ASHP Statement on the Role of Pharmacists in Primary Care

Abstract

ASHP believes that pharmacists have a role in meeting the primary care needs of patients directly and in collaboration with other healthcare providers. Primary care pharmacy practice is the provision of integrated, accessible healthcare services by pharmacists who are accountable for addressing medication needs, developing sustained partnerships with patients, and practicing in the context of family and community.1 Primary care pharmacy practice is accomplished through the provision of direct patient care and medication management services (MMS) for ambulatory patients, development of long-term relationships, coordination of care, patient advocacy, wellness and health promotion, triage and referral, and patient education and self-management. The primary care pharmacist provides primary care services in a variety of settings, including institutional, private, and community-based clinics. Primary care pharmacists help offset deficits in the primary care workforce caused by a shortage of physicians and other healthcare providers, particularly for underserved populations, by providing MMS in interdisciplinary team-based settings as well as in areas such as telehealth, population health, transitions of care, employer-based services, lifestyle medicine, accountable care organizations, and public health. Primary care pharmacists are often embedded into the primary care practice to provide MMS. Many states allow pharmacists to partner with physicians via collaborative practice agreements (CPAs) that enable physicians to delegate specific tasks (eg, initiation, titration, and discontinuation of medications; laboratory monitoring of therapy; medication and disease state monitoring) to a pharmacist. ASHP supports passage of federal and state laws and regulations that authorize pharmacists as providers within collaborative practice and that facilitate reimbursement for services provided by pharmacists.2 Further, ASHP advocates that pharmacists be recognized as providers in federal, state, and third-party payment programs. Provider recognition would facilitate direct billing for services provided, similar to billing by physicians, nurse practitioners, clinical nurse specialists, and physician assistants.3 Until that recognition is obtained, ASHP encourages healthcare organizations to use a variety of models to ensure the financial sustainability of services provided by primary care pharmacists, such as through indirect funding, incident-to billing, and increased use of the limited direct insurance billing opportunities available. Several states have passed pharmacist provider status laws or reimbursement parity laws allowing for reimbursement for direct patient care pharmacist services by state Medicaid and/or commercial plans.4 As pharmacists become core members of the primary care workforce, credentialing and privileging with payers and healthcare organizations will be essential. As credentialed providers, pharmacists are able to both provide patient care services and contribute to the financial sustainability of those services. Privileging protects their employing organizations from legal risk and ensures patients receive care from qualified and competent providers. ASHP recommends the use of credentialing and privileging in a manner consistent with other healthcare professionals to assess a pharmacist’s competence to engage in patient care services.5 Credentialing and privileging systems already exist for physicians, physician assistants, and nurse practitioners, but are far less common for pharmacists. Integration of pharmacists into existing processes will enable the profession to function collaboratively and in parallel with their colleagues and assist in preparing for pharmacist provider status. There are many opportunities for pharmacists who practice in primary care settings to seek additional credentials beyond a pharmacy degree and licensure, and certain credentials may be required to obtain specific privileges to provide MMS. The variety of state requirements to provide primary care pharmacist services can be a barrier to patient access to those services, thus standardized credentialing is needed. A 2021 National Academies of Science, Engineering and Medicine report defined high-quality primary care as “the provision of whole-person, integrated, accessible, and equitable health care by interprofessional teams that are accountable for addressing the majority of an individual’s health and wellness needs across settings and through sustained relationships with patients, families, and communities.” 6 The report stated that high-quality primary care is a critical component to achieving the quadruple aims of healthcare: enhancing the patient experience, improving population health, reducing costs, and improving the healthcare team experience.6 Primary healthcare is a comprehensive and holistic care approach to health and well-being that is centered on and tailored to the needs of individuals, families, and communities. The World Health Organization (WHO) has developed a 3-component definition of primary care7: Meeting people’s health needs through comprehensive promotive, protective, preventive, curative, rehabilitative, and palliative care throughout the life cycle, prioritizing key healthcare services aimed at individuals/families through primary care and the population through public health functions as the central elements of integrated health services. Systematically addressing the determinants of health (social, economic, environmental, as well as people’s characteristics and behaviors) through evidence-informed public policies and actions across all sectors. Empowering individuals, families, and communities to optimize their health, as advocates for policies that promote and protect health and well-being, as co-developers of health and social services, and as self-carers and care-givers to others. Primary care pharmacy practice is the provision of integrated, accessible healthcare services by pharmacists who are accountable for addressing medication needs, developing sustained partnerships with patients, and practicing in the context of family and community.1 This