Statement of University of North Carolina at Chapel Hill

In 1999, the state of North Carolina enacted landmark legislation, which licensed Clinical Pharmacist Practitioners as mid-level pharmacist practitioners with the North Carolina Medical Board. The Medical Practice Act (G.S. 90-18.4) states (a) any pharmacist who is approved under the provision of G.S. 90-18(c) 3a to perform medical acts, tasks, and functions may use the title “Clinical Pharmacist Practitioner.” It further states that a CPP may implement drug therapy and order laboratory tests pursuant to a drug therapy agreement. The NC Pharmacy Practice Act 90-85.3 defines CPP’s as having the authority to collaborate with physicians in determining the appropriate health care for a patient.

In order to qualify as a CPP, a pharmacist is required to complete advanced training and certification and be approved by both the NC Board of Pharmacy and Board of Medicine. This expands the scope of practice of a clinical pharmacist to allow for prescriptive authority and complex medical decision-making. This legislative action in the North Carolina General Assembly, allowed CPP’s to establish their own practices, often within a physician’s office or clinic, focusing only on the provision of clinical services in collaboration with physicians. CPP’s deliver care and function as mid-level providers in a manner equivalent to nurse practitioners and physician assistants. In all cases, CPP’s provide very detailed evaluation and management of extremely high risk patients with multiple co-morbidities who are at risk for bad outcomes (i.e. hospitalization, ER visits, etc.) unless their clinical status for diabetes, CHF, COPD, anticoagulation, etc. is closely monitored. The attending physician provides direct oversight as required by the incident-to guidelines.

Clinical Pharmacist Practitioners (CPPs) are North Carolina registered pharmacists who have an advanced scope of practice, similar to Nurse Practitioners, who via collaborative practice agreements with supervising physicians, provide direct patient care under the supervision of a physician. Accordingly, CPPs are considered mid-level providers, however, pharmacists, at any practice level, are the only health care practitioners who are not recognized under Part B of the Social Security Act.  Why is that the case?  Consequently, CPPs are not allowed to bill for seeing Medicare-eligible patients for provision of clinical care.  Thousands of high-risk patients (i.e., hypertension, diabetes, CHF, anticoagulation, chronic pain) in North Carolina (and beyond) risk a critical interruption in care when they are not allowed access to the entire spectrum of health care providers.

In 2004, HR 4724, which was intended to cover a higher level of a collaborating pharmacy practitioner which largely exists only in North Carolina and New Mexico at present. This piece of legislation, submitted in 2004 by then-Representative Richard Burr as a stand-alone bill, went nowhere, even though it was supported by all of the national pharmacy organizations and the American Medical Association. Such legislation, had it passed, would not have enabled all pharmacists, such as dispensing pharmacists, to receive reimbursement for Part D-related activities, but only for those advanced practice pharmacists who provide patient care activities under Part B, such as through a collaborative agreement with a physician.  At present, there are at least 41 states that have state legislation approved for expanded clinical roles for pharmacists, such as noted above.  The only barrier is our Federal government.

In reading your e-mail message, we noticed that Rep. Stark suggested that a review of the payment systems for fee-for-service providers, and that the majority of Medicare beneficiaries and payments are under the fee-for-service system.  If you are looking for efficient and appropriate health care provision, then we would submit that you also take a look at the use of advanced practice pharmacists, to provide health care, decrease medication costs through application of pharmacotherapy, and monitor for and reduce the risk of adverse drug events.  The attached document outlines the benefits of clinical pharmacists in managing care and it attendant costs, and while it is several years old, it delineates the value, both in patient outcomes, and in cost savings (e.g., $14 to $17 saved for each dollar spent) in the Medicare population.

We have also noticed that the Chair of the Medicare Payment Advisory Commission testified at your hearing. We would respectfully suggest that you review the MedPAC report on Clinical Pharmacists, produced in 2002.

We would love to talk to anyone who is interested in improving health care for our nation’s seniors, with a potential cost savings to the system.  The Medicare recipients in our state, and all others for that matter, depend upon your support of this request to consider including advanced practice pharmacists as approved health care providers under Medicare Part B.  Just ask yourself one question: If the Federal government will not let pharmacists take care of America’s prescription drug use problem, then who will?  Physicians are too overloaded to work on this issue, and there is a national shortage of nurses.  Imagine how you could start to fix the Medicare Part D problems if you truly let pharmacists come to the table and do it.  Most often, your best solutions are not related to more technology or regulations, but actually are right in front of you, in the communities across the country, where problems can be dealt with face-to-face.  Please support advanced practice pharmacists, the most accessible health care provider in the community.

Please enter these comments into the record, but more importantly, please call upon us to continue the conversation.

Sincerely,

Timothy J. Ives, Pharm.D., M.P.H., BCPS, FCCP, CPP

Robb Malone, Pharm.D., CDE, CPP

Betsy Bryant Shilliday, Pharm.D., CDE, CPP