Physicians Opposing Pharmacist Expanded Practice

[TranslationalRPh]

Top News: APhA addresses AMA's inaccurate description of H.R. 7213 and viewpoints of most physicians working along pharmacists​

APhA is reinforcing the importance of H.R. 7213, which would allow limited but significant Medicare reimbursement for pharmacists, after the American Medical Association (AMA) tried to undermine the bill. AMA laid out a case against the proposal in a letter to key lawmakers on April 12, but APhA says the medical society painted an inaccurate picture of the legislation and presented a view not reflected by the majority of doctors who work with pharmacists. Rather than collaborate on meaningful and impactful health care reform, APhA suggests AMA is on a self-serving mission to preserve a competitive edge for its membership. The Equitable Community Access to Pharmacists Services Act has been a long time coming, it says, and the role of pharmacists in vaccinating underserved populations and alleviating the burden on physicians during the COVID-19 outbreak only clarified its need. "Now, more than ever," APhA emphasizes in a new statement, "it is time to recognize pharmacists for all they have done, and all they can do, to keep our country safe, and help us avoid or manage the next pandemic — not block these health care professionals from serving to the full extent of their training, practice, and license." (Read More) ​

Received this notice from APhA. You can click through to read the full response and AMA's stated opposition to proposed expanded RPh practice rights.

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[VA Hopeful Dr]

So what would this bill, if passed, allow y'all to do that you currently can't?

 

[TranslationalRPh]

So what would this bill, if passed, allow y'all to do that you currently can't?

H.R. 7213 would allow pharmacists to test and initiate drug regimens for influenza, respiratory syncytial virus, or streptococcal pharyngitis. It would also allow pharmacists to administer vaccines and provide related services for COVID–19 or influenza, address public health needs related to public health emergencies, and provide services as determined by the
Secretary of the Department of Health and Human Services for undefined programs, including closing the gaps in health equity.

 

[VA77]

I hope it will let me finally write a script for diabetic supplies. Most ignorant thing that we cannot write for something as simple as a glucose meter.

 

[Mad Jack]

H.R. 7213 would allow pharmacists to test and initiate drug regimens for influenza, respiratory syncytial virus, or streptococcal pharyngitis. It would also allow pharmacists to administer vaccines and provide related services for COVID–19 or influenza, address public health needs related to public health emergencies, and provide services as determined by the
Secretary of the Department of Health and Human Services for undefined programs, including closing the gaps in health equity.

I'll just speak to why there is a lot of pushback from a physician perspective. Misdiagnosed strep has led to more than one significant adverse outcome that I've seen over the years. RSV can lead to significant morbidity and potential mortality in vulnerable patients. The vagueness of the final bits of language are very concerning, as that could mean literally anything with regard to scope and that could be quite dangerous. Treating patients implies one can construct a differential and perform physical exams and testing to back that differential. How are pharmacists equipped to do this by virtue of their training? I'm not opposed to expanded scopes if they have associated expanded training, but scope without the skills to back it up can be dangerous and potentially deadly.

 

[WheezyBaby]

H.R. 7213 would allow pharmacists to test and initiate drug regimens for influenza, respiratory syncytial virus, or streptococcal pharyngitis. It would also allow pharmacists to administer vaccines and provide related services for COVID–19 or influenza, address public health needs related to public health emergencies, and provide services as determined by the
Secretary of the Department of Health and Human Services for undefined programs, including closing the gaps in health equity.

What training do pharmacists get on say evaluating for suppurative complications of strep pharyngitis or differentiating strep colonization from other causes of pharyngitis? What treatments exactly are being prescribed for RSV? Not being snarky, genuine questions. Some of these things seem fine, others maybe not

 

[Mad Jack]

I hope it will let me finally write a script for diabetic supplies. Most ignorant thing that we cannot write for something as simple as a glucose meter.

This is the sort of stuff that should be allowed without issue. A lot of DME is well with within the ability of pharmacists to prescribe based on their training and requiring physicians to do so is an unnecessary barrier to care

 

[VA77]

This is the sort of stuff that should be allowed without issue. A lot of DME is well with within the ability of pharmacists to prescribe based on their training and requiring physicians to do so is an unnecessary barrier to care

Yep. Plus I gotta bother docs to get ICD codes. Like I said ignorant.

