- Email: [email protected]
Advancing pharmacist prescribing privileges: Is it time?
SCIENCE AND PRACTICE Journal of the American Pharmacists Association xxx (2019) 1e4
Contents lists available at ScienceDirect
Journal of the American Pharmacists Association journal homepage: www.japha.org
COMMENTARY
Advancing pharmacist prescribing privileges: Is it time? Kayleigh R. Majercak* a r t i c l e i n f o
a b s t r a c t
Article history: Received 4 March 2019 Accepted 12 August 2019
Objectives: The rising cost of health care, impact of the aging population, physician shortages, and access to care issues have stressed the U.S. health care system. There is no single solution to combat the complexity of issues concerning the health care system; however, there are potential solutions, such as expanding the role of pharmacists, in efforts to alleviate some stress. Advancing the scope of pharmacy practice with the inclusion of autonomous prescribing authority may enhance access to health care if barriers to pharmacist-provided patient care are removed. Understanding the perceptions of pharmacists, providers, and patients regarding the expansion of prescribing privileges may assist in this effort. Summary: Collaborative practice agreements between physicians and pharmacists have fostered the expansion of the role of pharmacists; however, autonomous prescriptive authority for pharmacists would promote access to vaccines, naloxone for opioids, hormonal contraceptives, travel medications, tobacco cessation medications, and more. Before experiencing the integration of a pharmacist into their practice, an initial concern of physicians consisted of not fully understanding the role of pharmacists. Additional concerns in advancing the pharmacy profession include liability, provider-provider communication, payment for services, as well as training and inadequate infrastructure. Conclusion: Among the states that have expanded prescriptive authority for pharmacists, experiences among stakeholders have been positive. As with any major change, it will take time to implement proper structures and processes, with continuous revisions to address barriers and/or challenges that may arise. There will be a need for training as well as educating various stakeholders about the changes in the scope of pharmacy practice. Leveraging the experience of states that already have prescriptive authority protocols in place can aid in this endeavor. Limiting pharmacists by not providing prescriptive authority would not be a good alternativedtapping into an underused resource is better than reinventing the wheel. © 2019 American Pharmacists Association®. Published by Elsevier Inc. All rights reserved.
The practice of pharmacy is constantly evolving, with the primary responsibilities of pharmacists shifting from preparing and dispensing medications to providing patient-centered care, including medication reconciliations, immunizations, chronic care management, and health screenings. Despite barriers that may need to be overcome, pharmacists are encouraged to continue advancing their scope of practice to the full extent of their training with the inclusion of autonomous prescribing authority. Leveraging the experience of states that already have prescriptive authority protocols in
Disclosure: The author declares no conflict of interest or financial interests in any product or service mentioned in this article. * Correspondence: Kayleigh R. Majercak, Department of Pharmaceutical Health Services Research, University of Maryland School of Pharmacy, 220 Arch Street, 12th floor, Baltimore, MD 21201. E-mail address: [email protected] (K.R. Majercak).
place can aid in this endeavor and help understand the perceptions of various stakeholders. Several states have passed legislation recognizing pharmacists as prescribers.1 For example, in Oregon, pharmacists may prescribe some formulary medications and devices such as smoking cessation aids.2,3 Similarly, Arizona permits emergency refills for maintenance medications, prescription of nicotine replacement therapy, and prescription and administration of oral fluoride varnish.4 Maryland permits pharmacists to prescribe contraceptives to individuals older than 18 years and has a statewide standing order for pharmacists to prescribe naloxone.4,5 Prescribing authority differs statewide with variability in restriction.6 The most restrictive is collaborative prescribing which can be patient-specific or population-specific collaborative practice agreements (CPAs). Therefore, pharmacist prescribing is dependent upon a relationship with a prescriber
https://doi.org/10.1016/j.japh.2019.08.004 1544-3191/© 2019 American Pharmacists Association®. Published by Elsevier Inc. All rights reserved.
