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Are Pharmacists Your Competitors or Your Collaborators?

Lola Butcher

April 11, 2018

Pharmacists' Scope of Practice Is Expanding

As America's physicians struggle to keep up with demand for their services, one group of healthcare professionals is rushing in to pick
up some of that business. Pharmacists are offering an increasing array of primary care services, from immunizations to laboratory
tests to birth control prescriptions to tobacco cessation drug therapy.

Many physicians are comfortable with this arrangement and feel glad that some patients are getting help through a different channel,
allowing doctors to concentrate on more serious or chronic conditions. However, for other physicians, there is some tension
surrounding pharmacists' expanding roles.

Until fairly recently, many physicians saw this trend as an incursion into their realm of responsibility.[1] And some still do. But the roiling
changes in healthcare delivery are changing that, prompting health systems and large practices to embed pharmacists into their care
delivery teams, while individual physicians enter into formal agreements with community pharmacists to share patient care.

Pharmacists' scope of practice is controlled at the state level, either through legislation or health departments, pharmacy boards, or
other state-designated bodies.[2] The spectrum of allowed duties ranges widely, but states do share one thing in common: All have
been steadily expanding the tasks that pharmacists can perform.[3]

All 50 states and the District of Columbia allow pharmacists to administer influenza vaccine, and many permit other vaccinations as
well. At least 40 states allow pharmacists to dispense naloxone (which blocks the effects of opioids), and six states allow pharmacists
to prescribe and/or administer oral contraception.

Most significantly, perhaps, pharmacists are being encouraged to play a bigger role in chronic care management in the hopes that they
can improve patients' health status and reduce the need for high-cost emergency and hospital care.[4]

Do Physicians Think Pharmacists Have Too Much Responsibility?

John Cullen, MD, president-elect of the American Academy of Family Physicians (AAFP), practices in Valdez, Alaska—population
4000—where he works with hospital-based and community pharmacists. "They are absolutely a part of the team," he says.

That said, he thinks that community pharmacists' growing list of primary care services may have some downside. For example, while
insurers may incentivize patients to receive vaccinations at a community pharmacy, doing so fragments their care. For one thing,
patients' vaccination records are maintained in the electronic medical record at the doctor's office. For another, the physician may
know more about a patient's medical situation that should be considered in the decision about whether to immunize.

Beyond that, the official position of the AAFP, which represents 129,000 physicians and medical students, is that only licensed doctors
of medicine, osteopathy, dentistry, and podiatry should have the statutory authority to prescribe drugs.

Some Physicians Lack Confidence in Pharmacists

"It gets down to the fact that diagnosis is complicated," Cullen says. "As family physicians, we've gone through extensive training

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because coming up with the right diagnosis is difficult. For example, with high blood pressure, it's never just blood pressure that is the
issue. There are a lot of other factors that go along with it."

Cullen's reservations are not uncommon, says Elizabeth Unni, PhD, a pharmacy professor at Roseman University of Health Sciences
in South Jordan, Utah. She was part of a research team that, in 2016, studied community physicians' perceptions of and readiness to
collaborate with pharmacists. Their finding: Physicians were hesitant to relinquish control of their patients to pharmacists and lacked
confidence in pharmacists' clinical judgment.[5]

The physicians interviewed for the study were aware of the pharmacists' educational level. "But they could not see any kind of role
expansion for pharmacists," Unni says. "It was still all the same old things, just dispensing drugs."

At Summit Medical Group in Tennessee, the pharmacist consults with a patient's physician before he recommends any prescriptions
be changed or dropped, even though his license would allow him to act autonomously. Eric Penniman, DO, Summit's executive
medical director, says it will take time for physicians to get comfortable with the pharmacist as a member of the team.

"There's definitely some pushback from physicians who feel like the pharmacist is treading on their turf," he says. "That's just
something that we have to work through and help them better understand the value of a pharmacist."

Physicians Irate About Prescriptions Being Modified

Physicians are sometimes irate about prescriptions being modified by a pharmacist. In most cases, a patient's insurance will not cover
a brand-name drug if a generic is available, and most states allow a pharmacist to change a prescription from brand to generic without
the prescriber's approval, says Unni.

The key to prohibit an unwanted substitution: Indicate "dispense as written" (DAW) on the prescription. That may prompt a phone call
from the pharmacy, alerting you that the patient's insurance will not cover the brand drug. Then you can choose whether to push the
matter with the insurance company or go along with its formulary.

