Tuesday, January 24, 2012

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.

25 comments:

  1. Isn't it a little bit ironic that the drug experts of the healthcare world aren't typically involved in prescribing the very compounds they spends years studying? I don't see pharmacists prescribing as a real threat to physicians but maybe that is why there has been resistance to the idea so far? The fact of the matter is that physician training is focused on diagnosis of disease and less centered around proper treatment. Pharmacists could fill a valuable role of proper and appropriate prescribing of medications if we would only have that chance. It is starting to happen with the advent of collaberative practice agreements, but our roles as prescribers could be expanded greatly.

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  2. As a pharmacy tech studying to become a doctor I could not agree more. The average med student has A semester, just one, on pharmacology. To me that's scary that after little exposure to medication, a doctor then is expected to diagnose a range of illnesses and prescribe the best medication for that diagnosis. Any retail pharmacist (or tech) can tell you how many times the prescriber has to change the medication due to the factors mentioned above on a daily basis!! Why not make healthcare less complicated and allow those who study medications for FOUR years decide the correct drug and have the prescribes who study human disease and diagnosis for FOUR (give or take) years decide the correct diagnosis.

    Needless to say I always talk to my pharmacist about my diagnosis and take her suggestion of drug to my DR BEFORE she prescribes a product....(Esp after a urgent care Dr told me she'd only prescribe Bactrim for my UTI --even after much protest-- because Bactrim is the only drug that can fight off a UTI with a high nitrate conc in urine. Google that one newbies!!!)

    ReplyDelete
    Replies
    1. As an MD I can say that my pharmacology course extended over an entire year and that at least half of the courses in my 2 pre-clinical years also involved education regarding medications. Medications were a huge part of the clinical years including my 2 years as a med student, my year as an intern and my 3 years as a resident. Not so much during my year of post-residency fellowship training. Microbiology includes the study of antibiotics, resistance, side effects and proper medication prescribing. Physiology and pathophysiology courses teach how the body systems operate and what can go wrong but they also involve education on the treatment of disease including a huge amount of material on pharmacologic therapy. It is the comprehensive nature of medical education that gives the physician the advantage in regards to prescribing medication, therapies, surgery, etc. A pharmacist has not been exposed to the many medical and surgical subspecialties to be able to fully counsel on the best approach to an individual patient. At our hospital we have an MTM clinic and I am appalled to see that pharmacists are now ordering physical therapy. They do not review mri's, perform a physical exam, access spine stability and yet they are ordering very generic PT. This is analogous to a nurse telling a patient with pain to take "pain medicine".

      I have great respect for the pharmacists I work with and hope the physician-pharmacist relationhip will always remain solid but in this case I think there are pharmacists prescribing who unfortunately do not know what they do not know and therefore see themselves as equally qualified to treat disease. If medications were the only consideration I might agree with this and in the case of anticoagulation, antibiotics, etc that is pretty close to true. In the case of complex disease management, merely being fantastic with medications and side effects, etc is not enough.

      Delete
  3. I totally agree it's past time for pharmacists to be given prescribing authority, at least on a limited basis. There are so many instances where a pharmacist could make the decision to appropriately select and prescribe from a limited formulary of medications for a number of common disease states.

    Pharmacists receive more intensive training and are more qualified to make decisions regarding appropriate medication therapy than most nurse practitioners or physicians assistants I know, and probably more qualified than many MDs as well.

    Prescribing authority is given to MDs, NPs and PAs, in my opinion, after receiving basic training algorithms to assist them in making prescribing decisions based on their diagnosis. They don't receive near the training or knowledge base in pharmacology, pharmacokinetics, adverse drug reactions and drug interactions that should be used in the drug prescribing process. They are also somewhat dependent on and easily swayed by the influence of pharmaceutical sales and marketing efforts, something which pharmacists are able to sort through by throwing out the hype and making better clinical decisions based on rational therapeutic approaches.

    And, from what I have seen, most prescribers are easily swayed by their patients as well. All of the direct to consumer pharma advertising has created a patient population who go the the doctor with their expectations of what should be prescribed... and sometimes get upset when they don't get what they want!