 

[Pronounce Doxazosin]

H.R. 7213 would allow pharmacists to test and initiate drug regimens for influenza, respiratory syncytial virus, or streptococcal pharyngitis. It would also allow pharmacists to administer vaccines and provide related services for COVID–19 or influenza, address public health needs related to public health emergencies, and provide services as determined by the
Secretary of the Department of Health and Human Services for undefined programs, including closing the gaps in health equity.

And importantly, it will allow pharmacists to bill federal insurance plans (Medicare and Medicaid) for said services

 

[TranslationalRPh]

What training do pharmacists get on say evaluating for suppurative complications of strep pharyngitis or differentiating strep colonization from other causes of pharyngitis? What treatments exactly are being prescribed for RSV? Not being snarky, genuine questions. Some of these things seem fine, others maybe not

Balanced and fair response IMHO. I wouldn't be surprised if this is where the majority is on this issue. I do wish YOU had written the AMA response.

 

[VA Hopeful Dr]

Balanced and fair response IMHO. I wouldn't be surprised if this is where the majority is on this issue. I do wish YOU had written the AMA response.

Yeah I'm inclined to agree with my pediatric colleague above. Diagnosing flu is easy, but you need vitals and an exam to determine if they are OK to go home or if they need to hit the ER for possible admission. You also have to make sure they are within the Tamiflu window and, if you're prescribing it, you're on the hook for medication side effects.

Also agree that diabetic supplies should be a no brainer, I'd happily give that one to y'all.

 

[Dred Pirate]

I do agree with the physician responses on this thread - I don't claim to be trained to clinically diagnose - we all can read a lab test, that is a no brainer, but the other issues is setting some overworked pharmacist at CVS up for a major lawsuit.

I will saw the words the AMA doesn't want to say out loud, is that they don't want to loose business. And this I don't blame them. The AMA seems to have a lot bigger impact at lobbying than any of our organizations. (allthough I would think they would have done a better job keeping NP's and PA's from getting as much autonomy as they do - that is where they have lost a lot of their business). Just like many of us don't want to see techs have a bigger role (tech check tech in a hospital, or giving immunizations at retail) - we prefer status quo unless it gives us more opportunities.

 

[Chrish]

Lol I have zero interest in diagnosing anyone after doing some online modules. I don’t want to do a half-a** job. Even symptoms that present with something minor might turn out to be deadly later on. I have heard of more than few occasions where pt would come at the otc window for heartburn recommendation that would later turn out to be symptom of heart attack. Does anyone want this liability without adequate training?

 

[Chrish]

but the other issues is setting some overworked pharmacist at CVS up for a major lawsuit.

No one would sue a pharmacist. They would sue CVS. You are covered under your employer; and besides who got the money?

 

[nowaysanjose]

Midlevels have little to no training in pharmacology but are allowed to write prescriptions. I can’t imagine how infuriating this must be for pharmacists. Honestly it feels like the horse has left the barn when it comes to scope creep.

 

[TranslationalRPh]

Midlevels have little to no training in pharmacology but are allowed to write prescriptions. I can’t imagine how infuriating this must be for pharmacists. Honestly it feels like the horse has left the barn when it comes to scope creep.

True

 

[TranslationalRPh]

I do agree with the physician responses on this thread

I will saw the words the AMA doesn't want to say out loud, is that they don't want to loose business. And this I don't blame them.

The responses here are not unreasonable. Basically I am hearing... expanded scope may be generally acceptable provided that it's commensurate with training and experience. That's kind of hard to disagree with.

Regarding midlevels apprehension, I get it. It's the way things are moving. It's kinda like fighting the inevitable.

Relatedly, not all MDs, mid-levels, and pharmacists are the same. Surely, some practitioners within a profession are more suited than others regardless of profession. I appreciate the inherent differences and limitations in the training. I do wonder in some cases whether pharmacists could have more flexibility and autonomy, particularly if they are willing to demonstrate competence. That said, I definitely concur with the statement of who would want a responsibility of increased practice scope that s/he could not competently manage. Maybe, a big problem here could be that the legislation should be more narrow.

 

[ValeRx]

That said, I definitely concur with the statement of who would want a responsibility of increased practice scope that s/he could not competently manage.

This is why I never wanted a totally expanded scope as a retail pharmacist. No access to Epic/etc. I'd want to see labs, microbiology results, etc before I would be comfortable prescribing anything.

 

[Mad Jack]

The responses here are not unreasonable. Basically I am hearing... expanded scope may be generally acceptable provided that it's commensurate with training and experience. That's kind of hard to disagree with.

