2014 Elections Strengthens Support for Pharmacist Provider Status - impacts for MDs?

[RedPill1785]

If this new bill goes through, what will be the implications for family medicine/GPs? Patients? Cost/access to care? Pharmacists have been lobbying long and hard for this for a while now. Will this affect nursing in any substantial way? These provider status services pharmacists do would be reimbursable under Medicare Part B if they are provided in medically underserved communities and consistent with state scope of practice laws according to ASPH.

"Among Tuesday’s winners were Representative Brett Guthrie (Republican-KY), who introduced the bill in the House of Representatives on March 11, 2014, and Representative Earl “Buddy” Carter (Republican-GA), who became the only pharmacist currently elected to Congress."

http://www.pharmacytimes.com/news/E...ngthen-Support-for-Pharmacist-Provider-Status

Tried posting this in family med section. No hits.. Thoughts?

---

Members don't see this ad.

 

[DermViser]

-- ---

 

[NickNaylor]

The idea of a pharmacist providing medical care given their current training is hilarious.

I say this as someone who thinks pharmacists are an absolute asset on many in-patient teams.

 

[DermViser]

The idea of a pharmacist providing medical care given their current training is hilarious.

I say this as someone who thinks pharmacists are an absolute asset on many in-patient teams.

I like how governments think they can interchange professions with each other. Pharmacists do not do physical exams on people and this is not learned in pharmacy school and not in pharmacy residency. They were invaluable people during rounds on an inpatient service.

 

[Psai]

What is all this bull**** about expanding access for underserved communities? They go to where the money is, just like everyone else. I've seen ent PAs, urology PAs, general surgery PAs, but haven't seen a single PA in an underserved community. I've seen some NPs there. But I've seen way more cardiology nps, gi nps, etc. than regular nps in clinics
Just a flowery statement that helps no one and dilutes our brand with nominal legitimacy for people who don't want put in the time and effort that underlies our training

They opened too many schools and now have too many graduates for their work and are now trying to flood our field with lesser trained "providers"

"health care team" means you work together for the patient, not everyone trying to pretend they're a doctor

 

[DermViser]

What is all this bull**** about expanding access for underserved communities? They go to where the money is, just like everyone else. I've seen ent PAs, urology PAs, general surgery PAs, but haven't seen a single PA in an underserved community. I've seen some NPs there. But I've seen way more cardiology nps, gi nps, etc. than regular nps in clinics
Just a flowery statement that helps no one and dilutes our brand with nominal legitimacy for people who don't want put in the time and effort that underlies our training

They opened too many schools and now have too many graduates for their work and are now trying to flood our field with lesser trained "providers"

"health care team" means you work together for the patient, not everyone trying to pretend they're a doctor

If optometrists can do it, why not pharmacists?
http://articles.latimes.com/2013/feb/09/local/la-me-doctors-20130210

 

[maxxor]

If optometrists can do it, why not pharmacists?
http://articles.latimes.com/2013/feb/09/local/la-me-doctors-20130210

At least Optometrists learn physical exam, differential diagnosis, and have prescribing rights in many states. They are definitely taught a lot of this, compared to pharmacists...

Honestly, if NPs can diagnose and treat primary care issues with their variable and often subpar training, I think an optometrist is far more qualified. At least they have a year of full time clinic much like MD/DO third year.

 

[DermViser]

At least Optometrists learn physical exam, differential diagnosis, and have prescribing rights in many states. They are definitely taught a lot of this, compared to pharmacists...

Honestly, if NPs can diagnose and treat primary care issues with their variable and often subpar training, I think an optometrist is far more qualified. At least they have a year of full time clinic much like MD/DO third year.

They do physical exams on the body other than the eye?

 

[maxxor]

They do physical exams on the body other than the eye?

Outside of the eye, I know they learn to take vitals, know how to get IV access for fluorescein angiography, and know how to do a comprehensive neuro exam. How much they use in actual practice, I have no idea as their practices now are specialized for a reason.