    Pharmacist prescribing would expedite patient care and lower the cost of care by facilitating or streamlining the process of finding the correct medication and dose to reach and maintain therapeutic goals. This would tie in very well with a medication therapy management type of pharmacy practice that monitors new medications and makes changes or adjustments quickly and efficiently based on patient response to therapy.

    All this would help to reduce costs associated with patient medication therapy,improve and streamline the process of reaching therapeutic goals, aid in assisting, educating and counseling patients to ensure compliance and adherence to drug therapy and improve patient outcomes.

    The PharmD vs. BSPharm status for prescribing authority will need to be addressed in some manner. Pharmacists were making decisions regarding appropriate medication selection and use decades ago. It wasn't until the prescriber and dispenser functions began to change that pharmacists began to lose the authority to 'prescribe' all but those medications given OTC status. Generally speaking, most RPhs have as much knowledge and decision making skills when it comes to prescribing as those who prescribe the prescription orders they fill and dispense. Same with PharmDs.

    Yes, it is time for pharmacists to be given prescribing authority, if even on a limited basis. I would expect that this authority would be expanded after a year or two of monitoring said prescribing authority based on the positive outcomes we would see.

    ReplyDelete
    Replies
    1. I cured an ulcer of 6 (six) centimeters (3.2 inches) of a patient who saw 8 (eight) physicians.
      I am Pharm.D. and Ph.D. and I developed formulas for regressing or healing about 30 incurable diseases. I will cite some of them: GERD (gastroesophageal reflux disease), gastritis and giant ulcers (over 3.0 cm). Please see my papers published in JOURNAL OF PINEAL RESEARCH in 2006:

      http://www.healthy-eating-politics.com/support-files/protexid-paper-1.pdf

      http://www.healthy-eating-politics.com/support-files/protexid-paper-2.pdf

      So, Let pharmacists prescribe drugs. That´s all.
      My students are solving problems that experienced physicians can not do.

      Prof. Dr. Ricardo de Souza Pereira, Pharm.D., Ph.D.
      Professor of Clinics and Therapeutics
      Professor of Pharmacodynamics
      School of Pharmacy
      University of Amapa
      Brazil

      Delete
  4. Thanks to you all for the input and feedback. It's amazing to me that there isn't more of a push for this. Hopefully, this will change!

    ReplyDelete
  5. This is a really helpful site. You have some great ideas.You ask some good questions here and bring up some interesting points. Thanks.

    ReplyDelete
  6. Pharmacists should have the discretion to fill partial prescriptions. My Doctor has left me high and dry with no pain medication, Basically he is a negligent Doctor. A phamacist should be able to fill a partial does when this occurs.

    ReplyDelete
  7. Excellent blog very nice and unique information related to Pharmacists. Thanks for sharing this information.
    Pharmacy Wholesaler

    ReplyDelete
  8. The non-metropolitan area of West Kentucky has a pay rate of $24,570 each year while the South Central areas are at $23,110. Workers who are employed in the non-metropolitan region of West Central Kentucky have a median annual income of $23,780 while those in the East Kentucky non-metropolitan area make $25,580 on average. Pharmacy Tech Salary in KY

    ReplyDelete
  9. The only down side to this is that it could be tempting for a pharmacist to skim narcotics from their patients. I do believe this should be a joint decision, maybe the pharmacist should advise the physician once receiving all pt information. Once an agreed plan is made the actual prescription should still come from the physician.....
    My last thought is when would the pharmacist have time to do all of this work? Physician notes are just that, brief notes. Those notes do not reflect the face to face time with the patient. There are individual personality traits and interactions that are not noted, they are just derived from the years of the Dr./pt relationship and are hard to put to paper. The physician is treating a person NOT a chart, if the pharmacist does the prescribing they are not treating anything more than a chart.

    ReplyDelete
    Replies
    1. I completely agree with this. Even though pharmacists know more about drugs, the do not have access to any information about the patient besides the simple diagnosis. There can be so many reasons why two patients with the same diagnosis should be prescribed two different drugs based on their past medical history, family history, social conditions etc. These are things that physicians are trained to take into consideration during diagnosis and prescription, so unless they write down absolutely everything for the pharmacist, the pharmacist would only be treating the symptoms and not the person. Even then, there would be a bigger chance of communication error because the pharmacist did not get the information from the patient first hand. So in my opinion let the same person who handles the first 80% of the process handle the last 20%..and pharmacists can just focus on the drugs and use their expertise to make sure that the drugs prescribed by the physicians aren't causing any harm.

