Contextual factors affecting implementation of Medicaid billing for community-based pharmacist services in Virginia:...

In 2023, Virginia mandated Medicaid payment for services provided by pharmacists under statewide protocols. Despite this legislative action, pharmacist registration as Medicaid providers remains limited, delaying access to expanded patient care services.

To identify contextual factors affecting pharmacist registration as Medicaid providers and implementation of Medicaid billing for patient care services in Virginia community-based pharmacies.

Semi-structured interviews were conducted with 16 community-based pharmacists between November 2024 and May 2025. The Consolidated Framework for Implementation Research 2.0 guided interview development and analysis. Interviews explored pharmacists' experiences with Medicaid provider registration, billing procedures, and implementation challenges. Recruitment continued until thematic saturation was achieved. Data analysis employed two-phase inductive and deductive coding, with 2 independent coders analyzing transcripts to ensure reliability.

Procedural complexity, high implementation costs, and poor system design emerged as major barriers to Medicaid billing implementation in community-based pharmacies, despite recognition of the potential financial benefits (innovation domain). Complex regulatory requirements and financing issues limited perceived viability of the innovation (outer setting domain). Inadequate technical infrastructure, insufficient organizational resources (inner setting domain), and knowledge deficits (individual domain) were described as significant obstacles, with mission alignment serving as a facilitator (individual domain). Pharmacists demonstrated unfamiliarity with credentialing and billing processes, and lack of implementation opportunity, while patients' needs for affordable care access were recognized (individual domain). Implementation processes were consistently problematic across planning, strategy development, execution, and evaluation phases (implementation domain).

Medicaid billing for pharmacist services remains in early stages of implementation in Virginia, with limited adoption among community-based pharmacists. Implementation barriers emerged across multiple domains including complex regulatory requirements, inadequate organizational support, and insufficient educational preparation. Targeted interventions addressing credentialing processes, technical infrastructure, and pharmacist education are essential to the implementation of Medicaid billing in pharmacists' clinical practice.