“Pioneers of Provider Status: How Two Alaska Pharmacists are Paving the Way for Reimbursement in Pharmacy Practice”
As the landscape for pharmacists continues to expand, barriers about sustainability and reimbursement must be addressed. To navigate these barriers the SETMuPP project has been working with two pioneering pharmacists for two years. The result of this collaboration has been expansion of health services provided by pharmacists and subsequent reimbursement by both public and private payers. In this interview, we spoke to two pharmacists who are among the first in Alaska to successfully perform and bill for medical services within their pharmacy practices. We discussed their challenges and triumphs in navigating this process and their overall “why?”.
Dr. Angela Jaglowicz is a clinical assistant professor at the University of Alaska and Idaho State University College of Pharmacy and a clinical pharmacist at Anchorage Neighborhood Health Center, a federally qualified health center.
Dr. Amy Paul is a clinical pharmacist at a family medicine residency site, Providence Family Medicine Center in Anchorage, AK. Previously, she worked with Providence Senior Care, where she established ambulatory pharmacy services.
Introduction:
Q: Would you mind telling us a little bit about yourselves, your background in pharmacy, and your place of work?
AJ: My mother, a community pharmacist, was the driving force in my choosing pharmacy as a career. During my time in pharmacy school, I was exposed to the world of ambulatory care during a pediatric diabetes rotation. After this experience, I decided to pursue residency training to be able to provide ambulatory care services. I served as a clinical pharmacist to the urban population in Oklahoma City before moving with my family to Alaska. Since moving here, I took a job with the UAA/Idaho State University College of Pharmacy Program, helping to implement clinical pharmacy services at Anchorage Neighborhood Health Center, a federally qualified health center. I love my job and my patients, and I hope I can continue to serve the community in this amazing way.
AP: I didn’t start out wanting to be a pharmacist, but I saw the impact pharmacists have on patient care, so I decided to come back to school and become a pharmacist. I had planned to work at Walgreens upon graduation, but after an ambulatory care rotation during my fourth year, I realized that I could use more of the clinical aspects I had learned in pharmacy school, along with that patient interaction that I loved in community pharmacy. I completed a PGY1 residency in ambulatory care at the Mayo Clinic in Minnesota, then I was told about a new pharmacy program and a senior clinic here in Anchorage, Alaska, which I applied for and was hired for in 2016. It turns out that I loved the job and Alaska. With Providence Senior Care, I established ambulatory pharmacy services there. Little by little, my responsibilities expanded there as providers saw the impact pharmacists could make, and they actually hired another pharmacist to fill those responsibilities. I now work in a Family Medicine Residency (Providence Family Medicine Center, Anchorage, AK), which is absolutely my dream job.
Q: What primary populations does your practice serve?
AJ: My practice serves primarily the urban population of Anchorage, and our patients include those covered by Medicare, Medicaid, cash payers, and those with commercial health insurance. We see a large variety of patients, pediatrics to geriatrics, of many different backgrounds and ethnicities.
AP: We are considered a “safety net” clinic, so we see everyone from birth to end of life. A majority of our patients are on Medicare or Medicaid or uninsured.
The “What”:
Q: You two have been doing some innovative and exciting work on a project involving reimbursement for performing health services as pharmacists. Tell us a little bit about the project--what new practices are you implementing?
AJ: The goal of this project is for medical payors, including private insurers, Medicaid, and Medicare, to reimburse pharmacists for clinical services not tied to dispensing, which include counseling services and disease state management. At my practice site, where I am considered a provider, I see patients for diabetes management, meaning I help them use medications, diet, and exercise to help them control their disease state. I submit claims to insurance for these services rendered.
AP: Historically, we as pharmacists have not been the best advocates for our profession, so we have been siloed into more dispensing-type roles and not recognized by commercial payor for the work that we do. Until recently, all reimbursement in Alaska came from the prescription side of patients’ insurance. So that means no payment for counseling services, recommendations to providers, etc. What our project is doing is that, in my clinic, I am considered a provider. I see patients on a referral basis from providers, similar to a nurse practitioner or a physician’s assistant. The difference is that I do not diagnose, I see people with an established diagnosis and help them manage their disease states. I have been submitting claims to insurance providers similar to how a doctor would: if I see a patient for diabetes, I provide the physical exam (diabetic foot exams, blood pressure), giving them immunizations, counseling on diet and lifestyle, and writing a clinical note and billing for those services. The goal is that the payors will recognize that pharmacists are doing this work and start paying for it
Q: What new health services are you currently providing and being reimbursed for?
AJ: Currently we provide disease state management services for patients with diabetes and on anticoagulation.
AP: We are providing chronic disease state management (for example, diabetes), we have a coumadin clinic where we can bill for the tests and medicine adjustment services. My current students and I have started medication reconciliation services for new patients which includes making recommendations to providers regarding their medications.
The “When” and “How”:
Q: How long did it take to develop these new processes and begin implementing them into your practice sites? How long did it take to receive your first reimbursement?
AJ: Adding clinical pharmacy disease management services took about 2 years. Once clinical pharmacy services were approved by the site, building a patient panel took a few months. The process of submitting claims for reimbursement was a year long process. We still are not reimbursed for every claim we submit, a barrier I expect will continue for some time.
AP: At my old clinic it took about a year and half to two years to develop a panel of patients and get the providers buy-in on pharmacists doing non-dispensing clinical services. It is definitely a relationship-building process. When it comes to getting our first reimbursement, there were some external barriers (payors not having pharmacists on their provider lists), but I found there were a lot more internal barriers than I anticipated. We had to educate our billers and coders here in Alaska that I was going to submit claims knowing they would be rejected, and then we switched to an outside biller and coder for our facility. So I was billing and coding for 6 months before I came across a claim that paid for the services I provided. Those internal billing hurdles are the main barrier I experience, and it still is a barrier to me.
