Why Can't Pharmacists Prescribe?

I have long wondered to myself, "Why can't pharmacists prescribe?"

The immediate answer is usually "Well they dispense medication and the physician prescribes them. It's always that way, checks and balances!"

It is hard to argue with a system that has been in place for such a long time, but really ask yourself "Why can't the medical professional who is the most focused on medications not prescribe them?" Doesn't that make some sense? If nothing else at LEAST the pharmacists with PharmD degrees have enough education to prescribe, hence why it is a terminal degree in medicine.

To me it just makes sense that an MD or prescriber would write a diagnosis on a prescription and a pharmacist would then select the correct medication for the patient based upon the prescribers diagnosis. Just include all patient labs with the prescription and I can easily come up with a good solution. That is the whole point of earning a PharmD degree (yes the D stands for doctorate!). Many times a day I have to call a prescriber's office to get a medication switched to something else for a variety of reasons. Never mind the amount of times I have to call due to drug interactions or another circumstance in which I give the prescriber my personal opinion on which medication would work for the patient. Doesn't this mean I am basically prescribing for the patient anyways?

Most MD's will admit that even though they know medication they do, to some degree, rely on pharmacists to a good extent. Personally, I catch, on average, 4 significant drug interactions and 8-10 people who are abusing, in some fashion, a controlled substance. On a daily basis I also see upwards of 25-40 patients a day who are not taking their medication correctly or run out of medication while waiting to hear from the physician, nurse practitioner or whoever else prescribes their medications. Many times this is because of cost issues, insurance prior authorizations or wait times to see the prescriber.

With so many patients who are not taking the medications or not taking them correctly, why can't pharmacists use their professional judgement to prescribe a similar medication that is less expensive, is easier to use or cover the period until the patient can see their prescriber? This is a minimal level of prescribing that can save an untold amount of money to the health care system, save the professionals the cost of time dealing with these issues, improve patient adherence and improve overall health care?

Recently there was an article published by the New England Health Institute (NEHI) that reported how non-adherence to medication costs $290 billion to the United States. (Link)

$290,000,000,000!

That's almost equivalent to what the United States spends on medication, which is $307 billion. (Link) That's a lot of wasted money! Money that could be saved by simple adherence to a drug regimen. Even if measures to improve drug adherence cost $100 billion that still saves $190 billion AND improve the overall healthcare provided.

I feel that pharmacists should be able to prescribe if nothing else in a limited role that could help improve healthcare and save money. A pharmacist can note if a patient is not getting their refills on time and counsel the patient as to why. Taking this into consideration the pharmacist could prescribe something that might work better for that patient. Even if a medication costs a little bit more but improves compliance (such as metoprolol ER versus metoprolol) the cost would improve the patient compliance and improve outcomes down the road, thus saving money overall.

This limited prescribing could also lead to changes in some brand name medications to alternative generics or switching a medication entirely if a patient complains of side effects that are limiting the daily activities or causing them other issues that warrant attention. In many cases, does a patient really need to see a prescriber just to get a medicine like naproxen 500mg or to get a prenatal vitamin? These simple medications could be addressed by a pharmacist very easily. All we need is the ability to bill for our services. This charge would be less that MD's and on par with most nurse practitioners, while increasing access to care from an equally qualified practitioner.

The major issue here is communication with the prescriber, which would require some sort of notification sent from the pharmacy to the physician.

Some people may say that medication therapy management (MTM's) is the same thing, yet many physicians who I have either talked to or worked with feel that MTM's are a way to micromanage their practice. MTM's also don't address the urgency that some patients may need or the waiting time to see the prescriber. Personally, I like the idea of MTM's but really feel there needs a prescribing aspect to them to make them excel.

A point that people may point at is the potential for a conflict on interest by the pharmacist to prescribe medications they make a higher profit from. This is a legitimate concern, however, most insurances have prior authorizations in place to stop the use of more expensive medications. If a pharmacist couldn't get these medications covered, they would defeat the purpose of their prescribing role, which is to save money. Also, most generic medications result in higher profits for pharmacies due to the lower cost, hence this is another incentive for pharmacists to prescribe generics. The system already has measures in place that would help pharmacists focus on providing optimal care while keeping the cost of medications low.

Another thing that I find ironic to my point is the hospital system. Many pharmacists will switch medications to similar ones in a hospital because the medication the prescriber wrote for is not on formulary. Wait, isn't that similar to limited prescribing? Why can't all pharmacists do this? Isn't this just further validation of the point that pharmacists should be able to prescribe, especially since it saves money?

Let me also clarify that I am not advocating for pharmacists to replace physicians, especially specialists. They clearly have an important role in providing healthcare. I am advocating for expanding the practice of pharmacy as a way to decrease total healthcare expenditures while improving care. Isn't that one of the major focuses by EVERY political party right now?

I am extremely interested in feedback on this and look forward to hearing from others on it.