognized health professions (ie, medicine,
dentistry).5 A major focus was to expand the profession's image and
scope as a “health service” by restructuring college curricula. Finally,
during the mid-20th century, the pharmacy profession embraced new
opportunities to further promote and advance pharmacists via creation
of the first doctorate of pharmacy curricula. As such, the Millis Commis-
sion on Pharmacy recommended addition of academic clinical educa-
tion in recognition of pharmacists' expanding patient care roles.2
4 | PROFESSIONAL DEVELOPMENT
4.1 | Expanding professional development
opportunities
The American College of Clinical Pharmacy (ACCP) defines clinical
pharmacy as a health science discipline whereby “pharmacists provide
patient care that optimizes medication therapy and promotes health,
wellness, and disease prevention”.6 In the 1960s, the American Soci-
ety of Health System Pharmacists (ASHP) joined forces to support the
advancement of clinical pharmacy.7 At roughly the same time in 1973,
the American Pharmacists Association (APhA) also endorsed the con-
cept of clinical pharmacy in practice.4
Shortly thereafter, the Board of Pharmaceutical Specialties,
founded in 1976, began recognizing pharmacists based on their phar-
macy practice specialty areas.8 During the 1980s, pharmacists contin-
ued shifting their primary responsibilities from medication dispensers
to a more vast, clinically recognized role that included vaccine admin-
istration, patient assessment, and enhanced patient care responsibili-
ties.8 In 2000, the Accreditation Council for Pharmacy Education
announced the conversion to the doctor of pharmacy (Pharm.D.) as
the sole entry-level degree for the profession, reflecting a paradigm
shift towards preparing pharmacists for more clinical responsibilities
rather than the traditional dispensing activities of yesteryear.9
5 | LEGISLATION FOR PHARMACISTS AS
PROVIDERS
5.1 | Pharmacists' roles
The expansion of the pharmacist's role in 1974 achieved a milestone
when Medicare required skilled nursing facilities to provide monthly
medication reviews by a “consultant pharmacist”.10 In 1990, the Fed-
eral Omnibus Budget Reconciliation Act was passed, further delineat-
ing pharmacists' role in performing drug utilization reviews as part of
their comprehensive medication regimen (eg, comprehensive medica-
tion review [CMR]) and counseling patients.11 The Model State Phar-
macy Act further identified pharmacy practice—“to provide
pharmacist care in all areas of patient care, including primary care,
33
medication therapy management, collaborative pharmacy practice, the
ordering, conducting, and interpretation of appropriate tests, and the
recommendation and administration of immunizations; and the
responsibility for compounding and labeling of drugs and devices,
proper and safe storage of drugs and devices, and maintenance of
required records”.12 In 1994, the first vaccine administration training
program was developed in response to the National Association of
Board's of Pharmacy's efforts. Immediately following this initiative,
the first collaborative practice agreement was created allowing phar-
macists to administer the influenza vaccine.2
5.2 | Payment for pharmacist services
In 2002, the Pharmacy Provider Coalition was formed to advocate for
pharmacists to receive recognition and payment for their services pro-
vided to Medicare Part B members.13 It consisted of several organiza-
tions, including the Academy of Managed Care Pharmacy, American
Association of Colleges of Pharmacy, ACCP, APhA, American Society
of Consultant Pharmacists, ASHP, and the College of Psychiatric and
Neurologic Pharmacists.14 Despite incremental progress in establish-
ing the role of pharmacists, the profession experienced a considerable
setback in 2004 when Congress rejected the Medical Clinical Pharma-
cists Practitioner Services Coverage Act. This Act would have given
advanced practice-designated pharmacists the ability to bill Medicare
Part B as mid-level providers, at 85% of physicians' reimbursement
rate.15 Instead, this was the beginning of an uphill battle to prove to
legislators that pharmacist-delivered services provided value on an
acute level as well as on a long-term basis. A big win for the Pharma-
cist Services Technical Advisory Coalition in 2005 was that the Ameri-
can Medical Association (AMA) added billing codes for Medication
Therapy Management (MTM), yet no actual payment structure nor
reimbursement was ever implemented based on these codes.
