Laws Expanding Pharmacists’ Scope, Payment Could Drive Lab Testing

Transformation of the health care system is propelling the dichotomous ambition of improving patient care and outcomes, while cutting costs. Better care coordination is anticipated to play a central role in improving medication adherence and reducing hospital readmissions. And neighborhood pharmacists may be the lynchpin in enhancing care coordination by assessing medication adherence, effectiveness, and safety, in part, through ordering laboratory tests.

According to the American Pharmacists Association (APhA), the majority of states allow pharmacists to fulfill preventive services called for in the Affordable Care Act, including cholesterol screening for adults with certain risk factors and type 2 diabetes screening for adults with high blood pressure. However, integration of pharmacists into routine clinical care is stymied by "antiquated" state laws that prohibit pharmacists from ordering appropriate laboratory tests or altering medication management based on test results and a lack of federal reimbursement for pharmacists' health care services. Efforts are underway to address both the state and federal regulatory shortcomings preventing pharmacists from playing a pivotal role in integrated care teams.

"The lack of reimbursement of pharmacists for services provided within their state scope of practice unnecessarily limits patient access to certain health care services and the contributions pharmacists can make to their health care and outcomes," says the APhA's Patient Access to Pharmacists' Care Coalition, in a statement. "Enabling pharmacists to practice at the top of their education and training, and be better integrated into the patient's health care team, will improve health outcomes and greatly benefit specific populations, especially those with chronic disease such as diabetes and cardiovascular disease."

Pharmacists, for decades, experts say, have played a role in the management of drugs for chronic diseases in the Indian Health Service, the Department of Veterans' Affairs and the Department of Defense. In the 1960s, the government called upon pharmacists to improve medication oversight and management of patients in long-term care through the provision of monthly medication regimen reviews (MRRs). An iteration of the MRR process now exists under the comprehensive medication review (CMR) annual benefit under Medicare Part D. CMMs will likely also play a role with calls for coordinated care with integrated care teams (that include pharmacists) under new delivery models like patient-centered medical homes and affordable care organizations. Yet, pharmacists are only paid to dispense medication.

Provider status bills were introduced with bipartisan support in Congress for the past two sessions. The bills, expected to be re-introduced again, propose an amendment to the Social Security Act to authorize the Secretary of Health and Human Services to federally recognize pharmacists as health care providers and develop pharmacist-specific codes for reimbursement as part of the physician fee schedule/Medicare Part B.

But, reimbursement is not the only challenge. For pharmacists, their scope of practice is dictated by state legislatures and regulated by a State Boards of Pharmacy and these vary state by state. According to the APhA, in 47 states and the District of Columbia pharmacists are authorized to enter into collaborative practice agreements (CPAs) with a physician or another prescriber and in 31 states pharmacists are also allowed to order and interpret lab tests as part of these CPAs. For instance, some CPAs are limited to permitting pharmacists to switch between drugs in the same class to meet formulary requirements. But CPAs in states with more progressive practice scope regulations can include ordering drug monitoring-related laboratory tests (usually CLIA-waived tests in the community pharmacy setting), initiating therapy (e.g., antibiotic therapy after a positive rapid strep test), or adjusting drug regimens based upon test results. CPAs also vary in the autonomy provided to pharmacists to act alone or in consultation with the prescriber.

"Pharmacists are trained to do much more than dispense medication, and they could help plug the growing gaps in chronic care management in the United States," John Gums, from the University of Florida, wrote Jan. 5 in The Conversation. "The trouble is that state pharmacy practice statutes were written in a different era, and haven't caught up with the training pharmacists receive today."

Efforts aimed at legislatively expanding pharmacists' role in patient care are supported by societies (including the APhA and the American Society of Consultant Pharmacists). Societies are calling for recognition and compensation for pharmacists as health care providers, as well as revision of laws and regulations to "facilitate pharmacist involvement in appropriate laboratory testing and health screening as essential components of patient care."

Takeaway: Legislative efforts underway at both the state and federal levels could expand pharmacists' role in patient care and medication management. With recognition as a health care provider (and with accompanying reimbursement) pharmacists are expected to play a larger role on integrated care teams and could expand compliance with recommended testing as part of drug management.