Regarding midlevels apprehension, I get it. It's the way things are moving. It's kinda like fighting the inevitable.

Relatedly, not all MDs, mid-levels, and pharmacists are the same. Surely, some practitioners within a profession are more suited than others regardless of profession. I appreciate the inherent differences and limitations in the training. I do wonder in some cases whether pharmacists could have more flexibility and autonomy, particularly if they are willing to demonstrate competence. That said, I definitely concur with the statement of who would want a responsibility of increased practice scope that s/he could not competently manage. Maybe, a big problem here could be that the legislation should be more narrow.

The other issue is that if you *can* do something, legally, there is a high chance chains will *demand* you do it as a condition of employment regardless of your personal level of comfort. They want the dollars however they get them, and that could put a lot of pharmacists in positions they don't feel comfortable with

 

[npage148]

Lol, I won’t even help a patient self-treat a runny nose. I send them to urgent care for evaluation.

What makes people think I’m gonna be able to diagnosis influenza or strep.

But I hate the AMA so I say let it rip

 

[steveysmith54]

Balanced and fair response IMHO. I wouldn't be surprised if this is where the majority is on this issue. I do wish YOU had written the AMA response.

Pharmacists can absolutely receive additional training if this expansion of scope benefits the patients. Even if it’s several week or months training. Pharmacists can learn new tricks if they want, most aren’t idiots; I guess some are though. I went to 4 years of grad school, whereas PAs went to school for 2 and are allowed to do some of the things. Having said that, I'd never want this role expansion and think it would not benefit the average retail RPh- more work with no additional pay or jobs created. This would also be used as propaganda for school deans to scam perspective students , like MTM had been in the last decade. I'll pass on this.

 

[Dred Pirate]

No one would sue a pharmacist. They would sue CVS. You are covered under your employer; and besides who got the money?

if you trust your employer to provide insurance for you, you are a fool. The company only has their best interest at heart - you (and myself) are expendable. Every pharmacist needs to have their own seperate personal coverage - it is very cheap for piece of mind

 

[Dred Pirate]

Midlevels have little to no training in pharmacology but are allowed to write prescriptions. I can’t imagine how infuriating this must be for pharmacists. Honestly it feels like the horse has left the barn when it comes to scope creep.

and they make an unbelievable number of stupid mistakes doing so

 

[Mad Jack]

if you trust your employer to provide insurance for you, you are a fool. The company only has their best interest at heart - you (and myself) are expendable. Every pharmacist needs to have their own seperate personal coverage - it is very cheap for piece of mind

Always remember that the job of a company insurance policy is to minimize losses to the company and that they work for the company, not you. They will absolutely throw you under the bus if it's in the company's best interests to do so, and will often force settlements that you do not believe should be settled.

 

[Chrish]

if you trust your employer to provide insurance for you, you are a fool. The company only has their best interest at heart - you (and myself) are expendable. Every pharmacist needs to have their own seperate personal coverage - it is very cheap for piece of mind

Malpractice insurance

Do any of you retail pharmacist have malpractice insurance? Am I required to tell my employer that I have malpractice insurance if I decide to get one?

forums.studentdoctor.net

Malpractice Insurance?

Anyone have a recommendation for malpractice insurance for pharmacist? Also do you have to be employed in order to purchase it? I would like to purchase it but I'm not currently employed as a pharmacist yet but would like to have it already once I start working. Thank you.

forums.studentdoctor.net

 

[Chrish]

if you trust your employer to provide insurance for you, you are a fool. The company only has their best interest at heart - you (and myself) are expendable. Every pharmacist needs to have their own seperate personal coverage - it is very cheap for piece of mind

No matter what you do at CVS and Walgreens, they are responsible for it. Why would any plaintiff attorney sue you when they can sue a 100 billion dollar corporation?

The only and I mean only value to these polices is they provide you with your own attorney if you go to trial or if you need to appear before your state board. Otherwise, they are useless. They only pay if the primary insurer is exhausted, If you comit malpractice I can't see you causing enough damage to bankrupt CVS.

Cvs can't throw you under the bus. The plaintiff attorney won't let them for 2 reasons, you don't have the money, the corporation does and two, the corporation is responsible for what you do on their behalf. Finally, they will only pay claims that exceed what your employer pays. That is why it is so cheap. SO if they get a big enough verdict to bankrupt CVS, your extra 1 million does not mean squat.