Thing is, you can diagnose a decent amount of systemic conditions from the ocular exam, so it is conceivable for an optometrist to see diabetic or hypertensive retinopathy in an undiagnosed diabetic/hypertensive patient, order an a1c/take a BP, diagnose, and then refer them to PCP with those results. Would they want to be managing all those things? I wouldn't want to, but then again, I'm not going into primary care. If we think NPs going off guidelines are good enough for that part of primary care, I think an OD could do it as well.

As a side note, How frequently does an ophthalmologist use a stethoscope?

 

[DermViser]

Outside of the eye, I know they learn to take vitals, know how to get IV access for fluorescein angiography, and know how to do a comprehensive neuro exam. How much they use in actual practice, I have no idea as their practices now are specialized for a reason.

Thing is, you can diagnose a decent amount of systemic conditions from the ocular exam, so it is conceivable for an optometrist to see diabetic or hypertensive retinopathy in an undiagnosed diabetic/hypertensive patient, order an a1c/take a BP, diagnose, and then refer them to PCP with those results. Would they want to be managing all those things? I wouldn't want to, but then again, I'm not going into primary care. If we think NPs going off guidelines are good enough for that part of primary care, I think an OD could do it as well.

As a side note, How frequently does an ophthalmologist use a stethoscope?

I've never even seen an ophthalmologist have a stethoscope.

 

[Dave89]

I've never even seen an ophthalmologist have a stethoscope.

You guys don't either, right?

Last time I went to a dermatologist, he was walking around with some kind of magnifying lens instead.

 

[group_theory]

People who think you can follow simple guidelines to treat diseases ... haven't been treating diseases for very long.

Hint: diseases don't read textbooks, and they sure don't read any guidelines

 

[DermViser]

You guys don't either, right?

Last time I went to a dermatologist, he was walking around with some kind of magnifying lens instead.

Definitely not. I was just referring to it bc maxxor said, "As a side note, How frequently does an ophthalmologist use a stethoscope?"

Most likely you saw this, a dermatoscope:

 

[DermViser]

People who think you can follow simple guidelines to treat diseases ... haven't been treating diseases for very long. Hint: diseases don't read textbooks, and they sure don't read any guidelines

Sad the govt. doesn't see it that way. All they seem to emphasize are guidelines - esp. when it comes to reimbursement.

 

[pharmnrp804]

Just for the record, this is not a scope of practice expansion. This simply allows pharmacists to bill for the cognitive services they already provide. In my state, pharmacists are REQUIRED by law to counsel on every new prescription, but no one will pay for that service, so it is essentially free. Unfortunately, that's not a very sustainable model, and community pharmacists have to fill scripts to make money, so the more time they take to counsel, the less they make. It's somewhat counter-intuitive. This also allows for a broader use of cognitive services to help patients maintain medication adherence and keep their chronic issues under control. It's a hell of a lot easier to walk into a pharmacy and speak with a pharmacist about maintenance meds than it is to schedule an appointment with a PCP. While we aren't masters of physical exam (though that is now being added to the curriculum), there are other ways that pharmacists can help keep people out of the hospital. Just thought I'd chime in, though I'm sure most of you don't particularly care for the opinion of a lowly pharmacy intern...

 

[DermViser]

Just for the record, this is not a scope of practice expansion. This simply allows pharmacists to bill for the cognitive services they already provide. In my state, pharmacists are REQUIRED by law to counsel on every new prescription, but no one will pay for that service, so it is essentially free. Unfortunately, that's not a very sustainable model, and community pharmacists have to fill scripts to make money, so the more time they take to counsel, the less they make. It's somewhat counter-intuitive. This also allows for a broader use of cognitive services to help patients maintain medication adherence and keep their chronic issues under control. It's a hell of a lot easier to walk into a pharmacy and speak with a pharmacist about maintenance meds than it is to schedule an appointment with a PCP. While we aren't masters of physical exam (though that is now being added to the curriculum), there are other ways that pharmacists can help keep people out of the hospital. Just thought I'd chime in, though I'm sure most of you don't particularly care for the opinion of a lowly pharmacy intern...

