The pandemic revealed that pharmacists played a critical role in a patient’s health care. It demonstrated that pharmacists are essential to providing the necessary care for patients during a time when accessibility to health care became limited.

In Wisconsin, the 2021 Wisconsin Act 98 allows reimbursement for pharmacy-related services rendered to Medicaid patients.

The proposed Equitable Community Access to Pharmacist Services Act (H.R. 7213), introduced in the House on March 24, 2022, outlines the expansion of reimbursable services to include pandemic-related services and future health emergencies. This allows for pharmacists to receive reimbursement for these services under Medicare Part B.

H.R. 7213: Equitable Community Access to Pharmacist Services Act

Pharmacists are one of the most accessible health care providers. H.R. 7213 was introduced to expand pharmacist reimbursement for pandemic-related services to Medicare patients.¹

This bill intends to not only expand the pharmacist’s role in rendering such services, but to ensure that pharmacists are equipped to respond to future public health emergencies. It allows pharmacists to bill for their services under Medicare Part B. Additionally, it will ensure that during treatment, a patient can have continued access and care with their pharmacist in between doctor visits.

2021 Wisconsin Act 98

2021 Wisconsin Act 98, enacted Dec. 3, 2021, add​ed pharmacists to the list of health care providers that may be reimbursed for their services under Wisconsin’s Medicaid program. This provides for the expansion of services that a pharmacist or pharmacy may provide to its community.

Act 98 allows pharmacists to get reimbursed under Medicaid for certain services provided to patients within the pharmacist’s scope of practice or under a Collaborative Practice Agreement (CPA).

Pharmacist’s Scope of Practice

The pharmacist’s scope of practice is defined in Wis. Stat. section 450.01(16). The CPA in Wisconsin allows for a physician to delegate certain health care services to the pharmacist, per Wis. Stat. section 450.033.

Act 98 does not change or expand a pharmacist’s scope of practice nor include prescriptive authority.

Statistics provided by the Pharmacy Society of Wisconsin (PSW) show that patients are three times more likely to stay out of the hospital when pharmacists oversee the patient’s care after discharge. Additionally, there is an average of $1,000 saved per patient when pharmacists aid in the management of chronic diseases.

PSW discusses two chronic diseases that pharmacists help patients manage through medication therapy management (MTM): diabetes and cardiovascular disease (CVD). Diabetes and CVD usually involve multiple medications, and may require the patient to monitor blood glucose and blood pressure readings at home in between doctor visits. Pharmacists can discuss with patients their medication regimen, the optimal times to take both readings, and ways to improve health outcomes.

The pharmacist's involvement in the patient’s treatment plan may lead to improved medication adherence, timely follow-up appointments with the patient’s primary care provider, and methods to prevent or respond to complications (i.e., Rule of 15 for hypoglycemia).

These services are either within the pharmacist’s scope of practice or delegated to them under the CPA, and may be submitted for reimbursement under Medicaid.

Pharmacist’s Provider Status – Impacting Communities

The pharmacist provider status benefits communities by increasing health care accessibility, especially in medically underserved areas. According to the PSW, two-thirds of Wisconsin have medical and health care gaps.²

Community pharmacies are more abundant than medical centers. Pharmacists can help address the medical and health care gaps in Wisconsin by providing certain health services to the community. The pandemic showed that pharmacists played a critical role in offering services, such as vaccines, to their patients. It also relieved some of the patient workload and stress in emergency rooms.

The pharmacist provider status may lead to overall health improvements and outcomes, lower health care costs, and an increase in accessibility to a health care provider.³ Pharmacists can provide services that help manage a patient’s disease and lead to better health outcomes. Some of these services include vaccine administration, blood glucose and blood pressure monitoring, MTMs, preventive care, and wellness screenings.

Reimbursement

Pharmacists are not automatically enrolled for the provider status under Medicaid to receive reimbursement. Rather, pharmacists need to opt in to the provider status under Act 98 and contract with Medicaid. The reimbursement is for services rendered by a pharmacist that are covered under their scope of practice or a CPA.

For more information and a quick overview of reimbursement and billing, PSW provides two infographics: Wisconsin Medicaid Provider Status: Billing Questions and Pharmacist Provider Status FAQ.

Additional Considerations

Although the expansion of the pharmacist provider status offers many benefits, there are some potential factors to consider.

Prior to the implementation of the reimbursable services, it is important to understand the pharmacy workflow and staffing. A few things to consider are:

• the additional workload for the pharmacists;

• possible pharmacist burnout; and

• adequate staffing to provide all these services.

These factors may affect the quality of services provided and may impact the patient’s overall health care.

Both Act 98 and H.R. 7213 provide patients with greater access to health services from pharmacists. They also reimburse pharmacists for the additional services. However, with this increase in services, there is a greater chance of pharmacist burnout and inadequate staffing. When adding more services, be careful not to compromise patients’ quality of care.

This article was originally published on the State Bar of Wisconsin’s Health Law Blog. Visit the State Bar sections or the Health Law Section webpages to learn more about the benefits of section membership.

Endnotes

¹ American Pharmacists Association, Pharmacy’s Top Priority: Medicare Provider Status Recognition.

² Pharmacy Society of Wisconsin, Pharmacists Provide Patient Care.

³ Id.