practice is accomplished through direct patient care and medication management for ambulatory patients, development of long-term relationships, coordination of care, patient advocacy, wellness and health promotion, triage and referral, and patient education and self-management. The primary care pharmacist may practice in institutional, private, and community-based clinics involved in the provision of direct care to diverse patient populations. Primary care pharmacists may help to offset deficits in the primary care workforce, including the physician shortage, by providing MMS in interdisciplinary team-based settings as well as areas such as telehealth, population health, transitions of care, employer-based services, lifestyle medicine, and public health. Clinical pharmacy services may include: Immunizations and travel vaccines Medication therapy management (MTM) Collaborative drug therapy management (CDTM) Comprehensive medication management (CMM) Focused specialty management of chronic diseases (eg, anticoagulation, diabetes, heart failure) Management of complex acute conditions or exacerbation of chronic conditions (eg, urinary tract infection, chronic obstructive pulmonary disease, asthma) Provision of personalized medicine (eg pharmacogenomics) Patient counseling, education, and training Examples of practice settings in which pharmacists provide primary care services include: Accountable care organizations (ACOs) Community-based or free clinic Community pharmacy Federally Qualified Health Center (FQHC) Hospital-based outpatient clinic Indian Health Service clinic Managed care integrated system Outpatient clinic associated with academic medical center Patient-centered medical home (PCMH) Private practice physician clinic Rural health clinic (RHC) Self-insured employee clinic Veterans Affairs (VA) medical center Primary care pharmacists are often embedded into the primary care practice to provide MMS. MMS has been defined by the Joint Commission of Pharmacy Practitioners (JCPP) as “a spectrum of patient-centered, pharmacist-provided, collaborative services that focus on medication appropriateness, effectiveness, safety, and adherence with the goal of improving health outcomes.” 8 For the purposes of this statement, MMS “encompasses a variety of terms, such as medication therapy management (MTM), comprehensive medication management (CMM), and collaborative medication management,” as in the JCPP definition.3 The pharmacist may be an employee of the practice, a department of pharmacy, or a health professions school or college, and may dedicate a part- or full-time effort to providing clinical pharmacy services. Care may be provided face-to-face or via telehealth visits to manage medications for patients with chronic illnesses such as hypertension, diabetes, chronic heart failure, asthma, chronic obstructive pulmonary disease, anticoagulation, osteoporosis, and many others. Primary care pharmacists often provide patient education about lifestyle choices or conduct annual wellness visits (AWVs) for patients with Medicare. Many states allow pharmacists to collaborate with physicians through CPAs that enable physicians to delegate specific tasks such as medication initiation, titration, or discontinuation; laboratory monitoring of drug therapy; and referral for medication and disease state management to the pharmacist. The term transitions of care refers to the movement of patients between healthcare practitioners, settings, and home as their condition and care needs change.9 During transitions, medication regimens are frequently changed and may include medication discontinuation, dosage changes, and new prescriptions that can be confusing for patients and caregivers to manage. Poor-quality transitions contribute to medication errors, hospital readmissions, and increased healthcare costs.9 Pharmacists in the primary care setting can support patients and caregivers as they adjust to new diagnoses, care plans, and medications. Established Transitional Care Management (TCM) Current Procedural Terminology (CPT) codes allow for billing of transitions of care services, providing a mechanism for reimbursement.10,11 There are 3 required elements to bill for TCM services: Interactive communication (eg, phone, text, email) must occur with the patient or caregiver within 2 days of discharge by a licensed clinical staff member, which can be the primary care pharmacist. Medical decision-making of moderate to high complexity occurs during the service period. The patient has a face-to-face or telehealth visit within 7 to 14 days of discharge. Services during TCM visits often include reviewing medical records, reconciling medications, coordinating future visits, and providing patient education. Pharmacists may be involved with all components of TCM, but the services can only be billed by a physician or a qualified nonphysician provider such as a nurse practitioner or physician assistant according to current Centers for Medicare & Medicaid Services (CMS) rules. Inclusion of pharmacists in the definition of a nonphysician provider would allow pharmacists to perform these services, among others, and reduce the burden on primary care providers. ASHP and the American Pharmacists Association (APhA) collaborated to develop the Medication Management in Care Transitions (MMCT) Best Practices that spotlight transitions of care models in pharmacy practice and provide resources for pharmacy leaders.12 Successful programs improved patient satisfaction scores and decreased readmission rates and medication discrepancies.12 A descriptive study that evaluated the impact of care transitions intervention on clinical, organizational, and financial outcomes found that adding a pharmacist to the care transitions team decreased hospital readmissions compared to usual care (9% vs 26%) and prevented 103 admissions per year, translating to an annual savings of over $1 million.13 Employers may offer chronic disease management or healthy lifestyle programs to employees as part of their human resources benefits package. Pharmacists are essential team members who can provide chronic disease medication management to employees enrolled in self-insured health plans. The Asheville Project