Advocacy Summary: APhA Urges CMS to Remove Regulatory Barriers in Physician Payment Rule to Maximize the Use of Pharmacists for Care Delivery

In October 5 comments to CMS, APhA advocated for the agency to fully remove regulatory barriers in the annual physician fee schedule (PFS) payment rule for 2021 that are more stringent than existing state scope of practice laws, or that limit health professionals, such as pharmacists, from practicing at the top of their license.

CMS’s annual PFS rule outlines payment requirements for physicians and other providers under Medicare.

During the COVID-19 public health emergency (PHE), HHS has recognized the important role that pharmacists play in maintaining and addressing the country’s economic, health, and safety efforts by authorizing pharmacists to order and administer COVID-19 tests and recognizing pharmacies as points of care for COVID-19 testing services. In addition, HHS has also authorized pharmacists to order and administer COVID-19 and childhood vaccines in states where this authority did not already exist—which has enhanced the position of community pharmacies and pharmacists as primary access points for patients to receive preventive immunizations and pharmacist-provided patient care services. 

“APhA recommended in our comments that CMS build upon HHS’s substantive work and implement the Administration’s recommendations by fully utilizing enforcement discretion to remove regulatory barriers to the delivery of, and payment for, pharmacist-provided patient care services for our nation’s Medicare beneficiaries,” said Ilisa BG Bernstein, PharmD, JD, FAPhA, APhA senior vice president of pharmacy practice and government affairs.

“These actions are particularly important due to the estimated shortage of up to 139,000 physicians by 2033 and patients’ access to care, which has only continued to grow due to workforce aging, population growth, and increased demand for health care services.”

To assist CMS in fostering patient care teams, APhA made the following recommendations:

  • Fully leverage pharmacists in telehealth delivery by adding telehealth care services provided by pharmacists and addressing payment barriers for pharmacists’ telehealth services, particularly pharmacy services provided outside of inpatient settings.
  • Make permanent the recent clarification allowing pharmacists to provide Diabetes Self-Management Training (DSMT) services via telehealth as part of Medicare-enrolled, accredited DSMT programs that are not affiliated with hospitals or physician clinics.
  • Remove any barriers that prevent CMS, beneficiaries, and federal taxpayers from garnering the significant avoidance savings available from integrating pharmacists into health care delivery and reimbursement models. 
  • Recognize “pharmacists” as “clinicians” that can be utilized by, and collaborate with, non-physician practitioners (NPPs) under new payment codes.
  • Reference and formally recognize the term and definition of “medication management services” (MMS) adopted for pharmacy practice by the Joint Commission of Pharmacy Practitioners (JCPP).  
  • Recognize complex “incident to” physician services provided by a pharmacist in team-based health care delivery models that can be billed by physicians and NPPs via higher-level Evaluation and Management (“E/M”) codes 99212-215 commensurate with the complex services delivered.
  • Use enforcement discretion to provide a clear payment pathway for the services associated with point-of-care tests (COVID-19, influenza, respiratory syncytial virus [“RSV”]) at pharmacies during the pandemic and beyond, equivalent with that of other qualified health care professionals including patient assessment, specimen collection, and counseling the patient on the results. 
  • Implement the increase in immunization administration rates prior to the January 1, 2021, effective date to address the current influenza season and prepare for the COVID-19 vaccine(s). 
  • Create an add-on code for initiation of medication-assisted treatment (“MAT”) in the emergency department and establish adequate reimbursement and add nasal naloxone, auto-injector naloxone, injectable naloxone, and overdose education services to the definition of opioid use disorder (OUD) treatment services by creating add-on codes and establishing adequate reimbursement.
  • Allow opioid treatment programs (OTPs) to bill an add-on code for periodic assessments conducted through the use of audio-only telephone calls after the COVID-19 PHE is over.
  • Add screening for potential substance use disorders (SUDs), including a review of the individual’s potential risk factors for SUD and referral for treatment as appropriate and a review of any current opioid prescriptions to the Initial Preventive Physical Examination and Annual Wellness Visit with adequate reimbursement. 
  • Require electronic prescribing for controlled substances (EPCS) compliance for covered Part D drugs under a Prescription Drug Plan (PDP) or an MA–PD Plan beginning on January 1, 2022.
  • Permit any supplier with a CDC-assigned National Diabetes Prevention Program (DPRP)-recognized supplier organizational code that specifies the service delivery mode of either in-person or combination be eligible to furnish Medicare Diabetes Prevention Program (MDPP) services at any time during the PHE or otherwise.

Read the October 5, 2020, APhA comments to CMS.