6 | PROVIDER STATUS
6.1 | More setbacks for pharmacists
Pharmacists worked on state and national levels to overcome the afore-
mentioned sustainability barriers (eg, opposition towards recognizing
pharmacists as professionals in the 20th century and legislative setbacks
in the 21st century). However, the majority of pharmacist provider advo-
cates incorrectly assumed the transition from fee-for-service models to
value-based services would facilitate pharmacist provider status. More-
over, to add to these mounting challenges, the Affordable Care Act of
2010 defaulted to the Social Security Act, further excluding pharmacists
as providers and making it impossible for them to bill for services.16
Lastly, the lack of pharmacists actively advocating for these initiatives
further limited progress towards provider status.
6.2 | New Triumphs for Pharmacist Providers
In 2009, after a nearly 5-year lapse in progress, the American Recov-
ery and Reinvestment Act included pharmacists and pharmacies as
health care providers.17 However, the Act was unsuccessful in achiev-
ing acceptance of pharmacists as providers among their health care
34
professional peers and community as this expanded level of participa-
tion in provision of care was not widely considered part of a pharma-
cist's scope of practice at that time. This lack of peer acceptance
remains a much larger issue and one that potentially involves interpro-
fessional education regarding pharmacists' expanded roles and
responsibilities, and ultimately, longer-term attitudinal change as well.
In 2010, the Patient Protection and Affordable Care Act gave
13
pharmacists the opportunity to provide home-based care services,
and receive reimbursement for provision of MTM services. In 2012,
the Joint Commission of Pharmacy Practitioners leadership collabo-
rated with several organizations to develop the “Principles for Improv-
ing Patient Health: The Pharmacist's Role”, a guide to support
provider status campaign efforts.18 In 2013, the Provider Status Task
Force was formed to develop strategic partnerships with the National
Health Council, the Council for Affordable Health Coverage, and the
Center for Medicare and Medicaid Services.19 The newly formed
board developed a pharmacist provider status webpage (https://
www.pharmacist.com/provider-status-what-pharmacists-need-know-
now) along with volunteer and campaign opportunity activities. They
further defined the value of pharmacists to legislators. The board con-
tinued to converse with congressional committee members and staff
about the urgency of pharmacy-related issues, including provider sta-
tus. The board held a Pharmacy Caucus Hill Brief on provider status
and highlighted the innovative and successful state-level effects of
supporting pharmacists' patient care services. 20
In 2014, the Patient Access to Pharmacist's Care Coalition drafted
a legislative proposal to broaden patient access to pharmacist-
delivered services, especially in medically underserved areas and/or
populations, as well as where shortages of health professionals
existed.20 The goal of the legislation was to increase access, improve
quality, and decrease cost. This proposal would amend the Social
Security Act by delineating those practitioners who could participate
in various delivery systems and payment models.
7 | H EA L T H C A R E S YS TE M CH A N G ES
7.1 | New demands for pharmacist services
In 2015, the Pharmacy and Medically Underserved Areas Enhance-
ment Act was introduced to provide Medicare coverage and payment
for certain services: (1) provided by a pharmacist in a health-
professional shortage area; and (2) that were otherwise covered under
Medicare if they were provided by a physician.21 In 2017, the Act also
was presented to the 115th Congress and still awaits approval, as has
been the case for several years now.
7.2 | Primary care provider shortage
The shortage of primary care providers coupled with an expanding
patient population, creates an environment whereby existing pro-
viders are overloaded and unable to keep pace with the associated
demand for health care.22,23 During patient office visits, providers
struggle to simultaneously address the acute, chronic, and
BINGHAM ET AL.
