January 17, 2020
[Submitted electronically via PatientsOverPaperwork@cms.hhs.gov]
The Honorable Seema Verma
U.S. Centers for Medicare & Medicaid Services
Department of Health and Human Services
P.O. Box 8016
Baltimore, MD 21244–8016
RE: Request for Feedback on Scope of Practice
Dear Administrator Verma:
On behalf of the American Association of Colleges of Pharmacy (AACP), we are pleased to submit our comments regarding the Centers for Medicare and Medicaid Services’ (CMS) request for additional input and recommendations, under Executive Order (EO) # 13890 – “Protecting and Improving Medicare for Our Nation’s Seniors,” regarding elimination of specific Medicare regulations that require more stringent supervision than existing state scope of practice laws, or that limit health professionals from practicing at the top of their license.
AACP, founded in 1900, is the national organization representing pharmacy education in the United States. The mission of AACP is to lead and partner with our members in advancing pharmacy education, research, scholarship, practice and service to improve societal health. AACP provides services for its members and stakeholders, including meetings and events, webinars, continuing education, publications, reports and searchable directories for faculty, speakers and grants. AACP also works to promote the profession of pharmacy and the value of pharmacy education to audiences beyond the academic community. We envision a world of healthy people through the transformation of health professions education.
Pharmacists are the most accessible health care providers and provide care and services in a wide variety of practice settings in communities across our nation. They are uniquely qualified to reduce clinical burdens and improve patient health. Pharmacists can also provide the type of medication and disease management services needed to not only stem adverse drug events and medication nonadherence, but also enhance patient outcomes through improved medication use. Pharmacists today receive clinically based Doctor of Pharmacy degrees (Pharm. D.), and many also complete postgraduate residencies and become board certified in a variety of specialties.
We strongly encourage that pharmacists be more integrated into primary care. Schools and residency programs train students to work with physicians, nurses and other providers to manage patients’ medication and ensure appropriate care transitions as part of interprofessional teams. Patient care discussions with other providers often revolve around the pathophysiology of disease or chronic conditions, but far too often patients receive little information regarding perhaps the most essential part of treatment — the medication prescribed to cure or manage the condition. In many cases, the prescribing clinician does not have the same medication expertise as a pharmacist. Thus, if the goal is to avoid overspending on drugs and to maximize the value of the drugs patients purchase, pharmacists must play a more prominent role in medication selection and modification, patient education, follow-up and monitoring of medication, and overall medication and chronic disease management.1
However, due to statutory and regulatory barriers such as references to “provider,” “eligible professional,” or similar terms that do not include pharmacists in their definition, pharmacists are often an underutilized health care resource. Meeting CMS’s goal of adding value and access through coordinated, team-based care delivery will require CMS to eliminate barriers that exclude/prohibit pharmacists and other nonphysician practitioners from providing patient care services. These services are well within pharmacists’ legal state scope of practice and pharmacy licenses.
It is important to also note, pharmacists in rural health settings should be leveraged to provide patient-care services that are covered by Medicare Part B as it could help prevent rural clinics and pharmacies from closing while providing care in underserved areas. Rural clinic and pharmacy closures also impact hospitals and other care settings, medication adherence, patient safety and leave significant gaps in care to important services such as administering vaccines.2,3,4,5 We urge CMS to carefully consider how pharmacists across all practice settings can be included in different aspects of Medicare in the interest of patient care and sustainability of the program.
Colleges/Schools of Pharmacy strive to prepare the pharmacist workforce, including current practitioners, to achieve the Quadruple Aim. AACP President Todd Sorensen, Professor at the University of Minnesota College of Pharmacy has completed research which suggests that comprehensive medication management (CCM) fosters achievement of the Quadruple Aim, including clinician well-being and burnout among primary care physicians.6
AACP has signed onto comments led by the American Pharmacists Association (APhA) detailing our request as a result of this comment period. We ask that you take those recommendations into account when drafting regulation and requirements.
AACP appreciates this opportunity to comment and provide feedback to CMS regarding barriers to allow pharmacists to practice at the top of their license/profession. If you have any additional questions, please contact Jasey Cárdenas, Associate Director of Strategic Engagement at firstname.lastname@example.org or 703-739-2330.
Lucinda L. Maine, Ph.D., R.Ph.
Executive Vice President and CEO
American Association of Colleges of Pharmacy
1Studies indicate that the inclusion of pharmacists on the healthcare team demonstrates a significant return on investment in both patient outcomes and real dollars. See, e.g., C.A. Bond and C.L. Raehl, Clinical Pharmacy Services, Pharmacy Staffing, and Hospital Mortality Rates, 27 Pharmacotherapy 482-93 (2007); See also, M.E. Arnold, et al., Impact of Pharmacist Intervention in Conjunction with Outpatient Physician Follow-up Visits after Hospital Discharge on Readmission Rate, 72 Am. J. Health-Sys. Pharm., Supp. 1 (2015).
2Qato, D.M., Alexander, G.C., & Chakraborty, A. (2019). Association Between Pharmacy Closures and Adherence to Cardiovascular Medications Among Older US Adults, Journal of the American Medical Association, 2(4):e192606, available at: https://www.ncbi.nlm.nih.gov/pubmed/31002324
3Traynor, A.P., Sorenson, T.D. & Larson, T. (2011). The Main Street Pharmacy: Becoming an Endangered Species, Rural Minnesota Journal, 2(1), available at: https://www.ruralmn.org/wp-content/uploads/2011/03/The-Main-Street-Pharmacy.pdf
4Bartch, S.M., Taitel, M.S., DePasse, J.V., Cox, S.N., Smith-Ray, R.L., Wedlock, P., Singh, T.G., Carr, S., Siegmund, S.S. & Lee, B.Y. (2018). Epidemiologic and economic impact of pharmacies as vaccination location during an influenza epidemic, Vaccine, 34(46), 7054-7063, available at: https://www.ncbi.nlm.nih.gov/pubmed/30340884
5Rural Policy Research Institute & Rural Health Research & Policy Centers, (2017). Issues Confronting Rural Pharmacies after a Decade of Medicare Part D, available at: https://rupri.public-health.uiowa.edu/publications/policybriefs/2017/Issues%20confronting%20rural%20pharmacies.pdf
6Primary care providers believe that comprehensive medication management improves their work-life. See, e.g., Funk KA, Pestka DL, Roth MT, Carroll JK, Sorensen TD. JABFM 2019. 32(4). 462-473.