Nobody said that - quit creating strawman arguments.

 

[link2swim06]

Nobody said that - quit creating strawman arguments.

But I bet most people on this thread are implying that. And the OP makes some very leading statements trying to imply that.

After reading that article it seems like it is just letting pharmacist bill for what they already do.

I guess the only controversy from this article is...."should pharmacist get paid for the time they spend talking to patients?"

 

[DermViser]

But I bet most people on this thread are implying that. And the OP makes some very leading statements trying to imply that.

Let's not surmise on what people are implying and instead just go based off of what they're saying. Makes it easier that way.

 

[BestDoctorEver]

But I bet most people on this thread are implying that. And the OP makes some very leading statements trying to imply that.

After reading that article it seems like it is just letting pharmacist bill for what they already do.

I guess the only controversy from this article is...."should pharmacist get paid for the time they spend talking to patients?"

PCP don't get paid for the time they spend with patients? Why should pharmacist get paid for that when they are already getting paid by the hours? Shouldn't that factor in?

 

[link2swim06]

PCP don't get paid for the time they spend with patients? Why should pharmacist get paid for that when they are already getting paid by the hours? Shouldn't that factor in?

PCPs do get paid. They get paid for the encounter...it is billed between a level 1 and level 5 depending on the services provided (explaining prescription drugs is part of that service). They also get additionally paid if they provide counseling. If I put "I proved tobacco cessation counseling" on the chart then my attending gets paid a fraction of an RVU for that (like $20 or $30 from medicare).

I think the traditional role of pharmacists (before pharmDs were required) was to just do the manual labor of 'filling the prescription.' Now that they are provided counseling it makes sense that they get compensated for their time.

Most patients don't ask for counseling from pharmacist but the subset that do and require lots of the pharmacist time probably should reimburse him/her for those services.

 

[doc baller]

Damn I should have went to pharmacy school instead.

 

[group_theory]

Just because you can "bill" doesn't necessarily mean you will get compensated

For example - there are CPT codes for telephone calls/advice by physicians - 99441 to 99443. So while there are billing codes, and physicians can bill for these telephone calls/advice - these codes are something that currently insurance companies are not reimbursing with rare exceptions. So just because it is something you can "bill" doesn't mean it is something that will be reimbursed. Insurance companies and Medicare/Medicaid aren't exactly chomping at the bits to add more things that they will "compensate" - esp if it is something that pharmacists are doing for "free" right now. If you were an insurance executive at a for-profit company, would you start to 'compensate' for something that right now is not costing you anything? (remember, you have a fiduciary responsibility to your shareholders, not to the pharmacists, society, or population health)

And be careful - once you start billing, you have to maintain appropriate documentations - and be prepare for audits from RACS. And the trend is going away from "fee for service" to "fee for values" ... so do you want your paycheck tied directly to your patient's satisfaction score at the pharmacy? Do you want your paycheck tied directly to how many patients still smoke? Do you want your paycheck (and job) tied directly to the readmission rate for that COPDer who still smokes who would rather use his money to buy a pack of cigarette than pay the copay for his antibiotics/inhaler/steroids?

You can provide an hour counseling time, bill it as a level 5 encounter, but depending on the insurance - that reimbursement (if you get reimbursed) might be lower than your current pharmacy salary (which, if you add the overhead expenses) means the pharmacy probably lost money for that counseling session. And if you are counseling/prescribing, and dispensing in the same building/same unit, there might be federal antitrust laws (or at least Stark laws) that might come into play.