SCIENCE AND PRACTICE K.R. Majercak / Journal of the American Pharmacists Association xxx (2019) 1e4
Key Points Background: Prescriptive authority protocols in health care date back to the early 1970s. Washington was the first state to achieve legal recognition of prescribing authority for pharmacists in 1979. Today, prescribing authority for pharmacists differs statewide with variability in restriction with collaborative prescribing agreements and autonomous prescribing. Findings: Nine states have autonomous prescribing rights for tobacco cessation products, whereas 6 states have autonomous prescribing rights for contraceptives. Recognizing pharmacists as prescribers may enhance access to care if barriers to pharmacistprovided patient care are removed. Concerns in advancing the pharmacy profession include liability, physician resistance, provider-provider communication, and payment for services.
and delegated by the agreement. The least restrictive is autonomous prescribing determined as a statewide protocol or unrestricted within a category of medications such as hormonal contraceptive products. It is important to note that autonomous prescribing is not synonymous with provider recognition. Autonomous prescribing gives the pharmacist independence, as delegation is not required.6 In 2014, Tennessee passed legislation for pharmacists and physicians to enter into a voluntary CPA.7 Under this law, pharmacists are able to deliver care to patients in the form of prescribing drugs or ordering laboratory tests contingent on the CPA. The Tennessee Pharmacists Association and Tennessee Medical Association developed the proposed law, with the Tennessee Hospital Association and Tennessee Nursing Association also supporting the proposal.7 The earliest forms of prescriptive authority protocols in health care date back to the early 1970s within the Indian Health Service.8 Similarly, California began piloting pharmacist prescribing programs in the late 1970s.9 Washington, however, was the first state to achieve legal recognition of prescriptive authority for pharmacists in 1979.10 Nine states (California, Arizona, Idaho, Colorado, New Mexico, Iowa, Indiana, Maine, and Oregon) have statutes or regulations for prescribing rights for tobacco cessation products, whereas 6 states (California, Colorado, Hawaii, Maryland, New Mexico, and Oregon) have prescribing rights for contraceptives.11,12 Varying by state, pharmacists may have authority to dispense naloxone, epinephrine, and travel medications.5,13,14 In Washington, independent pharmacies base their prescription services (e.g., conjunctivitis and strep throat) on the need of the demographics of the population (e.g., children).15
2
To be granted authority to prescribe in California, pharmacists must meet 2 of the 3 requirements: (1) earn certification in respective area of practice, (2) complete a 1-year residency program, and (3) 1 year of experience in a CPA. Pharmacists receive a Drug Enforcement Administration registration number with mid-level provider status. This policy is supported especially by patients in need of immediate care (e.g., pain management).14 The Ohio State University Medical Center demonstrates an example of a CPA by allowing pharmacists to order and analyze blood and urine tests and adjust medication regimens.15 This helps the provider to be more efficient by focusing their efforts on new or more complex patients.16 Under a collaborative agreement, Kaiser Permanente of Colorado’s Clinical Pharmacy Cardiac Risk Service allows clinical pharmacy specialists, who have 2 years residency training, to prescribe appropriately necessary medications for elevated lipid levels, hypertension, and diabetes.15 Results of a published study showed that within 90 days of enrolling a patient with their service (after the individual experienced an event such as a heart attack), an 88% reduction in cardiovascular-related mortality was observed.15 Positive findings from studies evaluating satisfaction support expanding pharmacist prescribing privileges.17-19 A mail survey (prescribers n ¼ 135, pharmacists n ¼ 84) assessing the satisfaction with prescriptive authority protocols in Washington revealed prescribers (98%) and pharmacists (95%) were satisfied with the collaborative practice agreements.18 Correspondingly, to determine the acceptance of pharmacists prescribing contraceptives, a survey was conducted at community pharmacies in Washington, with results showing that most women surveyed “expressed willingness to continue to see pharmacist prescribers for this and other services.” In addition, 70% had continued using their prescribed contraceptive for at least 12 months.19
