Pharmacists are now recognized as prescribers to some degree in almost all states. Legislation in most states reflects the provider role, and in some cases even allows pharmacists to bill for services. In some regions, pharmacists may initiate or modify therapy for common conditions such as diabetes, asthma, COPD, or conditions requiring anticoagulant or cardiac drugs.
But this new long-sought status brings new frustrations: liability issues, physician resistance, and lack of payment for value-added services.
“It’s a big step for a pharmacist to be out front with the new expanded responsibilities.” said David Brushwood, RPh, JD, Professor of Pharmaceutical Outcomes and Policy at the University of Florida College of Pharmacy. Because of that, added Brushwood, some practitioners prefer to remain in the traditional role.
APhA spokesperson Mohamed A. Jalloh, PharmD, said that this should come as no surprise.
“With greater responsibilities there is a higher risk of liability,” said Jalloh. While he is unfamiliar with the specifics regarding pharmacist’s insurance rate characteristics, he suspects that the cost of malpractice insurance for pharmacists will rise as they take on these expanded roles.
To limit liability concerns, it’s important that pharmacists not practice beyond the scope of authority granted by law, explained Brushwood. He pointed out that pharmacists have “limited prescribing authority” based on an individual state’s regulations. At the same time, he noted that health institutions often misunderstand the expanded role of the pharmacist, so the pharmacist may be misrepresented under a health-system’s malpractice coverage.
“The health-system pharmacist should purchase individual malpractice insurance as a supplement to an institution’s coverage, to make sure everything you do is covered,” said Brushwood.
Speaking for the community pharmacy arena, Linda Garrelts MacLean, RPh, FACA, Clinical Professor, College of Pharmacy at Washington State University, said: “In Washington, when I sign a collaborative drug therapy agreement, I assume the liability to care for my patients.” She added that it’s important to let insurance carriers know that [pharmacists] are practicing within the scope of practice allowed in their state.
Kevin Day, Associate Director of Strategic Initiative, NCPA, said that the purchase of additional liability insurance usually isn’t required in the community setting when pharmacists work under collaborative practice agreements. Premiums should remain relatively stable as long as pharmacists operate within their scopes of practice.
NACDS declined to comment on pharmacist liability.
Technical mistakes, such as those that involve dispensing, are the most common liability claims pharmacists face, said Brushwood. Issues that arise as pharmacists initiate or modify therapy are “more difficult to quantify and are therefore more protected.”
NCPA’s Day said to date, he is not aware of any situations where a pharmacist was the subject of a litigious claim for initiating or modifying therapy or administering a medical test.
But pharmacists cannot rest on their laurels, countered Brushwood. There is a lag time between an event and a case appearing in litigation, so it’s possible there are cases currently working their way through litigation channels. “Pharmacists who are initiating or modifying therapy need to be vigilant and take steps to ensure they are protected,” said Brushwood.
In dealing with patients, Brushwood cautioned, you don’t want any surprises. “Identify yourself to the patient as a pharmacist right from the beginning,” he said. And in the hospital setting, Brushwood said that it’s a good idea to establish an effective line of communication with risk management. “Make sure that that department understands the expanding scope of pharmacy practice. And as a means to avoid errors, don’t be afraid to use computer algorithms to help you figure out the right drug and the right way to use it,” said Brushwood.
Lastly, he asserted, don’t replace old arrogance with new arrogance. Doctors, for example, sometimes get defensive when questioned by a pharmacist about a drug order. “Don’t do the same thing. Don’t let arrogance get in the way of a legitimate question another member of the health-care team may have about a drug order you initiated or modified,” said Brushwood.
Up next: Physician resistance
While state boards of pharmacy around the nation are expanding the pharmacist’s scope of responsibilities, some physicians are still resisting pharmacists taking on these expanded duties, said Eric Maroyka, PharmD, BCPS, Director, Center on Pharmacy Practice Advancement, ASHP. “Pharmacist prescribing has been embraced more in the public sector than in the private sector.” In the VA health system for example, the pharmacist has long been accepted in this expanded role (Figure 1).
“Some states such as Washington, Wisconsin, and Ohio offer good advocacy for the pharmacist through the state legislatures," Maroyka explained; this has helped the pharmacist earn the physician’s trust and develop collaborative relationships.
Jalloh, an Assistant Professor, Clinical Sciences Department, Touro University California College of Pharmacy, agreed that it’s important for the profession to advocate for itself at the state legislature level.
To establish trust with physicians within a health-system, Maroyka said it’s not a good idea to be defensive. “Don’t shove it in his or her face that you are now able to initiate or modify therapy. Start with small wins, such as approval for reviewing maintenance medications,” said Maroyka. She added that as pharmacists establish good rapport with physicians, they will see their scope of practice expand.
“Pharmacists need to educate other health-care professionals about the value of the services a pharmacist can provide. “We need to clarify the letters next to our name, and let people know we’re certified in a certain area,” said Jalloh.
In addition, Jalloh urged pharmacists to attend conferences, and not just pharmacy conferences but conferences hosted by other health-care professionals. “Do presentations and let other members of the health-care team learn the value of the pharmacist,” he said.