- From other threads

 

[Rockinacoustic]

Why can't a Pharmacist follow the same protocol a PA/NP/Physician currently does during a 15 minute telemedicine visit to screen for treatment with Paxlovid/molnupiravir or oseltamivir?

 

[owlegrad]

Why can't a Pharmacist follow the same protocol a PA/NP/Physician currently does during a 15 minute telemedicine visit to screen for treatment with Paxlovid/molnupiravir or oseltamivir?

I agree with you…but I am not sure “other people are negligent and we can be as negligent as anyone else!” is really a good case.

Also, I don’t want to do this.

 

[JustFillIt]

I'll just speak to why there is a lot of pushback from a physician perspective. Misdiagnosed strep has led to more than one significant adverse outcome that I've seen over the years. RSV can lead to significant morbidity and potential mortality in vulnerable patients. The vagueness of the final bits of language are very concerning, as that could mean literally anything with regard to scope and that could be quite dangerous. Treating patients implies one can construct a differential and perform physical exams and testing to back that differential. How are pharmacists equipped to do this by virtue of their training? I'm not opposed to expanded scopes if they have associated expanded training, but scope without the skills to back it up can be dangerous and potentially deadly.

What I would really love to hear a gatekeeper physician explain is - Why do you feel it is safe for a NP/PA to practice at the level that they do and not a pharmacist?

I would, perhaps, agree that pharmacist who do not want this role and have lost the skills necessary (because they are out there filling millions of your inappropriately dosed prescriptions) to provide care at a higher level may not be the best. But there are those of us who practice pharmacy at a very high level and are well equipped/competent to provide care at the same level as an NP - easily. Perhaps some extra credentials may not be unreasonable to prove competency but that’s it.

As far as I see it - it is a psychological/territorial conflict that current providers can’t get over due to personal reasons. It’s an issue of ego, in my opinion, and many need to just get over it. In fact, many current providers may feel insecure in entertaining this option because they may find out at we do it better than they do.

 

[steveysmith54]

I agree with you…but I am not sure “other people are negligent and we can be as negligent as anyone else!” is really a good case.

Also, I don’t want to do this.

I agree with you about not wanting to do this, I am fully confident that I could if I wanted to.
My reason is it won’t create a single job and just contribute to the propaganda about “provider status” and “emerging clinical roles” all over again. This could MTM on steroids type of misinformation for new students. In California, we added birth control prescribing, PreP/PEP, among other things- none of which helped improve working conditions or create new jobs, as advertised and was intended. As far as vaccinations, the techs vaccinate now.

 

[Mad Jack]

What I would really love to hear a gatekeeper physician explain is - Why do you feel it is safe for a NP/PA to practice at the level that they do and not a pharmacist?

I would, perhaps, agree that pharmacist who do not want this role and have lost the skills necessary (because they are out there filling millions of your inappropriately dosed prescriptions) to provide care at a higher level may not be the best. But there are those of us who practice pharmacy at a very high level and are well equipped/competent to provide care at the same level as an NP - easily. Perhaps some extra credentials may not be unreasonable to prove competency but that’s it.

As far as I see it - it is a psychological/territorial conflict that current providers can’t get over due to personal reasons. It’s an issue of ego, in my opinion, and many need to just get over it. In fact, many current providers may feel insecure in entertaining this option because they may find out at we do it better than they do.

The training of both PAs and NPs is geared toward diagnosis and treatment. The training of pharmacists does not include differential diagnosis, nor a practicum during which you diagnose and treat illness. I have no issue with someone properly trained treating something, but there is no clinical training for pharmacists in this area, and that is what makes it dangerous. NPs have 650 minimum clinical hours of comprehensive patient care, with some specialties requiring 2000 hours. PAs have a minimum of 2000 hours. Physicist have around 13,000 hours minimum.

The other difference is in the goals of education- APPs and physicians are trained for the entirety of their education to diagnose and treat illness at an advanced level. Pharmacists have an entirely different focus. If you want to add a minimum of two years of training like everyone else to diagnose and treat illness that's fine by me. Just do the training to provide some measure of quality of care and that's fine by me.

 

[JustFillIt]

The training of both PAs and NPs is geared toward diagnosis and treatment. The training of pharmacists does not include differential diagnosis, nor a practicum during which you diagnose and treat illness. I have no issue with someone properly trained treating something, but there is no clinical training for pharmacists in this area, and that is what makes it dangerous. NPs have 650 minimum clinical hours of comprehensive patient care, with some specialties requiring 2000 hours. PAs have a minimum of 2000 hours. Physicist have around 13,000 hours minimum.