Benefits in the advancement of pharmacist prescribing privileges Pharmacists are considered to be more accessible compared with other health care providers, with 95% of individuals living within 5 miles of a pharmacy. Despite geographic proximity, however, pharmacists are the most underused health care providers.13,20 Moreover, community pharmacies have the highest number of visits per year when compared with outpatient visits and visits to their primary care physician.13 Pharmacists develop a relationship with their patients, and patient satisfaction is rated high because of trust, easier access, and lower cost for services.21 In the state of Washington, patients are satisfied with and support pharmacists providing care, as they avoid the emergency department (ED) and are able to get access after hours.15 Granting pharmacists prescriptive authority will improve access to care by lessening the impact of the current and upcoming physician shortages. The populations positively affected will include those currently facing issues associated with access to care, ED frequent fliers, women of childbearing age, older population, and many others. In Oregon, an individual may wait between 28 and 34 days before seeing their health care provider.2 The expansion of pharmacy services
SCIENCE AND PRACTICE Expanding pharmacist prescribing
may remove access barriers, thereby improving quality of life, health outcomes, and patient satisfaction as well as reducing health care expenditures.22 With the movement in health care from fee for service to value-based care payment systems, this may incentivize providers to support pharmacists prescribing authority, as providers may benefit by performing better on quality and performance measures. Furthermore, prescribing authorization may facilitate value recognition and coverage for pharmacist-provided patient care services. Based on data from the National Alliance of State Pharmacy Associations, more than 20 states have granted “provider status” to pharmacists in 2017 with more than 50 state provider status bills in 2018.4 One of the states that passed this legislation included Idaho, which has a physician shortage and ranks as the second to last state in the number of physicians per capita.4 With the passage of the legislation of 3 provider status bills, pharmacists are able to prescribe, administer, and interpret tuberculosis tests, prescribe tobacco cessation treatment, and prescribe drugs and devices for certain conditions.4,23 Attaining coverage and payment of these services is progressing with a proposed amendment to the Social Security Act, which would grant provider status to pharmacists under Medicare Part B. This proposed bill will pay for services in rural and underserved areas, introduced as the “Pharmacy and Medically Underserved Areas Enhancement Act.”13,15 Pharmacists would be reimbursed at 85% of the Medicare physician fee schedule, comparable to nurse practitioners and physician assistants.13 Washington enforced a mandate for private health plans to recognize pharmacists as providers, thus being covered under the benefits as a physician as well as ensuring a representative number of pharmacists are included in the network.13,19 Following suit, Tennessee passed a similar bill for private insurance plans.4 Varying by state, Medicaid pays for services such as medication therapy management (MTM), smoking cessation counseling, and immunizations.13
unintentional complications of treatment plans for their patients.24 These initial concerns generated negative feelings toward collaborating with pharmacists.24 Furthermore, lack of sharing patient records and communications across providers contributes to physician resistance, which pharmacists perceive as a barrier as well.15 As pharmacists continue to capitalize on opportunities to expand, the breadth of tasks and responsibilities of a pharmacist continue to stretch their bandwidth. Demands on pharmacists are high in their current role, and additional services will increase this workload, possibly leading to increased rates of already cited sources of burnout.25 Even with the advances in technology, such as robots filling prescriptions, there is still a waiting period before the widespread use of this technology. A study published in 2018 identified the following factors as perceived barriers by pharmacists in the provision of pharmacist-provided services: lack of training, resistance to implement services, communication gaps, access to health care records, and logistical and work space issues.26 Consequently, pharmacists may need additional help to manage the volume of patients and services, as well as supplemental training with the development of proper processes. With the development of platforms to aid in the implementation of clinical services within pharmacies, these platforms may be viable solutions for patient engagement opportunities, documentation, and billing functions.27,28 Finally, even though pharmacists have demonstrated being capable of providing additional services from the traditional fill and dispense roles, capturing payment continues to be a struggle. By advocating and demonstrating savings and benefits gained by patients and employers for this service, MTM services are a covered benefit under Medicare Part D.19 Just as MTM services took time to set up and implement a payment system, so will billing for prescriptive authority granted to pharmacists.
