So Pharmacists Want to Be a Provider:
Where the Profession Lost Its Way
and Perhaps a Path to Get Back

In August of 2007, I was a PGY-2 cardiology pharmacy resident at UPMC Presbyterian. I drafted a letter arguing that pharmacy's central problem was not the message, it was the audience. Eighteen years, a health plan directorship, and an AI acquisition later, the diagnosis has not materially changed. What has changed is my understanding of why.

The problem is not the message and it is not the audience. The profession has gotten better at both over two decades. The problem is that pharmacy never built the operational infrastructure that would allow it to capture the value it demonstrably creates. Not the credentialing systems. Not the network contracting capability. Not the RCM-compliant documentation standards. Not the interoperability architecture. Not the solvent business models that would sustain provider-equivalent care delivery at scale.

This piece is an attempt to name that gap precisely, trace how it formed, and make the case for what closing it actually requires. It is written from a vantage point that spans the clinical, the commercial, and the payer side of this problem simultaneously. The value case for pharmacists as providers is real. It has always been real. What follows is the harder conversation.

1. The Profession Worth Defending

Pharmacy has a legitimate claim to being one of the most clinically undertapped professions in American healthcare. The PharmD is a rigorous doctoral program. Pharmacists graduate with deep training in pharmacokinetics, pharmacodynamics, drug-drug interactions, and clinical therapeutics that most physicians will tell you privately exceeds their own. In institutional settings, pharmacists are embedded in ICUs, oncology units, and antimicrobial stewardship programs, functioning as indispensable clinical partners.

The peer-reviewed literature quantifies what that clinical depth looks like at scale. The pCATCH methodology, developed at UNC Hospitals to objectively allocate clinical pharmacist specialist resources, scored service-specific pharmacy intensity across 31 inpatient services using patient census, acuity, drug expenditure, high-priority medication use, and teaching intensity as composite metrics. Cardiac surgery, bone marrow transplant, solid-organ transplant, and the medical ICU ranked among the highest-intensity services in the health system.1 The workload those rankings represent is substantial. In high-acuity inpatient settings, clinical pharmacists manage pharmacokinetics for narrow-therapeutic-index agents, anticoagulation in LVAD and ECMO patients, HIT protocols, Class III antiarrhythmic monitoring, TPN, CRRT dosing, perioperative antibiotics, and immunosuppression management in transplant populations. They develop institutional guidelines, serve on transplant and critical care quality committees, support antimicrobial stewardship programs, and staff emergency response teams. They manage medication reconciliation from the ED through the ICU to step-down, medical-surgical, and transitions-of-care handoffs, the points in the continuum where medication errors cause the most harm. This clinical presence is not concentrated at a single institution. It is the standard practice model across academic medical centers and large community hospitals in the United States.

Community pharmacists occupy an equally distinct access point. No appointment required, present in virtually every zip code, trusted, credentialed, and in many cases the only consistent clinical touchpoint for patients managing multiple chronic conditions. The cost data on pharmacist-managed minor illness is real. The outcomes data on pharmacist-led MTM, adherence support, and chronic disease management is robust. The case for expanded pharmacist utilization has never been the problem.

2. The Harder Truth

The pharmacy profession has operated on an island for most of its modern history, and in many ways it built that island itself. The dominant business model in community pharmacy has been dispensing. Fill the prescription, collect the fee, repeat. That model made sense when it was designed. PBMs, drug manufacturers, and health plans built an entire economic ecosystem around it. Over time the profession's identity, infrastructure, and revenue model calcified around that function.

Meanwhile the rest of healthcare was evolving. Scope of practice expanded for nurse practitioners and physician assistants. Dentistry built its own coding infrastructure and fought successfully for independent recognition in benefit design. Medicine aligned to provider-based reimbursement and built the institutional scaffolding around it over decades. Pharmacy watched most of that happen from the dispensing counter.

The verbal acknowledgment of pharmacist value has never been the problem. Health plans, hospital systems, and policymakers will all affirm pharmacists matter. What they have been consistently unwilling to do is pay for it through formal reimbursement structures, evolve scope of practice in ways that require real regulatory and contractual commitment, or integrate pharmacy into care delivery as a recognized provider rather than a vendor. This is not a new dynamic. The debate over pharmacist provider status has been active for over thirty years, and the pattern is familiar.

3. How Every Other Profession Did It

The pharmacy provider status debate treats reimbursement as something that gets granted through advocacy. The history of every other provider profession tells a different story. Reimbursement gets built, through deliberate strategic decisions to own the infrastructure around clinical value before the policy window opens.

The American Medical Association owns the CPT coding system. This is not a minor administrative detail. It means medicine controls the language through which clinical services are defined, valued, and paid for across every payer in the United States. The AMA is actively extending that machinery into AI-guided clinical decision support, publishing a formal taxonomy for assistive, augmentative, and autonomous AI services with CPT codes already in place for algorithmic ECG assessment, coronary FFR estimation, and autonomous retinal imaging. That is a profession continuously expanding its billing infrastructure in real time.

