As lifelong learners, we pride ourselves in expanding our knowledge in all aspects of pharmacy practice and regulation. However, in a rapidly evolving healthcare landscape, further impacted by staff shortages, supply chain issues, and regulatory changes in 50 states and D.C., it's a lot to keep up.
We sat down with RSG Director of Program Management, Jennifer Baumgartner, to dive in on considerations related to prescriptive authority as part of pharmacists' scope of practice to better understand the nuances in this complex issue.
Why should pharmacists have expanded prescriptive authority? What are the benefits?
Pharmacists are among the most accessible health care professionals. Approximately 90% of Americans reside within 5 miles of a community pharmacy, and patients are reported to visit pharmacists 12 times more frequently than primary care physicians. When pharmacists are utilized to drive drug selection, their expertise can aid in minimizing duplicative, excessive or unnecessary medication. Leveraging pharmacists can result in increased patient access points in the healthcare system to provide high-quality, cost-effective care that reduces burden on other health care providers. Additionally, with the pharmacy serving as a hub for patient access, expanded roles for pharmacists to engage in patient care plans will be in demand.
What is the current landscape and opportunities for pharmacist prescribing?
States determine the scope of practice of the health care professionals they license and extent to which they may engage in prescriptive activity. Prescriptive authority for pharmacists currently exists on a continuum with states differing in how the authority is defined and the degree of autonomy. Two primary categories exist: Collaborative Prescribing and Autonomous Prescribing.
Collaborative Prescribing
A Collaborative Practice Agreement (CPA) serves as the primary means a pharmacist may initiate, modify, or discontinue medication therapy or provide other patient care services outside state law scope of practice. Nearly all states allow pharmacists to enter into a CPA, providing authority for medication management for acute and chronic diseases where a diagnosis has been made. A formal practice relationship is created between the pharmacist and prescriber, identifying specific functions delegated to the pharmacist under conditions outlined in the agreement. CPAs can be patient-specific or population-specific, serving to improve the efficiency and effectiveness of collaborative care delivery. However, states may restrict which patient populations may be cared for under a CPA as well as limiting which prescribers and pharmacists may enter into an agreement and/or where services can be delivered.
Autonomous Prescribing
Autonomous prescribing, which includes statewide protocols and category-specific unrestricted prescribing, is less restrictive than collaborative prescribing in that it gives pharmacists authority independent of agreements with prescribers. Statewide protocols refer to a framework for specific conditions under which pharmacists are authorized by a state-level protocol to prescribe specific medications or categories of medications. Authority is ratified by the state and protocols are established by Boards of Pharmacy. Current statewide protocols vary state-to-state. Some allow for pharmacists with qualifying criteria to prescribe specific medications or medication categories, while others require pharmacists obtain additional licensure, complete specific continuing education, and/or notify primary care physicians following treatment. Statewide protocols can help to create continuity of care within a state as well as a path for standardized access to care for populations in a state, often with focus on public health initiatives.
Unrestricted (category specific) prescribing comes into play when the state authorizes pharmacists to prescribe certain categories of medications without the need for a statewide protocol. Currently used primarily for preventive care and public health, pharmacists are granted authority to prescribe a category of medications based on clinical guidelines and professional judgment. Pharmacists aren't required to have a partnering prescriber, and there are no explicit restrictions on patient populations.
How has pharmacist prescriptive authority been impacted by the COVID-19 pandemic?
We've seen a HUGE response to the pandemic by the pharmacy profession. Under the Public Readiness and Emergency Preparedness (PREP) Act, pharmacists have been at the front lines ordering and administering COVID-19 tests and vaccines to keep our communities healthy. According to data from the American Pharmacists Association (APhA), pharmacists have administered 290+ million COVID-19 vaccinations - more than half of all COVID-19 vaccinations administered in the U.S. - from December 2020 to November 2022. The Prep Act also authorized pharmacists to order and administer certain COVID-19 therapeutics and prescribe Paxlovid for eligible patients.
Additionally, the impact of COVID-19 on pharmacy practice led some states to expand the scope of practice of pharmacy technicians to keep up with demand, utilize telepharmacy services to increase access, and/or employ remote capabilities for data entry, order verification, and compounding oversight.
States that have expanded pharmacy-access programs have set an example that other states can look to in enacting patient-centric policies. Although federal efforts lag, state lawmakers can ensure that citizens have increased autonomy, freedom to choose, and healthier lives overall.
How can we expand the prescribing authority of pharmacists -- what is next?
Pharmacists have unique training and expertise to provide an array of patient care services. Prescribing authority remains a public health and access to care issue that continues to be politicized. The pharmacy profession’s impact on COVID-19 outcomes is a strong talking point. The federal government’s authorization for pharmacists to prescribe COVID-19 therapies in order to expand access to treatment offered recognition that pharmacists’ roles can be expanded to include prescribing. Additionally, experience and outcomes from states and countries that have expanded prescriptive authority protocols in place should be leveraged.
However, despite positive gains from those recent initiatives, the same political issues remain and scope issues continue to be a turf war among the health professions. For example, the American Medical Association (AMA), "opposes federal and state legislation allowing pharmacists to independently prescribe or dispense medication without a valid order by, or under the supervision of, a [physician]." AMA also boasts of a coalition of 108 national and state associations actively working to block such legislation. It will take concerted and strategic legislative efforts at the individual state level to ensure pharmacists can practice at the top of their license. Pharmacist autonomous prescribing authority should be the gold standard for practice. It is incumbent on state regulators to expand pharmacists' scope of practice, allowing a wider range of medications to be prescribed to patients who would otherwise be limited in their access to a prescriber.
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