The other difference is in the goals of education- APPs and physicians are trained for the entirety of their education to diagnose and treat illness at an advanced level. Pharmacists have an entirely different focus. If you want to add a minimum of two years of training like everyone else to diagnose and treat illness that's fine by me. Just do the training to provide some measure of quality of care and that's fine by me.

Fair enough. However I would argue that we have more than adequate training in the area of treatment - in fact, treatment with medication is what we have the most training in. I would agree that we are not so well trained on things like anatomy and physical therapy etc. But when it comes to treatment with pharmacology, a good clinical pharmacist is a very strong member of the team and has a lot to offer. In fact, most pharmacist don’t want to diagnose - we would, however, like a role in the treatment end.

I would argue that the best place for a provider pharmacist is in a setting where the diagnosis has already been made (especially in chronic conditions) and an initial treatment plan is initiated. At that point a competent clinical pharmacist can step in and take the care over as a partner (not a subordinate) to the physician. This will help the system see more patients and expand access to more quality care to the public.

I’ve seen it done this way and it works very well. In my opinion there is no good argument against this model.

 

[WheezyBaby]

I mean your argument is just really inconsistent and reeks of condescension. First, the "gatekeeper physicians" who you are sure totally love NP independent practice are, due to ego, denying pharmacists the ability to practice medicine, when they definitely practice medicine at a comparable level to APPs. In fact, we're denying you the ability to practice medicine because we fear your eventual superiority to us. Then you say, well actually the correct role for pharmacists is modifying therapies for chronic conditions in collaboration with a physician after a preliminary treatment plan has been established. I have worked with inpatient clinical pharmacists essentially daily for years, and I have previously worked in primary care collaborating with pharmacists in management of diabetes and heart failure patients. I am well aware of the value they bring, and that isn't what's being discussed here. Your second post is just entirely inconsistent with your first.

 

[JustFillIt]

I mean your argument is just really inconsistent and reeks of condescension. First, the "gatekeeper physicians" who you are sure totally love NP independent practice are, due to ego, denying pharmacists the ability to practice medicine, when they definitely practice medicine at a comparable level to APPs. In fact, we're denying you the ability to practice medicine because we fear your eventual superiority to us. Then you say, well actually the correct role for pharmacists is modifying therapies for chronic conditions in collaboration with a physician after a preliminary treatment plan has been established. I have worked with inpatient clinical pharmacists essentially daily for years, and I have previously worked in primary care collaborating with pharmacists in management of diabetes and heart failure patients. I am well aware of the value they bring, and that isn't what's being discussed here.

Well whatever dude - I outlined an entirely reasonable model, and yes - I do suspect that a lot of the resistance is due to ego.

And let’s also clarify something - your are not at all denying access to anything as a body of physicians. You do not have this authority. This is being denied due to legislation, which has been heavily lobbied in one direction. It is our body of government, and ultimately legislation, which decides this.

Anyways - I stand by the model that I stated above. And you are correct to say that you have to slog through my condensation in order to get the meat of my proposal - which is certainly there, and very reasonable, if you do not let your ego get in the way.

😁

 

[WheezyBaby]

Well whatever dude - I outlined an entirely reasonable model, and yes - I do suspect that a lot of the resistance is due to ego.

And let’s also clarify something - your are not at all denying access to anything as a body of physicians. You do not have this authority. This is being denied due to legislation, which has been heavily lobbied in one direction. It is our body of government, and ultimately legislation, which decides this.

Anyways - I stand by the model that I stated above. And you are correct to say that you have to slog through my condensation in order to get the meat of my proposal - which is certainly there, and very reasonable, if you do not let your ego get in the way.

😁

I'm working hard to try to get through the condensation, believe me. You're the one calling physicians "gatekeepers", so I don't really understand the tangent into legislation. Regardless, as I just said, your model already exists and I have first hand experience practicing in it, and it is unrelated to what the "gatekeeper physicians" in this thread are arguing

 

[JustFillIt]

I'm working hard to try to get through the condensation, believe me. You're the one calling physicians "gatekeepers", so I don't really understand the tangent into legislation. Regardless, as I just said, your model already exists and I have first hand experience practicing in it, and it is unrelated to what the "gatekeeper physicians" in this thread are arguing

We are in agreement then - pharmacists would make great providers in the domain treatment with pharmacology.