 

[tofuuu]

The more I read about this, the more confusing everything sounds...
So let me get this straight, this bill just allows pharmacist to bill Medicare and Medicaid for services that they already provide but only those working in underserved areas get this privilege, correct?

From the conversations i'm seeing above, it seems like physicians tend to be against this bill. Can someone expand on the reasons why?

 

[Psai]

underserved areas is a bs term that they use to get support for their bill
basically they want to call themselves doctor and play doctor but not go to medical school and do a real residency to do it properly

 

[DermViser]

underserved areas is a bs term that they use to get support for their bill
basically they want to call themselves doctor and play doctor but not go to medical school and do a real residency to do it properly

I don't think actual "in the trenches" pharmacists want to do this.

 

[pharmnrp804]

underserved areas is a bs term that they use to get support for their bill
basically they want to call themselves doctor and play doctor but not go to medical school and do a real residency to do it properly

Come on. Seriously? That's not even remotely close to correct. I really hate when physicians/med students hate on pharmacy, because I, and most of my ilk, am on your side on every other issue. If you want to get mad at someone, get mad at the nurses. They have the public's heart and ear, and are actively trying to take your jobs, as well as those of every other health profession. Physicians are "in charge" of patient care. As they should be. I don't want to be a physician. If I did, I would have applied to medical school instead. I don't want to prescribe, I just want to be able to bring in an income that makes medication management a viable practice. As of right now, pharmacists are paid based on the profit from scripts. As you and everyone else well knows, the reimbursement from insurance/CMS for scripts is getting smaller and smaller. How can we afford to keep any stores open if we're getting $0.40 from that month's supply of metoprolol? If that's our average profit from generics, which make up the majority of fills, that is in no way sustainable. We already have to provide counseling services for new scripts and many chronic disease states, but that takes time that we need to fill prescriptions. These services are especially important in areas where other healthcare providers aren't fond of working, and the bill states very specifically that these are the only areas covered. A Walgreens in Manhattan wouldn't be able to use this, but the pharmacy down the street from my home could. If I can spend my time making sure a patient knew how to us his/her inhaler, I might be able to keep that person out of the hospital. That's the point. If professions like social work, psychology, dietetics/nutrition, and physical therapy are counted as "providers" according to CMS, there's no reason pharmacists shouldn't be, as well.

Just because you can "bill" doesn't necessarily mean you will get compensated

For example - there are CPT codes for telephone calls/advice by physicians - 99441 to 99443. So while there are billing codes, and physicians can bill for these telephone calls/advice - these codes are something that currently insurance companies are not reimbursing with rare exceptions. So just because it is something you can "bill" doesn't mean it is something that will be reimbursed. Insurance companies and Medicare/Medicaid aren't exactly chomping at the bits to add more things that they will "compensate" - esp if it is something that pharmacists are doing for "free" right now. If you were an insurance executive at a for-profit company, would you start to 'compensate' for something that right now is not costing you anything? (remember, you have a fiduciary responsibility to your shareholders, not to the pharmacists, society, or population health)

And be careful - once you start billing, you have to maintain appropriate documentations - and be prepare for audits from RACS. And the trend is going away from "fee for service" to "fee for values" ... so do you want your paycheck tied directly to your patient's satisfaction score at the pharmacy? Do you want your paycheck tied directly to how many patients still smoke? Do you want your paycheck (and job) tied directly to the readmission rate for that COPDer who still smokes who would rather use his money to buy a pack of cigarette than pay the copay for his antibiotics/inhaler/steroids?

You can provide an hour counseling time, bill it as a level 5 encounter, but depending on the insurance - that reimbursement (if you get reimbursed) might be lower than your current pharmacy salary (which, if you add the overhead expenses) means the pharmacy probably lost money for that counseling session. And if you are counseling/prescribing, and dispensing in the same building/same unit, there might be federal antitrust laws (or at least Stark laws) that might come into play.