preventative health care needs of patients especially as disease bur-
den increases with age.24
Moreover, the proportion of older adults residing in underserved
communities ranges from 25% to 58%, depending on the area.25 In
rural settings, this shortage has become particularly dire, prompting
government incentives for providers willing to practice in these under-
served areas. To address this gap in clinical services, pharmacists are
now expanding their scope of practice into these areas using innova-
tive technologies to enable them to more effectively reach these
populations (eg, medication reconciliation, counseling, education).23
7.3 | Pharmacists as integral partners on care team
Team-based care is essential to accomplish the breadth of care
required. Professional organizations have endorsed team-based care
as a solution to draw on the strengths of different professionals and
solve complex patient issues in an efficient and cost-effective
way.26–28 As the primary care physician supply dwindles,29 the
demand for interprofessional team-based approaches in delivery of
primary care services increases.30 Government agencies, such as the
Centers for Medicare and Medicaid Services and the Centers for Dis-
ease Control and Prevention, have specifically recommended pharma-
cists as part of the interprofessional team for services such as
cardiovascular disease prevention, Medication Therapy Management,
and opioid prescribing.31 Moreover, pharmacists play an integral role
on collaborative health care teams in provision of clinical services to
help patients manage their chronic conditions and medications.32
7.4 | Pharmacists as trusted medication experts
With 6 to 10 years of education and training, pharmacists are
uniquely qualified to address management and monitoring of condi-
tions requiring medications. Physicians report observing positive per-
sonal, patient, and health system outcomes with clinical pharmacy
services specifically related to increased access to care for patients,
improved disease outcomes, and decreased physician workload.32
Additionally, the AMA's STEPS Forward program to transform practice
improvement, encourages physicians to adopt strategies such as
embedding a clinical pharmacist within their practice.33 It is encourag-
ing to observe the AMA's commitment to establishing and maintaining
provision of a team-based health care system.
7.5 | Pharmacist-related patient outcomes
When pharmacists are part of the interprofessional team, improve-
ments in both clinical and economic outcomes are observed. Specifi-
cally, pharmacists can improve health outcomes and adherence to
long-term medication therapy.34 Furthermore, three pivotal articles
review primary compilations of evidence for positive pharmacy-
related outcomes and thus, provide substantial and vital documenta-
tion in the continuing push for provider status.32,35,36
A recent systematic review reported the effects of therapeutic,
safety, and humanistic outcomes of pharmacy services; this compre-
hensive review of nearly 300 studies indicated significant improve-
ments in adverse effects, medication adherence, and chronic disease
BINGHAM ET AL.
biomarkers.35 A 2011 report to the United States Surgeon General
highlighted outcomes associated with clinical pharmacy services
including a comprehensive repository from clinical trials. In 2014, an
independent report commissioned by major pharmacy organizations
described pharmacist-delivered services and their impact since the
2011 report.36 This review included 171 recently published studies
and found positive outcomes for improvements in low-density lipopro-
tein cholesterol, hemoglobin A1C, blood pressure, immunization rates,
and medication adherence; improved economic outcomes in care tran-
sitions, including decreased hospitalizations, were also noted.
7.6 | Sustainability of pharmacist services
The current health care payment model is moving toward value-based
care, yet it is still largely fee-for-service (FFS). According to the 2017
CMS Financial Report, Medicare processes over 1 billion FFS claims
per year; an analysis of 2016 claims puts value-based alternative pay-
ment model payments at 25% in terms of reimbursement.37 The
Health Care Payment Learning and Action Network's 2016 survey
found similar results, with 43% FFS payments, 28% FFS with rates
adjusted for quality, and 29% based entirely on quality measure per-
formance.38 In Deloitte's 2017 Survey of US Health System chief
executive officers, low implementation rates for value-based models
have resulted in less emphasis on outcomes in favor of FFS as the cur-
39
rent financially sustainable model. With time and as incentives
increase, implementation rates are expected to improve.
7.7 | Direct billing for clinical pharmacist services
Direct billing opportunities for pharmacist services in Medicare Part B
40
are limited. Current Procedural Terminology codes, established spe-
cifically for pharmacy services, remain largely unpaid by most medical
carriers and government programs. Beyond these, revenue-generating
FFS opportunities for pharmacists include facility fees or physicians
billing incident to pharmacists' services for evaluation and manage-
ment codes, Chronic Care Management (CCM), Transitional Care
Management (TCM), diabetes self-management training, Medicare
41
Annual Wellness Visits, and other services.
