Despite overwhelming evidence of the positive impact pharmacists can have on patient health, pharmacists are not recognized as healthcare providers under the Social Security Act and, therefore, cannot be paid by Medicare for therapy management and patient consultation services. The Social Security Act does recognize other healthcare professionals such as dieticians, nurse practitioners, physician assistants, nurse midwives, and clinical social workers.
By changing the compensation structure allowed under Medicare, we can ensure that patients have access to the medication expertise of pharmacists. Studies have shown that when a pharmacist is directly involved in patient care, patients have fewer adverse drug reactions, experience improved outcomes, and healthcare costs are reduced.
Response to Petition
By Jonathan Blum
Thank you for your petition on recognizing pharmacists as health care providers under the Social Security Act.
As you noted, pharmacists are not recognized in the Social Security Act as health care providers who are authorized to bill and receive payment for their services from Medicare. To do so would require a change to the statute by Congress.
But we recognize and value the trusted role that pharmacists play in the community, and their importance to patient care -- in particular to Medicare beneficiaries who need prescription medications.
The term "provider" is defined in Medicare regulations at 42 C.F.R, §400.202 and includes hospitals, skilled nursing facilities, and home health agencies. That term does not include pharmacists. Moreover, the Medicare law specifically authorizes the health care providers who can bill and receive payment from Medicare. For instance, section 1861(r) of the Social Security Act defines "physicians" under the Medicare program. This definition includes, with various restrictions and exceptions, doctors of medicine and osteopathy, doctors of dental surgery and dental medicine, doctors of podiatric medicine, doctors of optometry, and chiropractors. The statute also authorizes several specific non-physician practitioners including nurse practitioners, clinical nurse specialists, physician assistants, nurse midwives, clinical psychologists, and physical therapists to bill and receive payment from Medicare for their professional services that fall within their State scope of practice.
So while pharmacists are not recognized as "providers" who are authorized to bill and receive payment for their services from Medicare, they can receive payment for their services when furnished to Medicare beneficiaries in certain circumstances. For example, pharmacists can receive payment for furnishing services "incident to" the services of a physician or non-physician practitioner. The requirements under the "incident to" provision must be met, including the supervision requirements. The physician or non-physician practitioner who bills for the "incident to" services that the pharmacist furnished would receive payment from Medicare, and the pharmacist would receive payment from the physician or non-physician practitioner based on the agreement established by the parties involved.
Pharmacists can also be paid under Part D by Medicare prescription drug plans to dispense prescription drugs as well as to provide medication therapy management services to patients to identify problems and perform medication reconciliation.
Please visit CMS.gov for additional information.
Jonathan Blum is the Principal Deputy Administrator at the Centers for Medicare & Medicaid Services.