The substitution issue is getting thornier with the advent of biologic drugs and biosimilars, which are not truly generic versions of the
biologics they seek to replace. In the past 5 years, at least 45 states have set standards for substituting a biosimilar to replace an
original biologic product.[6]

The laws vary; but, in general, a physician can prevent a biologic substitution by indicating DAW or "brand medically necessary." The
initial state laws required physicians to be notified when a pharmacy made an allowable substitution, but more recent legislation
requires pharmacists to "communicate with" physicians, according to the National Conference of State Legislatures. This means that
the pharmacist must note the substitution in a record for the physician to see, but the physician cannot delay the substitution.

Working With Pharmacists to Improve Chronic Care Patient Management

Many physicians find themselves in a bind when trying to see and schedule new patients; their days are filled with visits from chronic
care patients, and new patients may have to wait for time in the physician's schedule. Some physicians have found that having
pharmacists more involved in follow-up for chronic care patients frees them to see more and newer patients sooner.

This is probably more useful for hospital and large clinic situations, in which teams are more likely to work together to lower costs and
have physicians see more patients.

Like many academic medical centers and large health systems, Virginia Commonwealth University (VCU) School of Medicine has
pharmacists on staff to support inpatient care. A couple days each week, a pharmacist rounds with cardiologists in the intensive care
unit or step-down unit, says Antonio Abbate, MD, PhD, vice chairman in the Division of Cardiology.

What is unusual at VCU, however, is the outpatient Cardio Pharmacotherapy Clinic, where pharmacists help manage patients. Abbate
started the clinic 6 years ago to improve follow-up care for existing patients and free up cardiologists to see new patients.

"Mostly what we use this clinic for is to treat to goal patients who need more aggressive treatment of hypertension, hyperlipidemia,
diabetes, or optimization of their therapies," he says.

Patients may visit the pharmacist every few weeks for blood-pressure checks, lab work, help with side effects, and adjustment of their
medications. Cardiologists and pharmacists use a formal agreement that identifies the treatment plan and the parameters in which the
pharmacist is authorized to make changes.

"We work as collaborators, so I will be notified (when medications are changed) but not necessarily asked to approve," Abbate says.

Pharmacists Working on the Primary Care Team

Summit Medical Group, the largest primary care organization in Tennessee, recently hired a pharmacist to provide medication therapy
management, reviewing a patient's list of medications and calling them at home to make sure they are filling prescriptions, taking

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medicines as directed, and avoiding potentially dangerous drug interactions.

"Some of the bigger health plans will hire their own pharmacists to do some of this work, but when a patient hears that they are from
the insurance company, they are instantly suspicious," says Penniman.

The pharmacist is focusing only on patients covered by Medicare Advantage shared-savings contracts. Summit succeeds financially in
those contracts only when its patients avoid unnecessary emergency department visits, and making sure medications are being used
properly is one way to do that, Penniman says.

Eventually, he hopes to follow the example of Cleveland Clinic, which embeds pharmacists into multidisciplinary patient care teams as
a value-based care delivery strategy.[7]

"If we prove that this is something extremely beneficial, I hope that some of our bigger sites actually have an embedded pharmacist
shoulder to shoulder with the provider," he says.

The Situation in Rural Towns

In small and/or rural towns where there are just a handful of doctors who don't have the staff or time available to see the available
patients, pharmacists may help with chronic management.

Goodrich Pharmacy, which operates six community pharmacies in small Minnesota towns, offers immunizations; management of
chronic conditions including asthma, diabetes, and hypertension; and other patient care services. The services are possible because
of collaborative practice agreements in which physicians have authorized pharmacists to perform certain tasks according to protocols
specified in collaborative practice agreements.

In one Goodrich location—the pharmacy at St. Francis County Market Grocery Store—a collaborative practice agreement permits
pharmacists to conduct rapid influenza and strep testing. If a patient tests positive, a pharmacist can prescribe an antiviral for flu or an
antibiotic for strep.

Policymakers Promote Pharmacy Power

While point-of-care testing is still quite new, collaborative practice agreements with physicians have led to an expansion of
pharmacists' practice in Minnesota for years. In some cases, Goodrich initiates the relationships; in others, the physicians ask the
pharmacists for help.

"Some of our collaborative practice agreements are for things like opioid tapers and blood pressure medication monitoring, where
[physicians] can refer their patients to the pharmacist for follow-up," says Erica Burman, PharmD, manager of that Goodrich site.

Although physicians may be ambivalent, federal and state policymakers are convinced that pharmacists are an underused resource for
primary care.

In 2011, the US Public Health Service issued a report saying that pharmacists could help alleviate the primary care provider crisis and
recommended that pharmacists' scope-of-practice laws be updated to facilitate that, and the Office of the Surgeon General responded
with enthusiastic support.[4,8] The Centers for Disease Control and Prevention has emerged as a strong advocate for increasing
pharmacists' responsibilities; last year, it led a multistakeholder group, including the American Medical Association, in publishing a
guide for physician-pharmacist collaborative practice agreements.

