With the federal health care law requiring millions of uninsured Californians to buy health insurance starting in January, the resulting influx of new patients could exacerbate the shortage of primary care doctors. That's prompted state legislation to expand the role of certain health professionals, such as nurse practitioners, optometrists, and physician assistants. It has also sparked a push to give pharmacists greater freedom to provide certain types of medical care. The California Medical Association opposes the move, arguing that pharmacists don't have sophisticated enough knowledge about drug interactions to operate without a doctor's supervision.
One can get a hint of the new role pharmacists could play at the El Monte Pharmacy on North Peck road; there, you won’t catch a pharmacist counting pills or filling medicine bottles.
That's because there are pharmacy technicians and even an automatic tablet counter to do that kind of work, allowing the pharmacists here to instead spend their time helping customers with their health issues – such as managing medications from multiple doctors who might write a prescription without being aware of what another of their colleagues has written for the same patient.
"We review all their medications," says pharmacist and owner, Ken Thai. " If we need to we’ll test their sugars, test their lipids…we’ll review all their vaccinations, make sure everything is up to speed."
Thai's pharmacy, like a growing number of others nationwide, is offering more than prescription oversight. Thai’s customers, for instance, can also get blood sugar tests; diabetic shoe fittings; flu shots and allergy care without waiting weeks or months to see a doctor. And that’ appealing to customers like Ping Kwong Chan, 80, of Rosemead.
Chan says that because his doctor has only a few minutes during any given appointment to answer his questions, Chan often relies instead on Thai and the two other pharmacists at El Monte Pharmacy for more detailed information about his high cholesterol, his heart medications and his allergy.
"When I come to the pharmacy… I can ask about my disease. I can bring in my lab work and then the pharmacist will spend the time and go over it with me," Chan says through a translator.
"There is growing appreciation – particularly in larger health systems across the country - that to the degree you’ve undergone education and trainining and have a skill set you should be working at the top of that skill set to provide care," says Susan Dentzer, a senior policy analyst with the Robert Wood Johnson Foundation. There is growing agreement that "it doesn’t make sense to do anything other than that."
Yet except for those pharmacists who work in collaborative practices with physicians, most work at levels far below their training, says Pete Vanderveen, dean of the USC School of Pharmacy. In the past, pharmacists could practice with a baccalaureate degree. But since 2003, pharmacists have been required to undergo a four-year Doctor of Pharmacy program, in addition to undergrad studies.
"They can practice at a much higher level and yet we’re still living under old laws that were written at the time that really wasn’t true," Vanderveen says.
But an effort underway in California would change that.
Senate Bill 493 by Ed Hernandez (D-West Covina) would allow pharmacists to provide more health care, independently of physicians. The intention of the bill is to help shore up the existing primary care physician shortage in the state that's expected to worsen with full implementation of the Affordable Care Act.
The proposed expanded scope of practice in the bill, which has passed the state senate, would allow pharmacists to, among other things, independently order and interpret tests to monitor drug therapies; order and administer routine vaccinations and prescribe smoking-cessation drugs. The measure is one of four bills that would expand the roles of “allied” health professionals (including nurse practioners, optometrists, and physician assistants). The state’s largest physician group opposes all of them.
"Pharmacists do have great education, but they have great education about medications," says Dr. Paul Phinney, president of the California Medical Association, which represents 37,000 physicians statewide. "They don’t have nearly as much education about disease processes inside of a body and how different diseases might interact with different medications to produce different results in different patients."
Smoking cessation drugs are a prime example, Phinney says. In some patients they can cause depression and suicide. Allowing pharmacists to independently prescribe them, he says, could compromise patient safety.
But others say that attitude ignores the fact that something must be done to ease the state’s doctor shortage.
"You can’t say out of one side of your mouth, 'we’re going to have a huge shortage of doctors,' and then say, 'Oh by the way, you have to see a doctor for these conditions,'" says Jeff Goldsmith, president of Health Futures, Inc. and an associate professor at the University of Virginia School of Medicine.
Goldsmith is among those who say if pharmacists and other allied health professional aren't allowed to do more than they're doing now, there may not be enough health professionals available to help the newly insured.
"We’re not looking to infringe on anybody’s turf," says Thai of El Monte Pharmacy. "That’s not the point of this. We’re just looking to do what we’ve been trained to do all these years, which is manage their medication and manage it well.”