      Delete
  10. The simple answer to why can't pharmacists prescribe is that they lack the appropriate education. A physician spends time in medical school learning about how to treat the patient and not just their symptoms. The focus of pharmacy school is different and although they might have more drug knowledge, their education is not focused on diagnosing the patient. With the way the education system is setup, physicians are much more qualified to prescribe.

    ReplyDelete
    Replies
    1. I am Pharm.D. and Ph.D. and I developed formulas for regressing or healing about 30 incurable diseases. I will cite some of them: GERD (gastroesophageal reflux disease), gastritis and giant ulcers (over 3.0 cm). Please see my papers published in JOURNAL OF PINEAL RESEARCH in 2006:

      http://www.healthy-eating-politics.com/support-files/protexid-paper-1.pdf

      http://www.healthy-eating-politics.com/support-files/protexid-paper-2.pdf

      So, Let pharmacists prescribe drugs. That´s all.
      My students are solving problems that experienced physicians can not do.

      Prof. Dr. Ricardo de Souza Pereira, Pharm.D., Ph.D.
      Professor of Clinics and Therapeutics
      Professor of Pharmacodynamics
      School of Pharmacy
      University of Amapa
      Brazil

      Delete
  11. And then there are the patients who watch the direct to consumer tv commercials and they think they know what the doctor should prescribe.

    ReplyDelete
  12. I am Pharm.D. and Ph.D. and I developed formulas for regressing or healing about 30 incurable diseases. One of them is gastroenterological disorders: GERD (gastroesophageal reflux disease), gastritis and ulcers. Please see my papers published in JOURNAL OF PINEAL RESEARCH:
    http://www.healthy-eating-politics.com/support-files/protexid-paper-1.pdf

    http://www.healthy-eating-politics.com/support-files/protexid-paper-2.pdf

    So, Let pharmacists prescribe drugs. That´s all.
    Prof. Dr. Ricardo de Souza Pereira, Pharm.D., Ph.D.
    Professor of Clinics and Therapeutics
    Professor of Pharmacodynamics
    School of Pharmacy
    University of Amapa
    Brazil

    ReplyDelete
  13. Start a Pharmedical school maybe? Are you kidding me? There is a reason why there is a medical school and a pharmacy school. Lets see why pharmacists do not need prescribing rights:
    1. Liability: we are otherwise saving asses of doctors,NPs who don't write legibly or who are ignorant of drug interactions/problems that the patient could have from taking drugs
    2.I don't want to pay large taxes nor do I want to pay 10,000 dollars and more on liability insurance.
    3. Get a life and learn to respect your area of expertise and be good at that than wanting to take more responsibilities and have no life. As it is we are under so much pressure.
    I understand that we need some sort of prescribing authority like partial fills or refills but not more than that, because we do not know half the things that goes on in the human body like a doctor does. I don't think I want to spend 15 years in school studying pharmacy to get a prescribing license and a pharmd. No thanks. I'd love to tackle problems rather.

    ReplyDelete
    Replies
    1. how ignorant is your comment?!!! wow
      15 more years of medical school, where are you getting all this information !!!

      M.D and DO go through 4 years just like Pharm.D and then additional 2 -3 years of residency depending on the area!
      so many of Pharm.D s also go through residency.

      This article does not argue diagnosis, rather drug therapy. In California, Pharmacist already have prescribing authority as a collaborative practice.

      I am the clinical Pharm.D. for Healthcare Partners In our setting Primary physicians diagnose pts with for example diabetes, hyperlipidemia, HTN, and or a need for anticoagulation. Then they refer the pt to my services which is considered speciality service just like referring a patient from primary to dermatology and neurology which are all in the same section. I then independently manage the pt, change medication or dosage, order labworks and based on the results implement new therapy or change therapy or dosage. Give pre-operation plans.

      reading your comments really amazed me!!!!!

      Delete
  14. I am so happy after the visit of this blog because it contains an informative and amazing post which i liked very much...