The American Dental Association did the same thing with CDT. A profession with a narrower clinical scope than medicine or pharmacy built its own coding system, its own credentialing standards, and its own payer contracting infrastructure. The strategic lesson is straightforward. Own the infrastructure and you control the terms on which your profession is valued.

Advanced practice providers spent three decades fighting scope of practice battles state by state, building supervision models that allowed them to operate within existing provider frameworks while gradually expanding independent authority. The incident-to billing model, collaborative practice agreements, and gradually loosening supervision requirements were not policy gifts. They were the result of organized, incremental, infrastructure-first strategy. Physical and occupational therapy did the same. They defined their services in CPT, built credentialing standards, negotiated network participation agreements, and created the compliance documentation requirements that made payer recognition possible.

4. The Infrastructure Stack Pharmacy Doesn't Have

The gap between pharmacist clinical capability and pharmacist reimbursement is not primarily a policy gap. It is an infrastructure gap. Closing it requires building five things that currently exist in fragmented, underdeveloped, or entirely absent form across the profession. Critically, these layers have a defined sequence that cannot be shortcut.

5. The Legal and Structural Operating Model

Even a profession that successfully builds all five infrastructure layers faces a structural problem that medicine long ago addressed and pharmacy has not. The question is who can legally employ a pharmacist rendering a cognitive service, and whether the entity controlling that employment relationship has interests that conflict with the clinical judgment being billed.

Corporate Practice of Medicine prohibitions exist in most states to prevent corporations from directly employing physicians or directing their clinical decisions. The underlying principle is that corporate financial interests and licensed clinical judgment should not be conflated within the same entity. The result in medicine is a structural separation. The Professional Corporation employs the licensed clinicians, holds the payer contracts, and owns clinical accountability. Outside capital and operational infrastructure enter through a Management Services Organization that contracts back to the PC for non-clinical services under a Fair Market Value Management Services Agreement.

Pharmacy has no equivalent protection in most states. The absence of a Corporate Practice of Pharmacy framework is part of why the dispensing model calcified so completely under corporate pharmacy ownership. CVS, Walgreens, and similar entities can employ pharmacists and direct their activities without the structural constraints that CPOM imposes on medicine. For dispensing, that created no obvious conflict. For cognitive services billed under a pharmacist NPI, it creates a material one. A pharmacist billing a CPT code for a clinical judgment rendered while employed by a corporation that also profits from the downstream dispensing transaction is operating in a conflict of interest structure that CPOM laws were designed to prevent. The CPOM question mark visible on the pharmacy MSO-PC framework diagram is not a minor compliance footnote. It is an unresolved foundational question that determines whether the billing infrastructure the profession is trying to build can operate compliantly at scale.

The MSO-friendly PC model, already well-established in medicine and increasingly in dentistry and behavioral health, provides the structural template pharmacy needs. A Pharmacist-Owned Professional Corporation employs the licensed pharmacists, holds the payer contracts, and owns clinical governance. A Management Services Organization handles the non-clinical infrastructure, contracting back to the PC under a formal MSA with FMV pricing. Core MSO functions include:

• Billing operations
• Credentialing
• Payer contracting support
• Technology and operational platform services

The key compliance framework this structure must navigate spans five areas:

• Anti-Kickback Statute. Prohibits remuneration that could induce referrals of federal healthcare program business
• Stark Law. Governs physician self-referral and has pharmacy analogs in certain state frameworks
• HIPAA and information security. Governs data exchange obligations between the PC and MSO
• Fee-splitting prohibitions. Applied at the state level
• Corporate practice of pharmacy (CPOP). Evolving as states define the corporate practice landscape in response to expanding clinical services, similar to that of Corporate Practice of Medicine (CPOM)

The practical implication for the profession is that building billing infrastructure inside the existing corporate pharmacy employment model without the MSO-PC structural separation creates compounding legal risk as volume scales. A pharmacist generating $23 in incident-to revenue per encounter is not a meaningful target for AKS or fee-splitting scrutiny. A network of pharmacist-owned PCs generating millions in cognitive services revenue under MSO-managed billing infrastructure is an entirely different compliance profile. The profession needs to define the operating model before it scales, not after regulators or plaintiffs define it for them.

6. The Business Model Question

The altruistic framing that dominates pharmacy advocacy is not wrong. Pharmacists generate real clinical value. The cost data is real. The outcomes data is robust. But altruism does not sustain a profession, and a value proposition without a solvent business model is just a slide deck.

The ASHP Pharmacist Billing and Coding Quick Reference Sheet, first published in 2016 and last updated in 2019, captures the state of pharmacist billing infrastructure with unintentional precision. The most accessible billing pathway for most pharmacists in physician-based clinic settings is the Level 1 E/M code, 99211, at an estimated reimbursement of $23.07 per encounter. Higher E/M levels are not routinely allowed by most payers without provider status. MTM codes are only billable through a Medicare Part D contract with reimbursement set by the Part D sponsor. Pharmacists cannot bill Chronic Care Management or Transitional Care Management directly.