I totally understand that FFS isn't the best plan, and likely many insurance companies won't pick it up, but it's a start and it's the only thing we have to work with right now. Outcome-based reimbursement is a much better idea, but that isn't very prevalent yet, so I'm not sure how much more practical it would be in this scenario. I'm not saying a full on switch to FFS is a good idea, but as long as it's used as an adjunct to the current system, anything is better than what we have now...

 

[AM508]

Based on personal experience, I am rather skeptical about pharmacists expanding their roles. A couple of years ago, I went to the pharmacy to pick up some goods and saw they were giving flu shots. I thought, "well this is convenient" so I signed up for one. The pharmacist proceeded to miss my deltoid muscle by about 2 inches, so rather than getting the shot deep IM as it was supposed to be given I essentially received it SQ. I ended up getting a vigorous local reaction to the shot due to not being slowly distributed through the muscle as the vaccine is intended. I know one incident, by one provider is not indicative of the entire system, but I personally would never go back to the pharmacy for anything other than picking up goods and prescriptions. I have gotten my flu shot subsequently at my family physician's office each year with proper administration and no reaction.

 

[a runner]

Based on personal experience, I am rather skeptical about pharmacists expanding their roles. A couple of years ago, I went to the pharmacy to pick up some goods and saw they were giving flu shots. I thought, "well this is convenient" so I signed up for one. The pharmacist proceeded to miss my deltoid muscle by about 2 inches, so rather than getting the shot deep IM as it was supposed to be given I essentially received it SQ. I ended up getting a vigorous local reaction to the shot due to not being slowly distributed through the muscle as the vaccine is intended. I know one incident, by one provider is not indicative of the entire system, but I personally would never go back to the pharmacy for anything other than picking up goods and prescriptions. I have gotten my flu shot subsequently at my family physician's office each year with proper administration and no reaction.

Come on now, as if a medical assistant is so much more reliable for giving a flu shot than a pharmacist.

 

[a runner]

Listen, I think if pharmacists (or nurses - they are the real problem - or anyone else) want to play doctor, they need to go to medical school. That's what I did. I left pharmacy school because I wanted to be a doctor. Some faculty told me some bs like "why go? Just do a residency and you're practically a PCP. I can do basically what a FP does and manage chronic diseases" but only a few pharmacists in academia hold these views. Most faculty were supportive and understood my decision.

I think most pharmacists just want to be paid for their services, which they are required by law to give, and have no interest in being a "provider" or prescribing or doing anything but med management, which is the thing they're trained to do. Seems fair if society is going to require them to counsel customers that the public health insurances at least pay them for their time.

 

[AlwaysContrary]

Not to revive a dead thread, but you guys are taking the term "provider" completely out of context when it comes to pharmacist. Provider status only means we are able to bill for the services we provide (which, by the way, we do completely for free which is bs). It does NOT mean we are going to start diagnosing!

Seriously though, I went to the chiropractor and was charged 80 dollars for 10 minutes of back cracking. Why not allow a pharmacist charge some money for making a life saving intervention?

 

[Peach Newport]

I've heard repeatedly that this isn't really because pharmacists want to be doctors, but because they want to keep their jobs. There's a lot of (very reasonable imo) fear among pharmacists that automation will render 90% of pharmacists obsolete. Insurance companies are trying to cut them out of the picture because they see them as expendable middlemen standing between patients and their drugs... who get paid a fortune.

Source: close family friend who's a VP at a major (perhaps the largest) health insurance company. She also tells me that the insurance companies are tacitly supporting expanded NP practice rights, but only when it comes to family medicine. She says that insurance companies are trying to make FM an NP-only field.

 

[AlwaysContrary]

There's a lot of (very reasonable imo) fear among pharmacists that automation will render 90% of pharmacists obsolete.

Saying automation will render a pharmacist useless is the same as automation rendering physicians who practice EBM useless. It will never happen. The provide status will allow pharmacist to bill for what they do allowing companies to make money off pharmacists. Not to protect against automation.