Conclusion Barriers to pharmacist-provided patient care Recognizing pharmacists as prescribers may enhance access to care if barriers to pharmacist-provided patient care are removed. A major concern in advancing the pharmacy profession is liability. Health institutions may not fully understand the expanded role of pharmacists, thereby having negative implications for pharmacists if they are misrepresented under a health system’s malpractice coverage.15 As a result, pharmacists should consider obtaining individual malpractice insurance supplemental to the institution or health system in which they are employed. Moreover, guidance on minimum standards for CPAs will need to be developed, differentiating community pharmacists compared with hospital-based pharmacist as well as situational agreements. Next, even though physician resistance is lessening, physician resistance still exists, primarily because of misconceptions physicians may have before working in a collaborative arrangement.24 Before experiencing the integration of a pharmacist into their practice, initial concerns of physicians consisted of not fully understanding the role of pharmacists, the disruption of workflow, and the perception that the integration of a pharmacist within the practice was a waste of time.24 Likewise, physicians exhibit uneasiness regarding pharmacists’ competency to manage disease states as well as
The rising cost of health care, impact of the aging population, physician shortages, and access to care issues have stressed the U.S. health care system. There is no single solution to combat the complexity of issues concerning the health care system; however, there are potential solutions, such as expanding the role of pharmacists. Pharmacists have training to perform dosing and monitoring of medications for patients, whereas it is not cost efficient for physicians to carry out these tasks. Removing barriers to pharmacist-provided care may positively affect patient access to health care services, safety, and clinical outcomes. Continuing efforts to demonstrate the impact and value pharmacists have on patient health and outcomes will further advocate the need for the expansion of pharmacist prescribing privileges. As with any major change, autonomous prescribing authority will take time to implement, with continuous revisions to address challenges that may arise. There will be a need for training as well as development and implementation of proper processes and infrastructures. Leveraging the experience of states that already have prescriptive authority protocols in place can aid in this endeavor. Despite the initial barriers to expanding the scope of pharmacy practice with more liberal prescribing privileges, increasing access to health care and reducing costs by tapping into an underused resource is better than reinventing the wheel. 3
SCIENCE AND PRACTICE K.R. Majercak / Journal of the American Pharmacists Association xxx (2019) 1e4
References 1. National Association of Boards of Pharmacy. Survey of pharmacy law. Mount Prospect, IL: National Association of Boards of Pharmacy; 2018. 2. D’Arrigo T. Oregon expands prescribing for pharmacists. Available at: https://www.pharmacist.com/article/oregon-expands-prescribing-phar macists. Accessed March 2, 2019. 3. Thompson CA. New Oregon law lets pharmacists prescribe formulary drugs, devices. Available at: https://www.ashp.org/news/2017/08/25/ new-oregon-law-lets-pharmacists-prescribe-formulary-drugs. Accessed March 2, 2019. 4. Yap D. State provider status advances in 2017. Available at: https://www. pharmacytoday.org/article/S1042-0991(18)30262-7/fulltext. Accessed March 2, 2019. 5. NASPA. Naloxone access in community pharmacies. Available at: https:// naspa.us/resource/naloxone-access-community-pharmacies/. Accessed March 4, 2019. 6. NASPA. Pharmacist prescribing: statewide protocols and more. Available at: https://naspa.us/resource/swp/. Accessed March 2, 2019. 7. Yap D. Pharmacists, prescribers team up for collaborative practice in TN. Available at: https://www.pharmacist.com/article/pharmacistsprescribers-team-collaborative-practice-tn. Accessed March 2, 2019. 8. Streit RJ. Long-term drug therapy. A program expanding the pharmacist’s role. J Am Pharm Assoc. 1973;13(8), 434e436 passim. 9. Stimmel GL, McGhan WF. The pharmacist as prescriber of drug therapy: the USC pilot project. Drug Intell Clin Pharm. 1981;15(9):665e672. 10. Christensen DB. Legal recognition of prescriptive authority for pharmacists. US Pharm. 1982;7(3):13e15. 11. NASPA. Pharmacist prescribing for tobacco cessation medications. Available at: https://naspa.us/resource/tobacco-cessation/. Accessed March 2, 2019. 12. NASPA. Pharmacist prescribing for hormonal contraceptive medications. Available at: https://naspa.us/resource/contraceptives/. Accessed March 2, 2019. 13. SingaporeeM.I.T Alliance for Research and Technology Center Retailing Rx. Pharmacist as provider: a view of the future. Available at: https://join. healthmart.com/business-and-operations/pharmacist-provider-view-fut ure/. Accessed March 2, 2019. 14. Leheny S. Could prescribing become a daily duty for pharmacists?. Available at: https://www.pharmacytimes.com/contributor/shelbyleheny-pharmd-candidate-2017/2016/05/could-prescribing-become-adaily-duty-for-pharmacists. Accessed March 2, 2019. 15. ModernMedicine Network, Drug Topics. Prescribing rights: worth it?. Available at: https://www.drugtopics.com/editors-choice-drtp/ prescribing-rights-worth-it. Accessed March 2, 2019.