You would agree then that all states (not just a handful) need to expand pharmacist prescriptive authority to practice under the model which we both see value and allow us to bill Medicare/Medicaid for the service.

I would encourage you to support us through supporting the legislation which is being discussed in many states which would allow pharmacist to prescribe for chronic conditions without the need for a CPA.

You may be one of the good guys - but I have been around in this industry long enough to know that ego is one of the largest issues which is keeping pharmacists on the outside.

If you are stuck in the “gatekeeper” thing - I would encourage you to research what that means in popular culture and try to relate to how the “gatekeeper attitude” is is very pervasive among many who seek to limit the role of others in healthcare.

 

[WheezyBaby]

We are in agreement then - pharmacists would make great providers in the domain treatment with pharmacology.

You would agree then that all states (not just a handful) need to expand pharmacist prescriptive authority to practice under the model which we both see value and allow us to bill Medicare/Medicaid for the service.

I would encourage you to support us through supporting the legislation which is being discussed in many states which would allow pharmacist to prescribe for chronic conditions without the need for a CPA.

You may be one of the good guys - but I have been around in this industry long enough to know that ego is one of the largest issues which is keeping pharmacists on the outside.

If you are stuck in the “gatekeeper” thing - I would encourage you to research what that means in popular culture and try to relate to how the “gatekeeper attitude” is is very pervasive among many who seek to limit the role of others in healthcare.

Ego is also one of the attributes that makes people want to pursue something they may not be well trained for. Curious your emphasis on no CPA. At any rate, I likewise look forward to your future work advancing the scope of practice of your technicians.

 

[WheezyBaby]

Here is a good definition of a, “gatekeeper”. There are several definitions to review

Urban Dictionary: Gatekeeper

When someone is an dingus enough to tell you that you don't have enough qualities to like what you want to like or be what you want to be, solely based on their opinions and experiences, even if they don't know as much about what said person aspires to like / be.

www.urbandictionary.com

😂🤣

I figured you were likely trolling but thanks for confirming, won't engage anymore

 

[Sparda29]

So what would this bill, if passed, allow y'all to do that you currently can't?

Hopefully, when someone walks into a pharmacy and asks me to recommend an OTC for whatever reason, I can bill for talking to them and recommending something.

 

[TranslationalRPh]

As others have stated, advanced pharmacy practice can lend itself to additional competencies that if demonstrated could be potentially recognized legislatively as has been previously successfully done.

Some pharmacists do have relevant training and perhaps could serve in the capacity of providers in some areas without added undue risk, certainly no worse than PAs/NPs IMHO. Hopefully, legislative efforts don't close the door for those who would like an opportunity to demonstrate competence in expanded areas. While veiled in the service and concern for patients, the AMA statement seems to weaponize H.R. 7213 against expanded practice scope while ignoring that expanded scope may be warranted in some instances and certainly hiding its own conflict.

 

[Mad Jack]

Fair enough. However I would argue that we have more than adequate training in the area of treatment - in fact, treatment with medication is what we have the most training in. I would agree that we are not so well trained on things like anatomy and physical therapy etc. But when it comes to treatment with pharmacology, a good clinical pharmacist is a very strong member of the team and has a lot to offer. In fact, most pharmacist don’t want to diagnose - we would, however, like a role in the treatment end.

I would argue that the best place for a provider pharmacist is in a setting where the diagnosis has already been made (especially in chronic conditions) and an initial treatment plan is initiated. At that point a competent clinical pharmacist can step in and take the care over as a partner (not a subordinate) to the physician. This will help the system see more patients and expand access to more quality care to the public.

I’ve seen it done this way and it works very well. In my opinion there is no good argument against this model.

I don't disagree. My issue with this legislation was that it allows treatment without training in differential diagnosis, which is just... Not a smart move.

 

[VA Hopeful Dr]

Fair enough. However I would argue that we have more than adequate training in the area of treatment - in fact, treatment with medication is what we have the most training in. I would agree that we are not so well trained on things like anatomy and physical therapy etc. But when it comes to treatment with pharmacology, a good clinical pharmacist is a very strong member of the team and has a lot to offer. In fact, most pharmacist don’t want to diagnose - we would, however, like a role in the treatment end.

I would argue that the best place for a provider pharmacist is in a setting where the diagnosis has already been made (especially in chronic conditions) and an initial treatment plan is initiated. At that point a competent clinical pharmacist can step in and take the care over as a partner (not a subordinate) to the physician. This will help the system see more patients and expand access to more quality care to the public.