demonstrated that pharmacists who cared for City of Asheville employees with diabetes improved patient satisfaction with their healthcare, decreased healthcare costs, and increased the number of patients who achieved hemoglobin A1c, lipid, and blood pressure goals.14 An evaluation of a national employer-based program offered by 10 organizations in 70 different communities indicated that pharmacists improved other diabetes-related population health metrics, including monofilament examinations, annual dilated eye examinations, foot self-exams, glucose self-monitoring, weekly exercise, and annual influenza vaccinations.15 A shift to population health strategies in primary care has been driven by increasing healthcare costs, emphasis on fee-for-service over value-based care, and lack of widespread prevention initiatives. Primary care pharmacists who dedicate their time to population health management focus on improving the quality of care for specific patient populations. Specific population health metrics that warrant improvement are identified by leaders within the PCMH, the ACO, through community health assessments, or by payers such as Medicare, Medicaid, and private insurers. Demonstration in improved quality metrics may be linked with pay-for-performance payment bonuses, or shared savings incentives. For example, if a metric of importance to the practice is to improve the quality of care for patients with diabetes, primary care pharmacists can provide MMS for high-risk patients to improve attainment of hemoglobin A1c goals.16 Expertise in the domain of public health is increasingly important for the primary care pharmacist due to the impact of public care challenges such as the opioid epidemic, unintended pregnancy with resultant negative maternal fetal outcomes, tobacco abuse, and the coronavirus disease 2019 (COVID-19) pandemic. The Opioid and Naloxone Education (ONE) program has demonstrated the ability of pharmacists to ensure safe opioid use, and prevent opioid misuse and abuse, through implementing naloxone prescribing while utilizing the pharmacist’s patient care process.17 A growing number of states allow pharmacists to prescribe hormonal contraception as a strategy to increase access to care and decrease negative maternal outcomes.18 Oregon pharmacists prescribing hormonal contraception prevented 51 unintended pregnancies and saved Oregon Medicaid over $1.6 million.19 As of February 2021, 7 states (Idaho, Colorado, Indiana, West Virginia, Vermont, North Dakota, and New Mexico) had authorized pharmacists to prescribe all Food and Drug Administration–approved tobacco cessation products, including varenicline, to combat the negative impact of smoking on public health; Oregon and North Dakota are currently developing regulations to implement authorizing legislation.20 Pharmacists in primary care settings are also well positioned to identify immunization needs of patients, provide education to promote vaccine confidence, and administer vaccines. During the COVID-19 pandemic, the US Department of Health and Human Resources authorized immunizing pharmacists to administer childhood vaccines21 and COVID-19 vaccines22 as part of the Public Readiness and Emergency Preparedness (PREP) Act. The Health Resources and Services Administration (HRSA) defines telehealth as “the use of electronic information and telecommunication technologies to support long-distance clinical health care, patient and professional health-related education, health administration and public health.” 23 Telehealth has been used for a variety of patient populations, including veterans, rural patients, and patients with psychiatric conditions. The COVID-19 the of primary care services by The federal in to increase access to telehealth during the through the Preparedness and Act. for of to allow physicians to provide in to promote social and protect healthcare Telehealth visits may be billed by physicians and nonphysician providers and are at the fee-for-service as visits for Medicare Pharmacists may be able to bill certain may for Medicaid and private Rural areas of the in the US for a over of the US in rural areas are often underserved and health that can between and across Many of the health-related challenges by rural are by the lack of services, particularly primary care providers and medical of within of a community pharmacy, additional opportunities for pharmacists to partner with primary care providers and provide clinical pharmacy services for underserved The of services in rural settings is an important strategy to health that are common of for who in rural communities for those in disease state health tobacco cessation management and of opioid use and lifestyle through diabetes prevention programs are of services that these common health and can be by pharmacists or through interprofessional collaboration with pharmacists as pharmacy practice training programs on rural pharmacy health exist at of pharmacy that focus on preparing pharmacists for in and rural Many health systems that rural receive reimbursement through payment models by Medicare and many state bill Medicaid plans. the lack of pharmacist recognition as an provider by the majority of including Medicare, can the financial of pharmacist services within these Pharmacists can assist or a key role in and programs in the of can to to rural health providers such as and the Indian Health Service as a mechanism to pharmacist Examples of practice models that care in rural areas include the or between a pharmacist and a primary care practitioner who is recognized as an with a pharmacist of other health in comprehensive care services as part of the or ambulatory primary care clinic care health services that focus on quality improvement and can increase reimbursement to the health system or primary care provider through visits with the pharmacist face-to-face or via telehealth, including monitoring of quality improvement include blood pressure rates of influenza and adherence to medication medications, Pharmacists involved in programs. between primary care providers and community critical access or academic can increase access to essential services such as immunization and disease state education and