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16. Pickett M. Robots are now handling pills. Will pharmacists be liberated or out of work?. Available at: https://www.kqed.org/futureofyou/153628/ when-a-robot-counts-out-your-pills-what-will-your-pharmacist-do. Accessed March 2, 2019. 17. Moreno G, Lonowski S, Fu J, et al. Physician experiences with clinical pharmacists in primary care teams. J Am Pharm Assoc. (2003). 2017;57(6): 686e691. 18. Fuller TS, Christensen DB, Williams DH. Satisfaction with prescriptive authority protocols. J Am Pharm Assoc (Wash). 1996;NS36(12): 739e745. 19. Deja EN, Fink JL. Pharmacists prescribing birth control: improving access and advancing the profession. Available at: https://www.pharmacytimes.com/ publications/issue/2016/november2016/pharmacists-prescribing-birth-cont rol-improving-access-and-advancing-the-profession. Accessed March 2, 2019. 20. Washington State Pharmacy Association. Landmark legislation: pharmacists as providers. Available at: https://www.wsparx.org/page/ ProviderStatus. Accessed March 2, 2019. 21. Melton BL, Lai Z. Review of community pharmacy services: what is being performed, and where are the opportunities for improvement? Integr Pharm Res Pract. 2017;6:79e89. 22. Chisholm-Burns MA, Kim Lee J, Spivey CA, et al. US pharmacists’ effect as team members on patient care: systematic review and meta-analyses. Med Care. 2010;48(10):923e933. 23. Duffy S. Idaho pharmacists able to prescribe meds for several conditions on July 1. Available at: https://www.empr.com/news/idaho-pharmacistprescriptive-authority-strep-throat-influenza-urinary-tract-infection/ article/776464/. Accessed March 2, 2019. 24. Kozminski M, Busby R, McGivney MS, Klatt PM, Hackett SR, Merenstein JH. Pharmacist integration into the medical home: qualitative analysis. J Am Pharm Assoc (2003). 2011;51(2):173e183. 25. Durham ME, Bush PW, Ball AM. Evidence of burnout in health-system pharmacists. Am J Health Syst Pharm. 2018;75(23 supplement 4): S93eS100. 26. Santos Júnior GAD, Ramos SF, Pereira AM, et al. Perceived barriers to the implementation of clinical pharmacy services in a metropolis in Northeast Brazil. PLoS One. 2018;13(10):e0206115. 27. Strand clinical technologies. Evolving the clinical pharmacy landscape. Available at: https://strandrx.com/. Accessed June 25, 2019. 28. PrescribeWellness. Expand patient care for a healthier community. Available at: https://www.prescribewellness.com/business. Accessed June 25, 2019. Kayleigh R. Majercak, MS, Graduate Research Assistant, Department of Pharmaceutical Health Services Research, University of Maryland School of Pharmacy, Baltimore, MD
Contents lists available at ScienceDirect
Journal of the American Pharmacists Association journal homepage: www.japha.org
COMMENTARY
Advancing pharmacist prescribing privileges: Is it time? Kayleigh R. Majercak* a r t i c l e i n f o
a b s t r a c t
Article history: Received 4 March 2019 Accepted 12 August 2019
Objectives: The rising cost of health care, impact of the aging population, physician shortages, and access to care issues have stressed the U.S. health care system. There is no single solution to combat the complexity of issues concerning the health care system; however, there are potential solutions, such as expanding the role of pharmacists, in efforts to alleviate some stress. Advancing the scope of pharmacy practice with the inclusion of autonomous prescribing authority may enhance access to health care if barriers to pharmacist-provided patient care are removed. Understanding the perceptions of pharmacists, providers, and patients regarding the expansion of prescribing privileges may assist in this effort. Summary: Collaborative practice agreements between physicians and pharmacists have fostered the expansion of the role of pharmacists; however, autonomous prescriptive authority for pharmacists would promote access to vaccines, naloxone for opioids, hormonal contraceptives, travel medications, tobacco cessation medications, and more. Before experiencing the integration of a pharmacist into their practice, an initial concern of physicians consisted of not fully understanding the role of pharmacists. Additional concerns in advancing the pharmacy profession include liability, provider-provider communication, payment for services, as well as training and inadequate infrastructure. Conclusion: Among the states that have expanded prescriptive authority for pharmacists, experiences among stakeholders have been positive. As with any major change, it will take time to implement proper structures and processes, with continuous revisions to address barriers and/or challenges that may arise. There will be a need for training as well as educating various stakeholders about the changes in the scope of pharmacy practice. Leveraging the experience of states that already have prescriptive authority protocols in place can aid in this endeavor. Limiting pharmacists by not providing prescriptive authority would not be a good alternativedtapping into an underused resource is better than reinventing the wheel. © 2019 American Pharmacists Association®. Published by Elsevier Inc. All rights reserved.