    ReplyDelete
  15. I found this blog because I've coming off a one-week Rx for prednisone. Same dosage every day. Now nothing. Let me tell you how I'm feeling...maybe not.

    How many physicians EVER order the blood tests that are advised before and after prescribing any number of medications? I'd like to see a study on that.

    I am now convinced that my physician has absolutely no idea what she is doing when it comes to prescribing medications. The problem is, if you're severely ill, you hardly feel like you can say - Excuse me - I want to check this medication out on the Internet.

    But I have to ask why more pharmacists don't intervene as you, thankfully, do.

    ReplyDelete
  16. As an MD I can say that my pharmacology course extended over an entire year and that at least half of the courses in my 2 pre-clinical years also involved education regarding medications. Medications were a huge part of the clinical years including my 2 years as a med student, my year as an intern and my 3 years as a resident. Not so much during my year of post-residency fellowship training. Microbiology includes the study of antibiotics, resistance, side effects and proper medication prescribing. Physiology and pathophysiology courses teach how the body systems operate and what can go wrong but they also involve education on the treatment of disease including a huge amount of material on pharmacologic therapy. It is the comprehensive nature of medical education that gives the physician the advantage in regards to prescribing medication, therapies, surgery, etc. A pharmacist has not been exposed to the many medical and surgical subspecialties to be able to fully counsel on the best approach to an individual patient. At our hospital we have an MTM clinic and I am appalled to see that pharmacists are now ordering physical therapy. They do not review mri's, perform a physical exam, access spine stability and yet they are ordering very generic PT. This is analogous to a nurse telling a patient with pain to take "pain medicine".

    I have great respect for the pharmacists I work with and hope the physician-pharmacist relationhip will always remain solid but in this case I think there are pharmacists prescribing who unfortunately do not know what they do not know and therefore see themselves as equally qualified to treat disease. If medications were the only consideration I might agree with this and in the case of anticoagulation, antibiotics, etc that is pretty close to true. In the case of complex disease management, merely being fantastic with medications and side effects, etc is not enough.

    ReplyDelete
  17. As a nurse, I'm the one that gives the medications the providers prescribe at the hospital and have had long conversations with the pharmacists I work with to try and work out better solutions for our patients.

    The triad of Physician-Nurse-Pharmacist seems to work well where I work, but I still think that the PharmD should have more authority in guiding the prescription process -- Especially for DC instructions. It could save the patient money, heartache, and side effects in my view. I often learn more from the PharmD than the MD/DO staff when it comes to treatment modalities.

    ReplyDelete
  18. I agree with you. I just cant understand whaht's the point of studying 5 year long Pharmacy degree and not getting the permission to prescribe medication. I think we Pharmacist know much more about drug interactions & their adverse effects than Physicians. No doubt Physicians are expert in diagnosis but Pharmacist should be given authority to prescribe medication.My personal opinion is that, after Pharm-D there should be a specialization in drugs of particular system for example cvs drugs.And that Pharmacist should sit with Physician (Cardiologist) and prescribe medicine and diagnose the disease respectively.

    ReplyDelete
  19. I'm sorry but you people are completely insane. The reason you have to call Doctors and change prescriptions is because you have a nice and handy computer sitting next to you that gives the doctor a checks and balance because many times a patient will be prescribed by more than one doctor. Furthermore, doctors study chemistry of the human body. You people simply make the meds ; you have no knowledge of a patients history and have not even the closest idea of making decisions that regards a patients life. Doctors spend years and years of being able to recognize even the smallest fractions of change in a patients over all review of systems. The evaluation of the over all change in time of the bodies chemical functions and the ability to use medicines because of in depth knowledge of how to maintain the over all homeostatic functions takes years to master. Some retard Pharmacist comes along and because he looks at a chart is going to all of a sudden think that they have a clue on the true cause and effect of medicine simply because you know how to make the medicine??? Just because a chef can bake a cake doesn't mean that he knows specifically what the cakes end molecular metobolic function will be or for that matter how the person's specific metabolism is like. You people are crazy. There's a reason why we work in hospitals and you all work in wal-mart. If you don't like it go med school.

    ReplyDelete