Fee-for-service is the backstop and it has to come first. It is the mechanism through which every other recognized provider profession generates the baseline revenue that funds operations, supports workforce development, and creates the financial stability to pursue value-based arrangements over time. You cannot negotiate a per-member-per-month care management contract with a payer if you have no claims history, no credentialed provider network, no compliant documentation infrastructure, and no actuarial basis for pricing the arrangement.

Value-based care models are worth pursuing for defined target segments, particularly in MTM for high-cost chronic disease populations, care transition support, and population health partnerships with ACOs and risk-bearing provider groups. But these are advanced models that presuppose FFS infrastructure already exists. They are not a bypass strategy for a profession that hasn't built the provider billing foundation yet.

The organizational accountability question spans the full JCPP membership, each with a distinct role. ASHP's accountability sits in the acute care and institutional settings where pharmacy's clinical integration is deepest. Publishing a billing quick reference sheet in 2016, updating it once in 2019, and leaving it there is not the work needed. ASHP should be defining compliant CPT-based documentation standards for inpatient and acute care pharmacist services and building payer coverage policy arguments specific to hospital and post-acute settings. APhA and NCPA own the ambulatory and community pharmacy territory, and their fragmentation is itself a structural barrier. Payers negotiate with organized provider groups. A fragmented advocacy landscape produces fragmented negotiating leverage. ACCP brings clinical evidence infrastructure. AMCP connects the managed care payer relationship. ASCP owns the long-term care and consultant pharmacy setting where deprescribing and medication optimization billing opportunities are substantial. NASPA provides the cross-state association network that scope of practice regulatory harmonization requires, and given the foundational nature of that work, its role is arguably the most critical in the sequence.

The Joint Commission of Pharmacy Practitioners is the right body to resolve this fragmentation. JCPP spans the major pharmacy organizations and exists specifically to provide unified strategic direction. That mandate requires a more directive and less consensus-bound role than JCPP has historically played. JCPP's own governing language acknowledges it has no intrinsic authority to speak for its members. The question is whether that posture, appropriate for 1977, remains appropriate when the infrastructure work requires someone to own the sequencing, fund the work, and hold organizations accountable to measurable outcomes rather than policy positions.

7. A Path Forward

The most encouraging recent development is the establishment of the Pharmacy Interoperability & Clinical Services Alliance (PICSA) led by Leavitt Partners that held its inaugural meeting in Washington, DC in April 2025. It is structurally more sophisticated than what the profession has attempted before. The deliberate separation from dispensing is meaningful. The April 2025 agenda addressed the actual hard problems:

• FFS billing pathways
• Medical versus pharmacy benefit billing
• Credentialing requirements across payer types
• HL7 FHIR and NCPDP standards
• EHR integration
• Claims and billing system alignment
• State-by-state scope of practice implications

The constructive challenge for PICSA, offered in the spirit of wanting it to succeed where prior efforts have stalled, is about how success gets defined and measured. Policy wins, endorsed standards, and favorable legislative language are necessary but not sufficient. Success for PICSA has to ultimately be defined in operational terms. The measures that matter are:

• Pharmacists credentialed as providers with commercial and government payers at measurable scale
• Documented claims volume for cognitive services billed under pharmacist NPIs
• Interoperable encounter data flowing into EHR systems
• Denial rates tracked and driven down through compliant documentation infrastructure

The path forward is infrastructure-first and it has a defined sequence that cannot be shortcut. NASPA and state pharmacy associations must lead scope of practice regulatory clarity first, because nothing else can be built compliantly until service definitions are legally established. Credentialing and provider identity infrastructure have to be established before network contracting is possible. Network contracting has to precede scalable billing. Billing infrastructure and RCM-compliant documentation standards have to be in place before the compliance work becomes urgent enough to drive institutional change. Interoperability cannot be treated as a parallel workstream, because without encounter data flowing from and to the longitudinal medical record, the clinical value pharmacists generate remains invisible to the care teams, payers and population health platforms whose coverage decisions determine whether any of this scales.

The FTE business case has to be solved in parallel with everything else, because until it is, the profession will keep losing the resource allocation argument at the practice level regardless of what happens at the policy level. A pharmacist who can generate billable RVUs or their equivalent under independent billing authority changes the conversation in every practice manager's office in the country. That outcome requires provider status, compliant documentation infrastructure, and network participation agreements to already exist. Which is precisely why the infrastructure work cannot wait for the policy environment to be perfect before it begins.

The uncomfortable truth is that the profession has known what needs to be done for a long time. The data behind the value case has only gotten stronger. What the profession has not done in the intervening decades is make the operational commitment to build the infrastructure that would allow it to capture that value at scale and make it visible on a balance sheet.

That is the work that remains. It is infrastructure work, regulatory work, contracting work, compliance work, and organizational alignment work. It is not glamorous and it does not generate the kind of advocacy momentum that fills conference rooms. But it is the only work that will break the cycle that has repeated, with remarkable consistency, for thirty years.

The infrastructure is buildable. The organizations and pharmacist initiatives exist. The clinical evidence is more than sufficient, but it cannot stand on soft financial end points to justify business cases. What the profession needs now is the collective will to build together, with the same deliberateness that every other provider discipline brought to the same challenge before it.