The practice of pharmacy is constantly evolving, with the primary responsibilities of pharmacists shifting from preparing and dispensing medications to providing patient-centered care, including medication reconciliations, immunizations, chronic care management, and health screenings. Despite barriers that may need to be overcome, pharmacists are encouraged to continue advancing their scope of practice to the full extent of their training with the inclusion of autonomous prescribing authority. Leveraging the experience of states that already have prescriptive authority protocols in
Disclosure: The author declares no conflict of interest or financial interests in any product or service mentioned in this article. * Correspondence: Kayleigh R. Majercak, Department of Pharmaceutical Health Services Research, University of Maryland School of Pharmacy, 220 Arch Street, 12th floor, Baltimore, MD 21201. E-mail address: [email protected] (K.R. Majercak).
place can aid in this endeavor and help understand the perceptions of various stakeholders. Several states have passed legislation recognizing pharmacists as prescribers.1 For example, in Oregon, pharmacists may prescribe some formulary medications and devices such as smoking cessation aids.2,3 Similarly, Arizona permits emergency refills for maintenance medications, prescription of nicotine replacement therapy, and prescription and administration of oral fluoride varnish.4 Maryland permits pharmacists to prescribe contraceptives to individuals older than 18 years and has a statewide standing order for pharmacists to prescribe naloxone.4,5 Prescribing authority differs statewide with variability in restriction.6 The most restrictive is collaborative prescribing which can be patient-specific or population-specific collaborative practice agreements (CPAs). Therefore, pharmacist prescribing is dependent upon a relationship with a prescriber
https://doi.org/10.1016/j.japh.2019.08.004 1544-3191/© 2019 American Pharmacists Association®. Published by Elsevier Inc. All rights reserved.
SCIENCE AND PRACTICE K.R. Majercak / Journal of the American Pharmacists Association xxx (2019) 1e4
Key Points Background: Prescriptive authority protocols in health care date back to the early 1970s. Washington was the first state to achieve legal recognition of prescribing authority for pharmacists in 1979. Today, prescribing authority for pharmacists differs statewide with variability in restriction with collaborative prescribing agreements and autonomous prescribing. Findings: Nine states have autonomous prescribing rights for tobacco cessation products, whereas 6 states have autonomous prescribing rights for contraceptives. Recognizing pharmacists as prescribers may enhance access to care if barriers to pharmacistprovided patient care are removed. Concerns in advancing the pharmacy profession include liability, physician resistance, provider-provider communication, and payment for services.