State legislatures have steadily increased pharmacists' scope of practice,[9] and the federal government is nudging them to go further.
Last year, the Center for Medicaid and CHIP Services issued guidance encouraging states to allow pharmacists to dispense drugs
"based on their own independently initiated prescriptions" through collaborative practice agreements with physicians, standing orders
issued by the state, or other protocols.[10]

Payment Remains a Barrier

Beyond the changing scope of practice, pharmacy is on a roll, says Russell B. Melchert, PhD, dean of the University of Missouri-
Kansas City School of Pharmacy. The number of pharmacy schools has doubled to nearly 140 in the past three decades, and they are
turning out more than 13,000 graduates a year.[11] Pharmacists make up the third-largest category of health professionals, after
doctors and nurses, and receive the second-longest education, after physicians.

Many states and some commercial insurers pay pharmacists to perform medication therapy management—reviewing all of a patient's
prescriptions to find duplications and risks for adverse drug-drug interactions. Some value-oriented physician groups have seen that if
pharmacists help their patients manage medications effectively, hospital readmissions can be avoided.

For community pharmacists, though, the pay breakthrough would be federal legislation that would allow pharmacists to be recognized
by the Centers for Medicare & Medicaid Services as providers of care—and eligible to be paid just as physicians are—if they work in a
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designated health-professional shortage area. More than 50 US senators and more than 250 US representatives have signed on as
cosponsors to the bills in their respective chambers.[12,13]

Physicians have their own point of view on this development. Cullen points out that rural communities need family physicians, and he
wants to see policies that make it easier for physicians to work in small rural communities. That means creating more training slots for
family physicians to increase the number of primary care physicians in practice and reducing paperwork that keeps physicians from
patient-care hours.

"There's a tendency to try to come up with short-term solutions that actually are not addressing the healthcare needs of those
communities," he says.

His own town, for example, is a 6-hour drive from the nearest tertiary care facility. "We need to have a primary care workforce within
this community that allows us to handle difficult cases," he says.

"Recognizing pharmacists as providers of healthcare would be a game-changer," Melchert says.

References

1. Guglielmo WJ. Doctors and pharmacists battle over scope of practice. Medscape. April 5, 2012. Article Accessed February 28,
2018.

2. American Academy of Family Physicians. Scope of practice—pharmacists. 2017. Article Accessed February 28, 2018.

3. American Pharmacists Association. Pharmacist scope of services. Article Accessed February 28, 2018.

4. Centers for Disease Control and Prevention. Advancing team-based care through collaborative practice agreements: a
resource and implementation guide for adding pharmacists to the care team. 2017. Article Accessed March 19, 2018.

5. Gordon C, Unni E, Montuoro J, Ogborn DB. Community pharmacist-led clinical services: physician's understanding, perceptions
and readiness to collaborate in a Midwestern state in the United States. Int J Pharm Pract. 2017 Dec 7. [Epub ahead of print]

6. National Conference of State Legislatures. State laws and legislation related to biologic medications and substitution of
biosimilars. Article Accessed March 7, 2018.

7. Knoer SJ, Rough S. Why health systems should invest in their internal pharmacy enterprise. American Hospital Association.
April 28, 2016. Article Accessed March 12, 2018.

8. Maine LL, Knapp KK, Scheckelhoff DJ. Pharmacists and technicians can enhance patient care even more once national
policies, practices, and priorities are aligned. Health Aff (Millwood). 2013;32:1956-1962.

9. National Conference of State Legislatures. Scope of practice archive database. September 1, 2017. Article Accessed March 7,
2018.

10. Centers for Medicaid & Medicare Services. State flexibility to facilitate timely access to drug therapy by expanding the scope of
pharmacy practice using collaborative practice agreements, standing orders or other predetermined protocols. CMCS
Informational Bulletin. January 17, 2017. Article Accessed February 28, 2018.

11. American Association of Colleges of Pharmacy. Academic pharmacy's vital statistics. Article Accessed February 28, 2018.

12. Congress.gov. H.R. 592, Pharmacy and Medically Underserved Areas Enhancement Act. Article Accessed March 6, 2018.

13. Congress.gov. S.109 - Pharmacy and Medically Underserved Areas Enhancement Act. Article Accessed March 6, 2018.

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Any views expressed above are the author's own and do not necessarily reflect the views of WebMD or Medscape.

Cite this article: Lola Butcher. Are Pharmacists Your Competitors or Your Collaborators? - Medscape - Apr 11, 2018.

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