Q: Do you have plans to further develop and add more services?
AJ: Yes, adding clinical pharmacists to the team would be the ultimate goal. Hopefully in the future we can expand our disease management services as well as include transitions of care.
AP: Yes, we are always trying to think of new ways that pharmacists can help. Our clinic is the only medical residency in the state, so we have 36 medical residents here for 3 years training on becoming rural clinicians. We want to add more diabetes management to help take better care of all our patients. We are currently training for diabetic retinopathy screening with some new retinal scanners.
Q: Has this new project changed your daily workflow?
AJ: Yes. Because of the documentation requirements, I have begun regularly taking vitals during my visits. I also have to allow more time for documentation, as this process is still new to me. I believe as time progresses, my daily workflow will improve.
AP: It has improved my daily workflow actually. At first it was a little clunky making sure my documentation was complete enough to bill appropriately, but most electronic medical records have tools to help you with that. I started making a lot of smart templates which helped to streamline my processes. It changed the way I practice. For example in my INR clinic, I never used to check vitals, but now I do, which has helped me find patients who actually needed to see a physician that day. So yes, and it has absolutely improved my practice.
Q: What challenges, facilitators, and barriers did you face?
AJ: Challenges included receiving board approval for our collaborative practice agreement and developing EHR templates and forms from scratch. Because the providers were unfamiliar with pharmacy services at the practice site, it took some time to develop a patient panel. And finally, facilitating pharmacist billing in a site that had not done so before was difficult, however, the SETMuPP team provided thorough training and was instrumental in overcoming this hurdle.
Some facilitators of the process were that the SETMuPP team was very helpful through this process by providing training for pharmacists and also for our billing team.
AP: We discussed barriers a little bit earlier, but some facilitators were that the billing and coding process itself is not as daunting and complicated as it seems. It is not actually that difficult to figure out how to submit a claim with the correct codes, and I had the support of Dr. Robinson and the SETMuPP team if I had any questions.
The “Why”:
Q: What initially motivated you to pursue this project?
AJ: Pharmacists have been providing these services for years, and these services should be reimbursed.
AP: Working in Alaska has made me more motivated to be active in the profession because pharmacists in Alaska are few but have a louder voice. It’s such an astronomical shortage of resources up here, so I really try to close gaps of care with patients. Luckily, I’m with a health system that recognizes the value of pharmacists, where we aren’t revenue generating but rather cost saving and improving patient care. Understandably, a lot of people have to look at a dollar amount. I know that for health systems who want pharmacists but can’t afford them, advocating for us to be reimbursed for services would allow those health systems to justify having pharmacists in more of a clinical role. Even in the community, pushing pharmacists out of the dispensing role and being able to provide more clinical services, even at Walgreens or Safeway, would be beneficial if we were reimbursed for that,
Q: Given the often-remote areas and diverse populations you serve in Alaska; how would you say that pharmacists providing and being reimbursed for health services impacts healthcare for your patients?
AJ: Pharmacists are the most accessible healthcare providers to the public, especially to our patients in rural areas here in Alaska. As pharmacists become able to be reimbursed for health care services, our patients will have access to regular, quality health care. Patients will no longer have to wait to go to a large city to receive care, they can go to their local pharmacist or even use telehealth medicine.
AP: Yes, especially during this pandemic, it’s interesting how we have launched into things that historically we have not done thinking we didn’t have the technology to do. At the beginning of the pandemic during one of my first zoom virtual visit with a patient with a mother and daughter (one in Nome, AK, the other in Anchorage) to do a medication review. At the end, they said it was such a valuable educational tool and that it brought their family together in a way that was not possible before.
Q: Now that you are providing health services and being reimbursed for them, would you say that your work environment and practice has changed for the better? How so?
AJ: Definitely! The center, providers, and patients are seeing the benefit of pharmacy services, and referring more patients for management. Receiving reimbursement will hopefully open the doors for pharmacists to provide more patient-centered care services in the future.
AP: Dr. Paul answered this question in a previous question.
Q: What advice would you give to other pharmacists (in Alaska or otherwise) who want to start providing and being reimbursed for health services?
AJ: Reach out to your state organizations like the Alaska Pharmacists Association, as they have some great resources and training. National associations also provide tools and literature to aid pharmacists in billing for non-dispensing services. You don’t have to go it alone!
This is an exciting time for Alaska pharmacists because efforts like this are not happening everywhere.
AP: Be involved with the state organizations, they have a lot of really good tools to help. We just need to start doing it. Like the old saying goes, “The squeaky wheel gets the grease,” no one is going to do it for us, so we have to start doing it and talking to legislators about it. We have to be the change if we want to see things happen.
Alaska is such a unique place; I hope pharmacists realize the potential impact we can have—it’s huge. We just need to be more of an advocate for our place in the healthcare team.
Conclusion:
The SETMuPP team would like to extend a big “thank you” to Dr. Jaglowicz and Dr. Paul for both their time and their honest, valuable insights into their practices and into their paths to service reimbursement. Our goal is to empower pharmacists to begin providing and billing for services in their practices, and we accomplish that by providing educational tools and support. We are fortunate to work with such innovative providers as Dr. Jaglowicz and Dr. Paul, and in the future, the project plans to expand to additional pilot sites.