and delegated by the agreement. The least restrictive is autonomous prescribing determined as a statewide protocol or unrestricted within a category of medications such as hormonal contraceptive products. It is important to note that autonomous prescribing is not synonymous with provider recognition. Autonomous prescribing gives the pharmacist independence, as delegation is not required.6 In 2014, Tennessee passed legislation for pharmacists and physicians to enter into a voluntary CPA.7 Under this law, pharmacists are able to deliver care to patients in the form of prescribing drugs or ordering laboratory tests contingent on the CPA. The Tennessee Pharmacists Association and Tennessee Medical Association developed the proposed law, with the Tennessee Hospital Association and Tennessee Nursing Association also supporting the proposal.7 The earliest forms of prescriptive authority protocols in health care date back to the early 1970s within the Indian Health Service.8 Similarly, California began piloting pharmacist prescribing programs in the late 1970s.9 Washington, however, was the first state to achieve legal recognition of prescriptive authority for pharmacists in 1979.10 Nine states (California, Arizona, Idaho, Colorado, New Mexico, Iowa, Indiana, Maine, and Oregon) have statutes or regulations for prescribing rights for tobacco cessation products, whereas 6 states (California, Colorado, Hawaii, Maryland, New Mexico, and Oregon) have prescribing rights for contraceptives.11,12 Varying by state, pharmacists may have authority to dispense naloxone, epinephrine, and travel medications.5,13,14 In Washington, independent pharmacies base their prescription services (e.g., conjunctivitis and strep throat) on the need of the demographics of the population (e.g., children).15
2
To be granted authority to prescribe in California, pharmacists must meet 2 of the 3 requirements: (1) earn certification in respective area of practice, (2) complete a 1-year residency program, and (3) 1 year of experience in a CPA. Pharmacists receive a Drug Enforcement Administration registration number with mid-level provider status. This policy is supported especially by patients in need of immediate care (e.g., pain management).14 The Ohio State University Medical Center demonstrates an example of a CPA by allowing pharmacists to order and analyze blood and urine tests and adjust medication regimens.15 This helps the provider to be more efficient by focusing their efforts on new or more complex patients.16 Under a collaborative agreement, Kaiser Permanente of Colorado’s Clinical Pharmacy Cardiac Risk Service allows clinical pharmacy specialists, who have 2 years residency training, to prescribe appropriately necessary medications for elevated lipid levels, hypertension, and diabetes.15 Results of a published study showed that within 90 days of enrolling a patient with their service (after the individual experienced an event such as a heart attack), an 88% reduction in cardiovascular-related mortality was observed.15 Positive findings from studies evaluating satisfaction support expanding pharmacist prescribing privileges.17-19 A mail survey (prescribers n ¼ 135, pharmacists n ¼ 84) assessing the satisfaction with prescriptive authority protocols in Washington revealed prescribers (98%) and pharmacists (95%) were satisfied with the collaborative practice agreements.18 Correspondingly, to determine the acceptance of pharmacists prescribing contraceptives, a survey was conducted at community pharmacies in Washington, with results showing that most women surveyed “expressed willingness to continue to see pharmacist prescribers for this and other services.” In addition, 70% had continued using their prescribed contraceptive for at least 12 months.19
Benefits in the advancement of pharmacist prescribing privileges Pharmacists are considered to be more accessible compared with other health care providers, with 95% of individuals living within 5 miles of a pharmacy. Despite geographic proximity, however, pharmacists are the most underused health care providers.13,20 Moreover, community pharmacies have the highest number of visits per year when compared with outpatient visits and visits to their primary care physician.13 Pharmacists develop a relationship with their patients, and patient satisfaction is rated high because of trust, easier access, and lower cost for services.21 In the state of Washington, patients are satisfied with and support pharmacists providing care, as they avoid the emergency department (ED) and are able to get access after hours.15 Granting pharmacists prescriptive authority will improve access to care by lessening the impact of the current and upcoming physician shortages. The populations positively affected will include those currently facing issues associated with access to care, ED frequent fliers, women of childbearing age, older population, and many others. In Oregon, an individual may wait between 28 and 34 days before seeing their health care provider.2 The expansion of pharmacy services
SCIENCE AND PRACTICE Expanding pharmacist prescribing
may remove access barriers, thereby improving quality of life, health outcomes, and patient satisfaction as well as reducing health care expenditures.22 With the movement in health care from fee for service to value-based care payment systems, this may incentivize providers to support pharmacists prescribing authority, as providers may benefit by performing better on quality and performance measures. Furthermore, prescribing authorization may facilitate value recognition and coverage for pharmacist-provided patient care services. Based on data from the National Alliance of State Pharmacy Associations, more than 20 states have granted “provider status” to pharmacists in 2017 with more than 50 state provider status bills in 2018.4 One of the states that passed this legislation included Idaho, which has a physician shortage and ranks as the second to last state in the number of physicians per capita.4 With the passage of the legislation of 3 provider status bills, pharmacists are able