March 15, 2019
It’s no secret that pharmacists continue to be underutilized. Research shows that when pharmacists are more involved in patient care, health outcomes and healthcare costs improve.
Expanding prescriptive authority allows pharmacists to increase their direct care, and it increases patients’ access to healthcare. “With a possible shortage of primary care prescribers by 2025, it is vital to note 89 percent of Americans live within five miles of a community pharmacy,” said Melanie Maxwell, senior vice president, pharmacy services at Pharmacy Providers of Oklahoma Inc. (PPOk), an organization that negotiates third-party contracts for independent pharmacies. “Independent pharmacists are an integral part of the focus to improve patient outcomes and reduce healthcare costs.”
Pharmacists can achieve that without stepping on prescribers’ toes. By giving pharmacists authority over minor issues that don’t need a physician’s immediate attention, both sides are happier and patients are healthier. “Pharmacists thrive on being the middle-men between patients and prescribers on a daily basis, and adding these services can further streamline patient care on the prescriber’s end,” Maxwell said.
Expanded authority also propels pharmacists closer to provider status by demonstrating to patients and healthcare providers the kind of clinical contributions pharmacists can make, she said. And provider status would open up a whole new world of billing to prop up independent pharmacies’ revenue, which has seen a steep decline.
The industry still continues to resist giving pharmacists more authority. As things stand, prescriptive authority is primarily limited to collaborative practice agreements, in which a partnering physician specifies the authority allowed and the conditions required for specific pharmacists.
The other route is through statewide protocols and standing orders, in which a state specifies the authority and conditions for all pharmacists in the area. These have generally been prompted by public health issues of particularly high need. For example, the opioid crisis motivated every state in the U.S. to allow pharmacists to dispense naloxone without a prescription.
Collaborative practice agreements generally allow greater authority while protocols mostly focus on specific medicines for minor conditions that require no diagnosis, such as cold sores. Within each state protocol, scope of authority varies widely. A few states, like New Mexico and California, have a more liberal scope for pharmacist prescribing. But in most states, pharmacist authority remains minimal.
However, the tides may be turning. Two laws enacted in the last two years, one in Idaho and one in Oregon, have expanded prescriptive authority for pharmacists through statewide protocols. In Idaho, pharmacists can now prescribe and dispense drugs for a long list of issues, such as cold sores, seasonal influenza, strep throat, uncomplicated UTIs, and diabetic conditions. In Oregon, pharmacists can now prescribe and dispense drugs that appear on a state-authorized formulary, which will continue to grow upon request and approval. Potential items on the formulary include diabetic testing supplies, smoking-cessation aids, epinephrine autoinjectors, albuterol inhalers, rapid strep tests, and spacers for inhalers.
Two states don’t make a trend, but they may start one. What Idaho and Oregon have done could serve as a template for the rest of the country, even if each approach looks different. “Expanding prescriptive authority is feasible for all states,” Maxwell said.
Although the drugs will depend on the needs of each area, Maxwell expects future formularies to continue to build on the management of diseases that pharmacists have already proven an aptitude for, such as hypertension, diabetes, cardiovascular risk factors, and wellness programs.
In 2017, a national workgroup convened by the National Alliance of State Pharmacy Associations and the National Association of Boards of Pharmacy said that for prescriptive authority expansion to truly succeed, pharmacists need to get paid. That piece is “critical for ensuring adequate patient access and impact on public health needs,” the report said. “Insurance policies should allow these products and services provided by pharmacists to be covered in the same manner as they are when provided by other healthcare professionals. Policy makers should consider whether state laws or regulations need to be modified to ensure that payment and insurance coverage are available and equitable for the products and services rendered by a pharmacist under a statewide protocol.”
Oregon set an example for this in 2015 that other states could replicate. The governor signed a bill permitting the Oregon Health Authority to reimburse pharmacists for providing any health service within their scope of practice.
Another report, from the National Governor’s Association, a bipartisan organization of the nation’s governors, identified three main barriers for expanding the role of pharmacists within the healthcare system: limitations within CPAs, provider status, and access to health IT systems. “Resolving these issues will enable pharmacists to maximize their efforts within the healthcare system and push for expanding prescriptive authority,” Maxwell said.
But change won’t happen without pharmacists leading the charge. Pharmacists will need to continue to advocate for provider status, Maxwell said. And they’ll need to continue to contribute to patient-centered clinical care.
“Achieving this first on the state level to meet each population’s specific needs will elevate the discussion on the federal level,” she said. “Actively participating with their state’s pharmacy association and board of pharmacy and engaging in policy discussions with legislators is key.”
Chelsea Price, PharmD, J.J. Peek, PharmD, and Andrew Llanes, PharmD candidate, contributed research for this article.
From the Magazine
This article was published in our quarterly print magazine, which covers relevant topics in greater depth featuring leading experts in the industry. Subscribe to receive the quarterly print issue in your mailbox. All registered independent pharmacies in the U.S. are eligible to receive a free subscription.
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