Establishing a good relationship with physicians, noted Day, can yield acceptance by patients. “There will always be patients in some communities who will be less accepting of the pharmacist in a prescribing role,” said Day.
Jalloh agreed that some patients only see pharmacists “in a traditional role.”
“Physician friends” who can talk to patients about the value-added services pharmacists can provide are important, Day said. “Physicians need to talk to patients and explain that the pharmacist is part of the health-care team. If the physician says: ‘I trust the pharmacist,’ then the patient will [most likely] be open to the pharmacist,” he said.
“Patients can be great advocates,” for the pharmacist, Maroyka asserted. If the patient is able to say “the pharmacist has been helpful to me,” other members of the health care team will take notice.
“And as the need for services and access increase along with the number of insured individuals, physician resistance is lessening,” said Bobbie Riley, RPh, Vertical Market Lead for Pharmacy for LexisNexis Risk Solutions, Health Care. Recently, she said, “as pharmacists have stepped up to provide naloxone, resistance lessened, and the ease-of-access to pharmacists for additional services was viewed by physicians, patients, and caregivers in a different light.”
Up next: More barriers for pharmacists
Payment for services
But barriers still remain to pharmacists who are embracing their expanding role of prescriber, Riley continued. The biggest barrier cited by pharmacists is being recognized as providers by payers. “Much of this comes from the reality that pharmacists have, in the past, provided many of these [expanded services] for greatly reduced rates or for free. Recognition of pharmacists as providers is even more important with the shifting from fee-for-service to value-based reimbursement and the expectation of treating patients more holistically,” said Riley.
Currently, pharmacists may bill for medication therapy management services under Medicare Part D, said Jalloh. Additionally, a handful of states allow pharmacists to bill for reimbursement, with the West Coast being the most progressive region, he added. In Oregon, when the bill establishing provider status for the state’s pharmacists was signed into law, it included a provision to “permit health insurers to provide payment or reimbursement for services provided by pharmacists through the practice of clinical pharmacy or pursuant to statewide drug therapy management protocols,” according to a release from APhA. It specifically mentions that “both private and public health insurers in Oregon can reimburse pharmacists for the clinical services they provide under the new law.”
Jeffrey Rochon, PharmD, and CEO of the Washington State Pharmacy Association, said a bill is in place that requires commercial or private health plans regulated by Washington State to enroll pharmacists into their provider networks, and it mandates that these plans pay pharmacists for services provided if they are within a pharmacist’s scope of practice.
But, said WSU’s MacLean, payment for pharmacists has been slow. To date, she said, only a “handful of pharmacists,” have been able to navigate the intricate private insurance networks and actually bill for assessments and other services.
There is some movement at the federal level to reimbursement pharmacist for services. At the 2017 APhA meeting, APhA Senior Vice President of Pharmacy Practice and Government Affairs Stacie Maass, BSPharm, JD, spoke about the Pharmacy and Medically Underserved Enhancement Act (H.R. 592/S. 109), which was reintroduced to Congress in January. She said the bill now has146 cosponsors in the House and 33 in the Senate. APhA Senior Lobbyist Alicia Kerry Mica noted that the bill, which would amend the Social Security Act, recognizes pharmacists as providers under Medicare Part B, and said the “bill addresses the physician shortage in rural areas, and paying pharmacists in underserved areas to engage in certain medical services could work well.”
Still, despite some of the frustrations, “collaborative practice agreements are a valuable tool for pharmacists to operate at the top of their education and assist the other members of the health-care team with their expertise,” said Nicholas Gentile, Director, State Grassroots Advocacy and Political Action, ASHP.
“State requirements ultimately define which disease states and/or medications can be prescribed by pharmacists,” said Gentile. He noted that state laws and regulations also define what pharmacists have to do in order to prescribe. “In some cases, if they have a collaborative practice agreement in place, pharmacists only need to be licensed in the state. In other states, a specific patient care service can only be performed by an advanced credentialed pharmacist,” said Gentile.
APhA’s Jalloh said that on the West Coast, the legislation ranges from states where the pharmacist has full prescriptive authority and may attain the title of Advanced Practice Pharmacist, to other states where that authority is limited to the administration of flu vaccinations. In California, Oregon, and Washington, for example, the pharmacist’s scope-of-practice includes hormonal contraceptives, nicotine replacement therapy, and travel medications.
By practice setting, the role of the prescribing pharmacist is growing most rapidly in the health-system arena, predominantly in clinics that are connected with hospitals, explained Jalloh. The trend is growing among community pharmacists, as well, although workload issues may prove an obstacle, particularly in chain stores. “Independents are more likely than chain pharmacists to be involved in prescribing,” Jalloh said.
Common conditions for which pharmacists may initiate or modify therapy in the health-care arena are diabetes, asthma, COPD, pain, and conditions requiring anticoagulant or cardiac drugs, said Maroyka. He added that behavioral health is a growing area for pharmacist intervention.
