Background:

The Every Category of Provider Law.

Under Washington's "Every Category of Provider Law," health carriers must permit every category of health care provider to provide health services or care for conditions included in the Basic Health Plan, a discontinued state program that provided coverage to low-income individuals for health services, including physician services, inpatient and outpatient hospital services, and prescription drugs and medication. The Every Category of Provider Law applies only if:

the provision of the health services or care is within the provider's scope of practice; and
the provider agrees to abide by standards relating to provision, utilization review, and cost containment; management and administrative procedures; and provision of cost-effective and clinically efficacious health services.

Pharmacists under the Every Category of Provider Law.

Pharmacists are licensed by the Pharmacy Quality Assurance Commission and may provide a variety of services, including:

interpreting prescription orders;
compounding, dispensing, labeling, administering, and distributing drugs and devices;
monitoring drug therapy and use;
initiating or modifying drug therapy in accordance with written guidelines or protocols established by a prescribing authority;
participating in drug utilization reviews and drug product selection;
properly and safely storing and distributing drugs and devices; and
providing information on legend drugs.

In 2013 an informal Attorney General Opinion stated that pharmacists are health care providers for purposes of the Every Category of Provider law and therefore must be compensated for services included in the Basic Health Plan that are within the pharmacist's scope of practice if the pharmacist abides by standards relating to cost containment, management, and clinically efficacious health services.

Essential Health Benefits.

The federal Patient Protection and Affordable Care Act requires individual and small group market health plans to offer 10 categories of "essential health benefits" both inside and outside of Washington's health benefit exchange. The essential health benefits are established on a state-by-state basis using a supplemented benchmark plan chosen by each state. Washington's benchmark plan is the largest small group market plan in the state.

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Summary of Amended Bill:

Health plans issued or renewed on or after January 1, 2016, may not deny benefits for health care services provided by licensed pharmacists if:

the service was within the pharmacist's lawful scope of practice;
the plan would have provided benefits if the services had been provided by a physician, osteopathic physician, advanced registered nurse practitioner, physician's assistant, or osteopathic physician's assistant; and
the pharmacist is included in the plan's network (mere participation of a pharmacy in the plan's drug benefit does not constitute inclusion in the network).

For purposes of the Every Category of Provider Law, health carriers are required to reimburse every category of provider for services or care included in the essential health benefits benchmark plan, instead of the Basic Health Plan, if the plan covers such services or care.

Amended Bill Compared to Engrossed Substitute Bill:

The amended bill:

delays the prohibition against a health plan denying benefits provided by a pharmacist until January 1, 2017;
removes the requirement that large group market health plans use a definition of essential health benefits authorized under federal law for purposes of the Every Category of Provider Law; and
requires that only services or care in the essential health benefits benchmark plan that are covered by the health plan are subject to the Every Category of Provider Law.

Staff Summary of Public Testimony:

(In support) Given a recent informal Attorney General's Opinion on pharmacists and the Every Category of Provider Law, the time is right to move this bill forward. The role of pharmacists is expanding beyond dispensing medications; they are part of a team to manage medications and reduce health care costs. Pharmacists have post-baccalaureate educations and engage in collaborative drug therapy based on one-on-one agreements with physicians. Pharmacists help treat a variety of diseases, including high blood pressure, clotting disorders, diabetes, and chronic pain. This is a patient access issue—having a pharmacist as part of the care team can help the team treat patients with complex conditions, can help ensure that patients are treated in their communities, and can lower costs. Pharmacists should be part of team-based health systems such as accountable care organizations. Pharmacists have been denied access and reimbursement just because they are pharmacists. Many pharmacists practice in clinical settings and do not dispense medications, but reimbursement is only allowed for pharmacists who dispense. Other providers who provide identical treatment to patients are reimbursed for their services, while pharmacists are not.

(With concerns) Pharmacists have a valuable role to play in the health care system, but this bill lacks specificity to guide health carriers through implementation. Health carriers are willing to expand their networks to include pharmacists, but it will take time to credential providers and build a network. This should be done carefully. This bill should be delayed by a year so that a structured stakeholder workgroup process can take place. This bill appears to extend the essential health benefits requirement to large group market health plans.

(Opposed) None.

(Other) The problems pharmacists are facing are understandable, but this is a radical concept. Washington would be the first state to have a law like this in place. There should be a stakeholder process to discuss how this bill would play out in the real world.

Persons Testifying: (In support) Senator Parlette, prime sponsor; Jeff Rochon and Jenny Arnold, Washington State Pharmacy Association; Glenn Adams, Confluence Health; Rick Weaver, Comprehensive Mental Health Services; Ian Corbridge, Washington State Hospital Association; and Don Downing.

(With concerns) Sydney Smith Zvara, Association of Washington Healthcare Plans; Chris Bandoli, Regence Blue Shield; Len Sorrin, Premera Blue Cross; and Chris Marr, Group Health Cooperative.

(Other) Sean Graham, Washington State Medical Association.