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Enacting Collaborative Drug Therapy Management Legislation

Gloria Sachdev, Pharm.D.

GLORIA SACHDEV, PHARM.D., calls her seven-month odyssey to win passage of an Indiana state law that expands collaborative drug therapy management (CDTM) for pharmacists a “wonderful eye-opening experience.” She would also prefer never to endure anything like it again.

“I’m trained as a clinician, and I’m used to moving quickly from Point A to Point B,” said Sachdev, clinical assistant professor of primary care at Purdue University, West Lafayette, Ind., and adjunct assistant professor in the School of Medicine at Indiana University. Until recently, Sachdev was also legislative chair for the Indiana Pharmacist’s Alliance (IPA).

“This ‘process’—and I use that term loosely—was like nothing I’ve ever experienced,” she said. “Things just kind of happened and then changed 180 degrees at the last second.”

Starting with the Grassroots

It all began in fall 2010, when the IPA’s Legislative Committee drafted a bill to permit Indiana pharmacists to adjust drug therapy per physician-signed protocol in any practice setting, as long as the pharmacist is under a physician’s direct supervision. At the time, Indiana allowed CDTM only in hospitals and long-term care facilities. (Currently, 48 states permit some degree of CDTM.)

Indiana State Capitol Building, Indianapolis

In January 2011, Rep. Steve Davisson, who happens to be a pharmacist, introduced the bill in the House. Sachdev learned that the bill first needed a hearing and a vote in the House Public Health Committee.

If passed there, the bill would proceed to the House floor, where it would have to pass two additional hearings. If it passed in the House, the bill would then float to the Senate, where it would proceed through a similar sequence. If the bill passed the Senate, it would proceed on to the General Assembly for a final vote. But first, the bill needed a House Public Health Committee hearing, or the bill would die. And it didn’t look like this first step was going to happen.

The IPA mounted a huge grassroots effort aimed at the committee chair: Physicians, hospital faculty, pharmacists, payers, and students wrote and called the committee chair, urging her to grant a hearing. Time was running out, and for a legislature embroiled in heated issues, the CDTM legislation was small fry.

But the grassroots effort paid off, and a hearing was scheduled for February 21, the last day of the committee’s schedule. Yet Sachdev was told the committee would likely not vote and instead push the bill into summer session—and almost certain demise. But the committee did vote, 11–0 in favor. “The whole thing took 10 minutes,” said Sachdev. “We were stunned and excited.” What happened next would also leave her stunned, though not so excited.

Back and Forth, and Back Again

Within hours, all but two of the 40 House Democrats bugged out for Illinois to thwart Republican efforts to pass anti-union legislation. None of the Democratic committee members had signed the bill. It died.

The Indiana House, in session

During the five-week Democratic boycott, the IPA’s lobbyist, along with Indiana Sen. Ron Grooms (the other pharmacist in the legislature), devised a strategy to resurrect the bill in the Senate as an amendment to another bill. After weeks more of legislative contortions, they worked something out. In the meantime, Sachdev undertook the critical task of getting the politically powerful Indiana State Medical Association (ISMA) to reverse its opposition to the bill.

“They were not a warm and fuzzy crowd,” Sachdev said. “About 50 people peppered me with questions for 20 minutes. I was smiling but nobody was smiling back.”

She succeeded. Briefly. Two days after coming out in favor of the bill, the group reversed its decision. Negotiations and several more ISMA flip-flops continued for two weeks and into the night before a hard-won Senate hearing (also held on the last day of its schedule). In the end, the group supported the bill.

Finally, on April 29th, the last day of the 2011 legislative session, the bill passed both houses—barely. A week later, the governor signed it into law, effective July 1. Sachdev calls it “the most important piece of state pharmacy legislation passed in over a decade.”

 ASHP Offers a Helping Hand

Along the way, Sachdev got some help from ASHP and other pharmacy organizations, such as strategy ideas and links to pharmacists who had enacted legislative change in their own states, as well as guidelines for preparing informational handouts for legislators.

“Our role is to support members and affiliates as a resource,” said Karen Noonan, ASHP’s director of state affairs and grassroots advocacy. “Advocacy is most effective and powerful if ASHP members tell their stories directly to legislators.”

In looking back over the legislative see-saw she encountered, Sachdev offered a few pieces of advice for colleagues attempting to pass CDTM legislation (or any pharmacy-related legislation):

•  Don’t underestimate the power of grassroots activism.

•  Enlist help from stakeholders beyond the pharmacy profession.

•  Engage your state’s medical association, which is not always in touch with frontline care issues but is often politically powerful.

•  Use pharmacists and other health care experts to build your case early on, then hand the baton to your lobbyists and give them whatever they need.

•  Invite legislators to visit pharmacy practices early in their session, when they’re less busy.

•  Don’t celebrate until the ink dries on the governor’s signature.