I’ve seen it done this way and it works very well. In my opinion there is no good argument against this model.

In primary care I'm not sure its needed. Let's say I diagnose someone with hypertension. Is it really time/cost saving to then send them to you and have you pick out a medication compared to me just prescribing something? Beyond that, I would still need the regular follow up appointments to monitor this which includes an exam and typically lab work.

For specialty stuff, I have also seen this model used and used well (HIV clinic is the most common in my neck of the woods).

 

[VA77]

What are the thoughts that pharmacists should be prescribing antivirals for covid?

 

[JustFillIt]

In primary care I'm not sure its needed. Let's say I diagnose someone with hypertension. Is it really time/cost saving to then send them to you and have you pick out a medication compared to me just prescribing something? Beyond that, I would still need the regular follow up appointments to monitor this which includes an exam and typically lab work.

For specialty stuff, I have also seen this model used and used well (HIV clinic is the most common in my neck of the woods).

It’s certainly okay to have this opinion - however we should be careful not to create roadblocks for the sake of making roadblocks.

I would encourage you to try it before you determine it is not needed. Seek out a high caliber clinical pharmacist, make them part of your team, and allow them the opportunity to engage in the practice that they are very well trained to do.

The areas which this works best, in my experience, are diabetes/glycemic control, heart failure, HTN, anticoagulation, med management in dialysis/renal failure, COPD, asthma, HLD and anything vascular, thyroid, GERD, allergy, BPH…. This is just to mention some…. I have seen some pharmacists also work in psych and engage in treatment of bipolar, schizophrenia, depression, insomnia, etc.

Anyways - these are all chronic conditions where a pharmacist will well trained in pharmacotherapy and can practice at a high level to support patients. And - admittedly, it works best when there is a “captain of the ship” which is usually a top quality physician of some sort which can be collaborated with on the tougher cases.

One of the states I am licensed in is a state that allows full prescriptive authority to pharmacists, without a CPA, up to controlled substance for the treatment of chronic conditions where monitoring is present. They can also bill Medicaid/Medicare for the service. I am part of some of these teams and I have seen it work, and work well.

To argue that there is not a need for this in the healthcare system is, in my opinion, not a good argument as our healthcare system is at a point where we need all the help we can get.

It works well…. And everyone is practicing within their domain of expertise. More patients are being seen and cared for…. Less burden on the system…. And jobs are being created.

Not sure why we are spinning our wheels here..

 

[JustFillIt]

What are the thoughts that pharmacists should be prescribing antivirals for covid?

This is a no brainer - absolutely they should be able to and they should be very careful to determine renal function and drug interactions as well.

If renal function is good, and drug interactions have been addressed appropriately, they should move forward (in patients who meet inclusion criteria) with treatment in a confirmed early case of COVID (especially in high risk populations).

 

[BC_89]

I would argue that the best place for a provider pharmacist is in a setting where the diagnosis has already been made (especially in chronic conditions) and an initial treatment plan is initiated. At that point a competent clinical pharmacist can step in and take the care over as a partner (not a subordinate) to the physician. This will help the system see more patients and expand access to more quality care to the public.

The areas which this works best, in my experience, are diabetes/glycemic control, heart failure, HTN, anticoagulation, med management in dialysis/renal failure, COPD, asthma, HLD and anything vascular, thyroid, GERD, allergy, BPH…. This is just to mention some…. I have seen some pharmacists also work in psych and engage in treatment of bipolar, schizophrenia, depression, insomnia, etc.

One of the best rotations I've been on was with a VA amb-care pharmacist doing just this. They order the labs (A1c, Chem-Profile, LFTs, etc.), schedule the follow ups, adjust/change medications as seen fit, so on and so forth. From what others have told me (let the record show I honestly have no idea just by word of mouth), the clinical pharmacists in the VA adopt this model nicely and it seems to be working with positive outcomes.

My second best rotation experience was with VA pharmacists that work in Mental Health doing the same thing for PTSD, GAD, Insomnia, Depression, Tobacco Cessation (thrown in there). As far as schizophrenia/bipolar disorders, the veterans would be referred out to other behavioral specialists (but same concept is applied).

On the notation of expanding diagnosis roles, I can't really comment. My knee-jerk reaction is a hard-no, but the idea of doing a provisional diagnosis vs. differential diagnosis would have to be something I'd need to look into and do some light research on the matter.

Anyway, food for thought as I obviously cant' speak above half-a-grain-of-salt over my shoulder at this point.