to prescribe, administer, and interpret tuberculosis tests, prescribe tobacco cessation treatment, and prescribe drugs and devices for certain conditions.4,23 Attaining coverage and payment of these services is progressing with a proposed amendment to the Social Security Act, which would grant provider status to pharmacists under Medicare Part B. This proposed bill will pay for services in rural and underserved areas, introduced as the “Pharmacy and Medically Underserved Areas Enhancement Act.”13,15 Pharmacists would be reimbursed at 85% of the Medicare physician fee schedule, comparable to nurse practitioners and physician assistants.13 Washington enforced a mandate for private health plans to recognize pharmacists as providers, thus being covered under the benefits as a physician as well as ensuring a representative number of pharmacists are included in the network.13,19 Following suit, Tennessee passed a similar bill for private insurance plans.4 Varying by state, Medicaid pays for services such as medication therapy management (MTM), smoking cessation counseling, and immunizations.13
unintentional complications of treatment plans for their patients.24 These initial concerns generated negative feelings toward collaborating with pharmacists.24 Furthermore, lack of sharing patient records and communications across providers contributes to physician resistance, which pharmacists perceive as a barrier as well.15 As pharmacists continue to capitalize on opportunities to expand, the breadth of tasks and responsibilities of a pharmacist continue to stretch their bandwidth. Demands on pharmacists are high in their current role, and additional services will increase this workload, possibly leading to increased rates of already cited sources of burnout.25 Even with the advances in technology, such as robots filling prescriptions, there is still a waiting period before the widespread use of this technology. A study published in 2018 identified the following factors as perceived barriers by pharmacists in the provision of pharmacist-provided services: lack of training, resistance to implement services, communication gaps, access to health care records, and logistical and work space issues.26 Consequently, pharmacists may need additional help to manage the volume of patients and services, as well as supplemental training with the development of proper processes. With the development of platforms to aid in the implementation of clinical services within pharmacies, these platforms may be viable solutions for patient engagement opportunities, documentation, and billing functions.27,28 Finally, even though pharmacists have demonstrated being capable of providing additional services from the traditional fill and dispense roles, capturing payment continues to be a struggle. By advocating and demonstrating savings and benefits gained by patients and employers for this service, MTM services are a covered benefit under Medicare Part D.19 Just as MTM services took time to set up and implement a payment system, so will billing for prescriptive authority granted to pharmacists.
Conclusion Barriers to pharmacist-provided patient care Recognizing pharmacists as prescribers may enhance access to care if barriers to pharmacist-provided patient care are removed. A major concern in advancing the pharmacy profession is liability. Health institutions may not fully understand the expanded role of pharmacists, thereby having negative implications for pharmacists if they are misrepresented under a health system’s malpractice coverage.15 As a result, pharmacists should consider obtaining individual malpractice insurance supplemental to the institution or health system in which they are employed. Moreover, guidance on minimum standards for CPAs will need to be developed, differentiating community pharmacists compared with hospital-based pharmacist as well as situational agreements. Next, even though physician resistance is lessening, physician resistance still exists, primarily because of misconceptions physicians may have before working in a collaborative arrangement.24 Before experiencing the integration of a pharmacist into their practice, initial concerns of physicians consisted of not fully understanding the role of pharmacists, the disruption of workflow, and the perception that the integration of a pharmacist within the practice was a waste of time.24 Likewise, physicians exhibit uneasiness regarding pharmacists’ competency to manage disease states as well as
The rising cost of health care, impact of the aging population, physician shortages, and access to care issues have stressed the U.S. health care system. There is no single solution to combat the complexity of issues concerning the health care system; however, there are potential solutions, such as expanding the role of pharmacists. Pharmacists have training to perform dosing and monitoring of medications for patients, whereas it is not cost efficient for physicians to carry out these tasks. Removing barriers to pharmacist-provided care may positively affect patient access to health care services, safety, and clinical outcomes. Continuing efforts to demonstrate the impact and value pharmacists have on patient health and outcomes will further advocate the need for the expansion of pharmacist prescribing privileges. As with any major change, autonomous prescribing authority will take time to implement, with continuous revisions to address challenges that may arise. There will be a need for training as well as development and implementation of proper processes and infrastructures. Leveraging the experience of states that already have prescriptive authority protocols in place can aid in this endeavor. Despite the initial barriers to expanding the scope of pharmacy practice with more liberal prescribing privileges, increasing access to health care and reducing costs by tapping into an underused resource is better than reinventing the wheel. 3
SCIENCE AND PRACTICE K.R. Majercak / Journal of the American Pharmacists Association xxx (2019) 1e4
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