Two recent studies found that the most commonly reported Medi-
care Part B reimbursed services were immunization delivery, diabetes
management, and hypertension screenings. 42,43
The most common
reported Medicare Part D services were CMR/targeted medication
review and medication adherence service.37 Additionally, a systematic
review of pharmacist-remunerated clinical care programs worldwide
found that most of the United States' programs focused on MTM or dis-
ease management services. CMR, adherence-directed interventions,
patient education and monitoring, prescriber consultations, and MTM
were the most frequently reported FFS provided. 44
7.8 | Facility billing for pharmacist services
Facility billing is intended to cover the non-professional fees associ-
ated with care at a health care facility, and as such, do not usually
cover the costs of a pharmacist's time apart from the services pro-
vided. Multiple factors influence pharmacists' ability to bill for
35
services. Attribution of pharmacists' roles in provision of services is
difficult to track, and one that reflects a break-even point in the cur-
rent FFS model is even more challenging. While having provider status
is not essential, it could facilitate billing for the corresponding profes-
sional fee. Incident-to-services are billed at the same rate as services
billed by a physician or non-physician provider and require direct
supervision by a physician, defined as the presence of the physician in
the office suite to render assistance if necessary. Having a physician
onsite can pose particular challenges in rural, community settings and
telehealth sites, especially given the current shortage in non-urban
areas.25 Thus, there is increasing emphasis on utilizing innovative
methods to provide care to those in rural settings and telehealth is at
the forefront of this effort. CCM and TCM are aimed at this improved
access to care with the expectation that services are largely delivered
by telephone-based methods. When CCM and TCM are delivered as
incident-to-services, general rather than direct supervision is required
thereby increasing patients' access to care and thus, offering more
opportunities for service provision by community or other geographi-
cally separated pharmacists. Based on the supervision requirements, it
remains unclear whether current methods will allow pharmacists to
bill for providing telehealth services. Billing is allowed by “physician
extenders” (eg, nurse practitioners and physicians' assistants), yet,
pharmacists are not considered physician extenders under most pay-
ment groups, calling into question this practice by pharmacists.38
7.9 | Continued importance of establishing provider
status
Despite the urgent need and overwhelmingly positive results, phar-
macy services remain difficult to justify in the current health care sys-
tem. Historically, and still today, college of pharmacy support has
been a commonly used model for provision of clinical pharmacy ser-
vices. Yet, as funding for education has tightened in recent years, the
expectations have changed and faculty are increasingly expected to
demonstrate financial sustainability for services. While grant support
has helped bridge this gap, with limited billable opportunities, long-
term sustainability remains elusive. Many pharmacy services are initi-
ated with grant funding or college of pharmacy support. A consistent
barrier cited for these relationships continues to be payment for ser-
vices, as cost avoidance is a complex scenario to sell to health care
administrators.
Based on experience, administrators continue to heavily insist on
FFS revenue generation to justify pharmacist positions. This may fur-
ther complicate the issue in providing team-based care, as attribution
of pharmacist impact in value-based care models is difficult to quan-
tify. Without provider status, limited opportunities exist for revenue
generation, particularly at sites where provider supervision is limited
or in states that limit levels of service for payment of pharmacy ser-
vices. Finally, multiple measures are needed to propel broader reim-
bursement of pharmacist services forward including establishing
pharmacists as Medicare Part B providers, standardizing methods for
billing for direct patient care provided by pharmacists at the state and
federal levels, and improved collaboration between the pharmacy and
medical benefit facilitated via health information exchange between
the pharmacist and health care team members.
36
In summary, obtaining provider status would provide more oppor-
tunities for pharmacy services to expand, ultimately improving access
to quality care and resulting in better health outcomes for patients. As
it currently stands, pharmacists have significant work arounds to
enable them to participate in clinical services within the current struc-
ture. For pharmacists in practice, this creates an increased burden in
trying to adapt and participate in different types of practices, with dif-
ferent billing codes and with different payer types, all of which take
away from their actual patient care time. Finally, multiple key articles
in the published literature already provide evidence about the benefits
of pharmacists impacting patient care outcome, however, professional
perseverance and legislative action are imperative until provider status
is achieved.
Conflict of interest
The authors do not have any conflicts of interest.
ORCID
Jennifer Bingham http://orcid.org/0000-0003-4855-9738
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