 

[Mad Jack]

What are the thoughts that pharmacists should be prescribing antivirals for covid?

If you're prescribing, you're taking responsibility for care. What happens if this patient gets worse? Are you going to be on-call to answer questions about whether they should go to the hospital or not and to monitor potential complications? Treatment isn't just prescribing, it is longitudinal care of an episode of illness. The easiest way to skirt around this is to make certain treatments OTC, so that patients are responsible for their own treatment, but that, too, has significant risks

 

[JustFillIt]

If you're prescribing, you're taking responsibility for care. What happens if this patient gets worse? Are you going to be on-call to answer questions about whether they should go to the hospital or not and to monitor potential complications? Treatment isn't just prescribing, it is longitudinal care of an episode of illness. The easiest way to skirt around this is to make certain treatments OTC, so that patients are responsible for their own treatment, but that, too, has significant risks

If you “get worse”, as in if your symptoms increase in severity to the point where you feel alarmed by your symptoms, you need to seek medical treatment asap. This should be clearly communicated.

You can send them home with an o2/pulse Monitor, home BP cuff, and an outline of alarm symptoms to monitor for. This is very similar to the care they would receive in the hospital.

If someone progresses in COVID severity, I would not just “blame the provider”. And I am sure you, in your own practice, are just as exhausted with the “blame the provider mentality”.

If someone from the public selects a pharmacist to visit for potential anti-viral treatment of Covid, this is only one selection of treatment and is their decision. We should let the market decide this.

I would hypothesize that if you ran statistics of outcomes associated with anti-viral treatment in the setting of a hospital vs. a clinical pharmacy setting where the objective treatment is the anti-viral, we would find very little to no statistical different outcomes.

What you say is really just speculation at this point.

 

[Mad Jack]

If you “get worse”, as in if your symptoms increase in severity to the point where you feel alarmed by your symptoms, you need to seek medical treatment asap. This should be clearly communicated.

You can send them home with an o2/pulse Monitor, home BP cuff, and an outline of alarm symptoms to monitor for. This is very similar to the care they would receive in the hospital.

If someone progresses in COVID severity, I would not just “blame the provider”. And I am sure you, in your own practice, are just as exhausted with the “blame the provider mentality”.

If someone from the public selects a pharmacist to visit for potential anti-viral treatment of Covid, this is only one selection of treatment and is their decision. We should let the market decide this.

I would hypothesize that if you ran statistics of outcomes associated with anti-viral treatment in the setting of a hospital vs. a clinical pharmacy setting where the objective treatment is the anti-viral, we would find very little to no statistical different outcomes.

What you say is really just speculation at this point.

My issue is more with regard to liability moreso than outcomes. As a physician that practices in a specialty I wouldn't prescribe COVID meds if a patient of mine asked, not because I can't handle it but because the liability would be enormous given that I cannot reliably provide follow-up for a medical issue. Prescribing a pulse oximeter and a blood pressure cuff along with some instructions to go to the ER isn't going to save me when they leave a message after hours saying they can't breathe and they are dying. Why do you feel you would have less liability than I would in this scenario?

 

[Mad Jack]

We are in agreement then - pharmacists would make great providers in the domain treatment with pharmacology.

You would agree then that all states (not just a handful) need to expand pharmacist prescriptive authority to practice under the model which we both see value and allow us to bill Medicare/Medicaid for the service.

I would encourage you to support us through supporting the legislation which is being discussed in many states which would allow pharmacist to prescribe for chronic conditions without the need for a CPA.

You may be one of the good guys - but I have been around in this industry long enough to know that ego is one of the largest issues which is keeping pharmacists on the outside.

If you are stuck in the “gatekeeper” thing - I would encourage you to research what that means in popular culture and try to relate to how the “gatekeeper attitude” is is very pervasive among many who seek to limit the role of others in healthcare.

I 100% think almost all physicians will push back against this for the reasons previously listed. The training isn't what it needs to be. Change the training and I'll change my tune. You are not trained to be practicing at an advanced diagnostic and prescriptive level as that is not what your training was designed to do.

It's like a pilot that has a good understanding of how a plane works thinking he can be a mechanic for a commercial aircraft. The training of a pilot and a mechanic is fundamentally different, one cannot substitute for the other. A few pilots that happen to be good at fixing aircraft from personal experience they've sought out doesn't change the fact that most pilots are fundamentally unqualified to be mechanics.