1. The Path to Provider Status
Christopher J. Topoleski
Director, Federal Legislative Affairs

2. Provider Status: It’s Not Just a Bill
Adds pharmacists to list of providers in Social Security Act
Gives patients access to pharmacists
Longstanding goal of the profession
ASHP’s main advocacy priority is gaining provider recognition for pharmacists.
Provider status means being listed in Section 1842 or 1861 of the Social Security Act as a supplier of medical and other health services.
Achieving provider status will expand pharmacists’ ability care for patients.

3. The Intersection of Healthcare & Policy
States grant authority to practice
Licensure
Scope of practice
Federal government determines reimbursement
Medicare
Private, state payers typically follow Medicare

4. Provider Status is About Patients
Achieving provider status is about giving patients access to care that improves patient safety, healthcare quality, and outcomes, and decreases costs for the healthcare system.

5. What is Federal Provider Status?
Becoming a “provider” in the Medicare program means that pharmacists can participate in Part B of the Medicare program and bill Medicare for services that are within their state scope of practice to perform.
This is the definition, at the federal level, of being a provider under Medicare.
Nothing currently precludes the utilization of pharmacists in ACOs and other settings, but there is no recognition, including compensation, for the care they give
May differ from state definitions of provider
This does not create a new category of pharmacist at the federal level
State scope of practice will continue to be important

6. The Intersection of Healthcare & Policy
Medicare
Part A
Medical benefit
Part B
Physician offices
Part C
Medicare Advantage (Managed care)
Part D
Outpatient prescription benefit

7. Social Security Act & Provider Status
Medicare resides under the Social Security Act
Social Security Act determines eligibility for current and new payment models
Pharmacists are not recognized under the Social Security Act as health care providers
Traditional fee-for-service will likely be phased out and replaced with new payment systems that emphasize quality, outcomes, and shared risk/savings/bundled payments
Section 1861 of the SSA remains the reference point for which practitioners are eligible to participate in new and emerging delivery systems and payment models like ACOs and Medical Homes
Therefore, to efficiently participate in new and current delivery and payment systems, pharmacists need to be listed in the SSA

8. Who Has Provider Status?
Physicians
Nurse practitioners
Physician assistants
Certified nurse midwives
Psychologists
Clinical social workers
Certified nurse anesthetists
Speech-language pathologists
Audiologists
Registered dietitians
Physical therapists
Provider status means being listed in section 1842 or 1861 of the Social Security Act as a supplier of medical and other health services. The list currently includes these professions…but not pharmacists.

9. Steps In The Right Direction. . .
Affordable Care Act (2010)
MTM Definition
Accountable Care Organizations
MTM Grant Program
Center for Medicare & Medicaid Innovation
Value-Based Purchasing Program
Medicare Modernization Act (2003)
Part D prescription drug benefit requires medication therapy management
No explicit payment

10. The Pharmacy and Medically Underserved Areas Enhancement Act

11. Patient Access to Pharmacists’ Care Coalition (PAPCC)
Coalition pushing for passage of legislation
Most pharmacy groups are active members
Patient advocacy groups
The Patient Access to Pharmacist’s Care Coalition (PAPCC) wrote and is working to build support for the legislation.
The coalition is comprised of more than 30 organizations representing pharmacists, pharmacies, patients, and other stakeholders.
Members include:
ASHP
APhA
NACDS
Walgreens
Healthcare Leadership Council
Cardinal Health
National Patient Advocate Foundation
National Rural Health Association

12. Access to Primary Health Care
Growing number of Medicare beneficiaries
Increasing patients with one or more chronic conditions
Newly covered patients via Affordable Care Act
Projected shortage of physicians
Projected shortfalls in primary care range between 14,900 and 35,600 physicians by 2025
If currently underserved populations utilized health care at the same rate as the rest of the population, up to an additional 96,000 physicians would have been needed in 2014
Source: AAMC Center for Workforce Studies, April 2016 Analysis

13. Projected Physician Shortage
Source: AAMC Center for Workforce Studies, June 2010 Analysis

14. Focus on Medically Underserved Communities
Help meet unmet healthcare needs
Increase patients’ access to care
Improve quality
Decrease costs
Strategy follows similar successful paths taken by other healthcare professionals to gain provider status
Help meet unmet health care needs
Increase access
Improve quality
Decrease costs
Follow similar successful paths taken by other health care professionals to gain provider status
Nurse practitioners initially only recognized as providers in rural health clinics; now have provider status in all settings.

15. State Scope of Practice
State scope of practice will determine what services pharmacists can offer
As provider status at the federal level is achieved continued efforts by states to ensure scope of practice for pharmacists is sufficiently robust will be vital

16. The Pharmacy and Medically Underserved Areas Enhancement Act
Increases access to healthcare for patients in medically underserved areas.
Promotes cost-effective healthcare by increasing opportunities for early interventions.
Allows pharmacists to provide services authorized by state scope of practice.
Legislation introduced in January, H.R. 592 and S. 314, the Pharmacy and Medically Underserved Areas Enhancement Act
Increases access to healthcare for patients in medically underserved areas.
Promotes cost-effective healthcare by increasing opportunities for early interventions.
Allows pharmacists to provide services authorized by state scope of practice.
We’ve had a lot of success in building support for the bills through the work of ASHP members and the members of the Patient Access to Pharmacists’ Care Coalition.
Bipartisan support is crucial to the passage of this bill
We need every member, to help make this happen.

17. The Pharmacy and Medically Underserved Areas Enhancement Act
Services
Managing chronic diseases
Medication management
Manage care as patients transition from hospital to home
Health and wellness testing
Administering immunizations
Overall impact:
Improved health outcomes
Reduced hospital readmissions
Reduced emergency department visits
Services are based what is allowed in each states scope of practice.

18. Next Steps Reintroduction
S.109 introduced January 12, 2017
Sen. Grassley lead sponsor
Introduced with 26 original cosponsors
H.R. 592 reintroduced January 20, 2017
Rep. Guthrie lead sponsor
Introduced with 107 original cosponsors
Maintained bill number from 114th to 115th Congress
Negotiation with committee staff (W&M, E&C, SFC)
Identify appropriate legislative vehicle

19. Keys to Success Pharmacy must maintain unified stance
Grassroots efforts must be robust
Focusing on the unmet need, new Medicare enrollees
Election results do not change our message