management to in rural areas with limited access to primary care are health providers of outpatient clinical services that receive from the Health Center to provide care to in underserved The primary of is the provision of primary care services in underserved and rural communities. are in community health but are also found in public primary care outpatient health programs by a or Indian health and healthcare for the the requirements of are the provision of a system for patients with of the federal provision of comprehensive healthcare services include pharmacy, and health an quality and a of often to the challenges of economic, and patient Primary care pharmacists in clinical within an can have a impact on the care of this underserved patient and challenges to medication therapy that pharmacists are well to help diseases are with a high of hypertension, diabetes, and tobacco The to report on quality of care providing an for pharmacists to assist in the and of clinical services aimed at meeting quality as well as in the from primary care in the that payment is for primary care An payment is the from that medical services, and service coordination provided to The specific payment is to and is on and the is provided through only who are recognized as healthcare providers by Medicare are to bill directly for services. pharmacists are recognized as healthcare providers services provided by a pharmacist may be billed directly but must be billed by an healthcare the limited opportunities for pharmacists to promote sustainability through direct such as Medicare are many primary care services provided by pharmacists in that the that in the Drug which provides medication savings to and patients as well as savings to the pharmacy, the savings to support clinical pharmacy services (eg, or support of a clinical Examples of services provided by pharmacists in include: Pharmacy Services Care Management and Care Management Care Health Medicare TCM information can be found in the ASHP Center for Pharmacy Services in Federally Qualified Health The National of recommends that including Medicaid, Medicare, commercial and self-insured shift a that fee-for-service and and that these models for integrated, team-based sustainability for services provided by primary care pharmacists may be achieved a variety of to lack of federal provider status for pharmacists and to directly bill Medicare as primary care providers, organizations and have become in financial sustainability of primary care pharmacist services. settings indirect funding, while of of the limited direct insurance billing opportunities to pharmacists in primary care billing opportunities will on the as well as laws and Medicare, Medicaid, and commercial health may pharmacists for certain services, while will direct with the health Several states have passed pharmacist state provider status laws and/or reimbursement parity laws allowing for reimbursement for direct patient care pharmacist services by state Medicaid and/or commercial plans.4 of direct and indirect billing are in As pharmacists to in the primary care workforce and credentialing and privileging with payers and healthcare organizations are essential. Credentialing and privileging are 2 Credentialing is the by which an individual’s credentials are to that they have the training to practice as a pharmacist. Privileging and providers to care within a of For example, if a pharmacist is practicing in a specialty clinic such as a they would have a different practicing in a primary care The privileging ensures have the training and to provide the services in a this is through a evaluation colleagues provide on the clinical and professional the of pharmacists, in and the increased complexity of healthcare, the credentialing and privileging is important Credentialing is required by payers in for providers to bill for services. As credentialed providers, pharmacists are able to both provide patient care services and contribute to the financial sustainability of the Privileging protects the from legal risk and ensures patients receive care from qualified and competent providers. systems already exist for pharmacists and their physician and nurse practitioner of pharmacists into existing processes will enable the profession to function in parallel and collaboratively with colleagues and assist in preparing for provider status. There are opportunities for pharmacists who practice in primary care settings to seek additional credentials beyond the pharmacy degree and licensure, and certain credentials may be required to obtain specific privileges to provide MMS. For example, pharmacists who prescribe hormonal contraception or who as immunizing pharmacists must training and/or programs to be to provide those services in their requirements must also be in to into CPAs and by Pharmacists who practice a in New and North are recognized as and Clinical and The variety of state requirements to provide primary care pharmacy services as a barrier to patient access to services, and to credentialing is needed. Employers may that primary care pharmacists a and/or a 2 training may also through the of Pharmacy or of an interprofessional such as the Care and Education or Care Provider among others. A of opportunities with for are in the programs an and pharmacists must a on the and requirements for of include confidence, improved increased and a in and The on Credentialing in Pharmacy has for credentialing of There are many in which pharmacists can become involved in primary care the practice and service will collaboration with other healthcare providers as well as a patient population and of federal provider status will allow pharmacists the ability to bill Medicare and services and financial as has been demonstrated in states with provider status As pharmacists become involved in primary care practice, healthcare will to the goal of and use of medications for all all of the ASHP the for reviewing the current of the and The of and to the of this are also The have of through the ASHP of Care Pharmacists and by the ASHP of on February and by the ASHP of on This the ASHP on the in Primary Care to for Pharmacy

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