Ernest Dole, Pharm.D., PhC, BCPS, FASHP, a pharmacist clinician at the Pain Consultation and Treatment Center of the University of New Mexico Hospitals in Albuquerque, has been writing prescriptions since 1996. Three years earlier, his state became the first in the nation to grant a subset of highly trained clinical pharmacists prescriptive authority, contingent on collaborative practice agreements with supervising physicians.
On a typical day, Dole writes prescriptions for NSAIDS, opiates, muscle relaxants, anti-seizure agents, and antidepressants.
“As a pharmacist clinician, I am more directly responsible for patients and provide more direct input into their care, which I believe has resulted in better outcomes,” said Dole. His broad freedom in making treatment decisions, as defined in the collaborative practice protocol he operates under, frees up his physician colleagues to see more patients and perform more epidural injections, whose revenues significantly offset the cost of his position. That is key to the success of pharmacist prescribing because Medicare does not recognize charges for pharmacist services—nor do most private insurers.
Dole is part of a larger national conversation happening within the pharmacy profession regarding the need to improve patient outcomes as part of collaborative, team-based care. The environment in which the conversation is happening is also changing. Current and future shortages of general practice physicians, physician assistants and nurses and potential reductions in federal spending for Medicare and Medicaid may be laying a groundwork for more widespread recognition of credentialed pharmacists as prescribers.
What’s Required to Prescribe?
Although 43 states now permit limited pharmacist-dependent prescribing as part of Collaborative Drug Therapy Management agreements, only three states—New Mexico, Montana, and North Carolina—allow pharmacists to initiate drug therapy.
To qualify for pharmacist clinician certification and subsequently apply for prescription writing privileges and a DEA number, New Mexico pharmacists must undergo a substantial amount of additional education, including (but not limited to) diagnosis and physical assessment training equivalent to what is required for physician assistants.
Betsy Shilliday, Pharm.D., CDE, CPP, became approved as a clinical pharmacist practitioner (CPP) by the North Carolina Board of Pharmacy and North Carolina Medical Board in 2003. An associate clinical professor at the University of North Carolina School of Medicine in Chapel Hill and a certified diabetes educator, Shilliday is the director of the Enhanced Care Programs, which includes midlevel clinics for anticoagulation, diabetes and chronic pain.
Shilliday’s primary work occurs in the anticoagulation clinic, where she can treat any active clinic patient under predetermined protocols approved by the state medical board. According to Shilliday, prescribing privileges enable pharmacists to independently handle all or part of a patient visit, freeing up physicians to treat more patients and attend to cases that fall outside of collaborative practice protocols.
Today, all pharmacists practicing in the hospital’s outpatient clinics are CPPs. Before the CPP approval process emerged, clinical pharmacists had to shuttle between patient and physician each time a prescription or medication adjustment was needed.
“It was a huge time sink,” said Shilliday. “With prescriptive authority, we can improve patient outcomes and efficiency.” The physicians, she added, are very receptive to CPPs. “They understand our expertise and are very comfortable with the protocols because they designed them. They are used to working side by side with us, and they trust us.”
Overcoming Medical Opposition
That’s not to say, broadly speaking, that there isn’t opposition from physician groups, which perceive some aspects of advanced practice pharmacy as threats to their authority. But, according to Dole, physicians are usually supportive once they understand that the arrangement is symbiotic and capitalizes on each profession’s strengths. That is especially true in primary care, where the number of physicians continues to dwindle, leaving large swaths of the population medically underserved and the workforce strained to the breaking point.
“In those situations, you can have a physician diagnosing and then turning over medication management to an advanced practice pharmacist, whose expertise lies not in diagnosis but in medication management,” he said. “That allows the physician to see more patients and more complicated patients throughout the day, which means increased health care access and increased revenue.”
Matthew Murawski, Ph.D., associate professor of pharmacy administration at the College of Pharmacy and Pharmaceutical Sciences at Purdue University in West Lafayette, IN., believes that pharmacists have a niche caring for patients who need to have their medication regimens modified rather than those who need an initial diagnosis.
“Our natural ‘home’ as advanced-practice pharmacists is in taking care of patients who need our deep knowledge of drugs and their impact,” he said. “It is incumbent on pharmacy to clearly define and demarcate a particular subset of patients whom we’re especially qualified to care for. Then, we have to make our case and not stray into areas in which our expertise is not as strong.”
A Case for Payment
Yet the greatest obstacle to widespread acceptance of prescribing authority remains the stubborn fact that health systems cannot directly bill Medicare for pharmacist services. In a recent paper about advanced practice pharmacists (Am J Health-Syst Pharm. 2011;68:2341-50), Murawski and his fellow authors wrote ominously that “unless some form of reimbursement through governmental channels is enacted, the model of advanced practice pharmacy is not likely to succeed.”
“Reimbursement is the issue,” added Dole. “If we don’t find a way to increase recognition for reimbursement or have advanced practice pharmacists recognized federally as providers under CMS Part B, other health care professions will fill the void created by the scarcity of primary care providers, and that window of opportunity will close for us.”
Amending the Social Security Act to pay for pharmacist services is one of ASHP’s longstanding legislative and regulatory goals, said Joseph M. Hill, the Society’s director of federal legislative affairs.
“That would open doors for pharmacists everywhere, but especially those in advanced practice and with prescribing authority,” he said, adding that ASHP continues to formulate strategies with other pharmacy organizations for the next push on Capitol Hill.
“Right now, we’re doing what we can behind the scenes to develop a strong foundation to make the case that advanced-practice pharmacists save dollars and improve patient care,” he said.
The current political climate along with an approaching election mean that it’s a waiting game for right now. “We’ll know a lot more come November when we see what the new Congress looks like and whether we have a new administration,” Hill noted.