Up next: Health systems
Trisha Jordan, PharmD, MS is the Associate Director of Pharmacy at Ohio State University Medical Center in Columbus, where 100 acute-care pharmacists and 25 ambulatory pharmacists perform clinical pharmacy services. In Ohio, Jordan practices under a consult agreement that allows pharmacists to order blood and urine tests, analyze those tests, and adjust medication regimens. “The law allows pharmacists to practice at the top of their license, which in turn helps the doctor to be more efficient,” she said. She noted that the law may be expanded in her state to give the pharmacist more independent prescribing authority.
Jordan sees emergency medicine and ambulatory clinics as “areas of opportunity within the health system to improve patient care.” Lab results are sent to the pharmacist for recommendation or modification of drug therapies. The pharmacist will also be the point person who will follow up with the patient after discharge, she explained.
Jordan said that in the inpatient setting, pharmacists will “round with the medical team” and make recommendations in just about every therapeutic area, excluding chemotherapy, which is still “physician-driven.” The pharmacists’ input in the infectious disease area can be critical, she said.
The pharmacy team initially faced resistance from the chief medical information officer regarding access to electronic medical records. “We did our due diligence; we met with the leaders and explained what the pharmacist can do.”
At Kaiser Permanente Colorado, Brittany A. Todd, PharmD, BCPS, CLS, is a Clinical Pharmacy Specialist in the Clinical Pharmacy Cardiac Risk Service (CPCRS). “We are very lucky because our collaborative drug therapy management agreement allows us to prescribe any medication appropriate for lipids, hypertension, and diabetes. It is a very broad scope of practice.”
At CPCRS, she explained, clinical pharmacy specialists are required to have two years of post-graduate residency training and be board-certified within two years of hire. “All of us are either board-certified in pharmacotherapy or ambulatory care.” KPCO has a post-graduate year 2 (PGY2) residency program that trains residents in ambulatory care, she said.
“All patients with a history of atherosclerotic cardiovascular disease (ASCVD) are referred to CPCRS where a pharmacist determines need for long-term management and enrolls the patient in the service,” Todd said.
Providers rely on CPCRS to manage their ASCDV patients. CPCRS focuses on the management of lipids, blood pressure, diabetes/prediabetes, smoking cessation, and hypothyroidism. “I may have a patient with a new heart attack and a drug-eluting stent placed last week. I ensure that the patient is on appropriate therapy such as a high-intensity statin, beta-blocker, ACE inhibitor/ARB (if indicated), and dual antiplatelet therapy. As a pharmacist, I review renal function and possible drug-drug interactions and adjust doses as needed. I order follow-up to ensure adequate response to therapy, as well as meeting safety parameters,” said Todd.
CPCRS published a study in 2007 that demonstrated that enrolling a patient in this service within 90 days of an event (heart attack, stent, coronary artery bypass) resulted in an 89% reduction in all- cause mortality and an 88% reduction in cardiovascular-related mortality, said Todd. “Delayed enrollment still resulted in a 76% reduction in all cause mortality and 73% reduction in cardiovascular-related mortality,” she added.
“Providers expect CPCRS to manage their ASCVD population and trust that the care that patients receive is exceptional,” Todd said.
One area that still needs work is collaborating with external providers. Todd said that some patients still receive care from providers outside of KPCO as well as in. For example, a patient may have KPCO as their insurance plan, but still see a non-KPCO cardiologist. “These ‘external’ providers are not as familiar with the care our clinical pharmacy specialists provide and may be hesitant to hand off their patients to KPCO pharmacists. Since these are external providers, they often do not share the electronic medical record, which makes communication slightly more difficult,” Todd explained.
The state of Washington is one of the most progressive in the nation in terms of giving pharmacists prescribing authority, said MacLean. “There is an entire collection of medications used to treat minor ailments” that pharmacists may prescribe under protocol in the independent setting (Figure 2). Generally, the protocols are tailored to the demographics of a particular pharmacy. For example, a pharmacy in an area with a high population of children would include pink eye and strep throat; those disease states might not be included in an area with a large geriatric population.
“In all of my experience, my patients have appreciated the ability to receive care from the community pharmacist. Patients are willing to come see us. They can come see us after hours, receive assessments, and avoid the emergency room. And in areas where there is a physician shortage, the pharmacist can fill the void,” said MacLean. She noted that a pediatrician had brought her own two children into the pharmacy to be tested and eventually treated for strep throat.
MacLean said that pharmacy has to evolve, and cannot let workload be a challenge. That prevents the pharmacist from providing patient care, she said. “The filling of prescriptions is secondary to taking care of patients and improving outcomes. Pharmacy must move in this direction. And in order to be effective, we need to surround ourselves with the right tools: technicians, technology, and software solutions,” said MacLean.
NCPA’s Day said that the dispensing function will still be the core function of pharmacists, but the role will evolve so that pharmacists will focus not on “counting by five,” but on patient care and patient safety.” Mac Lean agreed. “Dispensing must be done and done very carefully. Pharmacy needs to assure that the right medicine is taken appropriately. The medicine works when the pharmacist does due diligence to ensure the best outcome. The future of pharmacy is about the value of the patient; keeping the patient healthy.”
CVS officials declined to comment for this story. Representatives from Walgreens and Kroger did not respond to requests from Drug Topics.