PHARMACIST ACCESS TO PROVIDER NETWORKS

To advocate for laws and regulations that require healthcare payers to include pharmacists in their provider networks as standard coverage when providing patient care services within their scope of practice and the services are covered benefits; further,

To advocate that payers provide comparative, transparent sharing of performance and quality measure data for all providers in their networks, including pharmacists.

Rationale

As hospitals and healthcare organizations increase their ambulatory care service footprint, pharmacists providing patient care services within those settings may find themselves excluded from healthcare payer networks. ASHP acknowledges that healthcare payers may develop and use criteria to determine provider access to its networks to ensure the quality of services and the financial viability of providers (i.e., ensuring sufficient patient volume to profitably operate). When creating provider networks, however, payers should include pharmacists providing patient care services within their scope of practice as standard coverage, when the services are covered benefits. ASHP advocates for laws and regulations that require healthcare payer provider networks to consider all qualified pharmacists who apply to participate as a provider in the network and to reimburse all participating providers fairly and equitably for services that are a covered benefit (see ASHP policy 2331, Sustainable Billing, Reimbursement, and Payment Models). To ensure the same level of patient care and equity for healthcare providers within a payer network, payers should be required to (1) disclose to participating providers and those applying to participate in a provider network the criteria used to include, retain, or exclude providers; (2) ensure those criteria are standardized across all network providers; and (3) collect performance and quality measure data on how well providers meet those criteria and report that data to providers. Pharmacist scope of practice is defined at the state level and is highly variable. Provider status recognition is also highly variable. Only a few states formally recognize pharmacists as providers and have established payer mandates to ensure reimbursement in a manner similar to other disciplines that provide patient care. As a result, pharmacy leaders typically have very limited experience regarding how payers manage networks and reimbursement. When pharmacists obtain provider status, health systems will require a substantial amount of infrastructure to support pharmacists as providers. Pharmacy leaders will need to have relationships across a broad range of internal departments and committees, including finance, revenue integrity, provider relations, medical staff services, and credentialing and privileging. They will also need to engage in external collaborations with payers, which often includes departments such as provider relations and contracting that have a very limited understanding of pharmacist patient care services beyond prescription fulfillment and dispensing services. Despite the risk that payer transparency could reduce market competition, comparative, transparent sharing of performance and evidence-based quality measure data could demonstrate to payers and providers how a provider's performance and quality compares to others. Ensuring that qualified pharmacists have access to payer networks improves patient access to pharmacist care, team-based coordination of care, and health outcomes.