Vaccination payments in states with provider status for pharmacists: a claims analysis.

Background: Federal-level legislation to recognize pharmacists as providers and thus allow insurance reimbursement for health services claims, not just prescription drug claims (known as provider status), has been advocated by the profession but is yet to be passed into federal law. Several state governments have enacted this recognition for commercial insurance and/or Medicaid plans. However, the impact of these laws on reimbursement and access to health services has yet to be explored empirically.

Objective: Compare commercial reimbursements for influenza and herpes zoster vaccinations for adults in provider status vs non-provider status states to determine whether these laws have had an intended effect of increasing reimbursement to pharmacists for provided services.

Methods: We used pharmaceutical and outpatient services claims from a national claims database, Marketscan, to examine payments made to pharmacies for all codes billed during vaccination visits. We then used a multivariable logistic regression model to compare the net revenue of vaccination visits in commercial provider status states versus non-provider-status states.

Results: Our dataset contained 2.3 million vaccination visits for influenza and herpes zoster during 2021-2022. We found that the odds of a vaccination visit having positive net revenue were slightly higher in provider status states (shingles OR: 1.03, p<0.001; influenza OR 1.01:, p<0.001). These findings are limited by the stark lack of health services claims by pharmacies in our dataset; only 0.4% of visits included any outpatient services claims, even among provider status states.

Conclusion: This indicates that pharmacists are not submitting claims for reimbursement to payors for health services they are providing. This absence could be due to several reasons and limits the ability to generate evidence about the effect of these laws on health and economic outcomes for patients and health systems. Further research is needed to identify and address barriers to implementation of provider status laws.