February 11, 2014:
Amidst the furor over last year’s failed attempt to ease a shortage of primary-care physicians by letting nurse practitioners operate without direct doctor supervision, a more modest piece of California legislation is quietly taking effect.
Senate Bill 493 became law on Jan 1. Pending the approval of California State Board of Pharmacy protocols later this year, it authorizes pharmacists to provide such medical services as furnishing routine vaccinations, hormonal contraception and nicotine replacement medications, as well as certain prescription drugs for travelers.
The law also establishes a new Advanced Practice Pharmacist credential. In collaboration with a patient’s primary care provider, pharmacists with certification for advanced training and experience will be allowed to assess and refer patients; to start, stop and modify drug therapies; to order and interpret drug therapy-related tests; and “participate in the evaluation and management of diseases and health conditions.”
Finally, SB 493 declares pharmacists to be “health care providers,” with legal authority to render health care services. Prior to the implementation of that language, pharmacists’ legal status concerned the delivery of medication. Being identified as a provider makes them part of a health-care team and able to collaborate with the primary provider in managing a patient’s health.
Supporters of the both the pharmacists’ and the nurse practitioners’ bills pointed out that only 16 of California’s 58 counties have the number of physicians that the federal government recommends. Both pieces of legislation sought to ease an even more severe shortage accompanying a surge in new health insurance enrollments under the Patient Protection and Affordable Care Act.
Jon Roth, Chief Executive Officer of the California Pharmacists Assn., said the changes will allow more pharmacists to practice to the full extent of their training and education, with a profound impact on the delivery of care.
“The ACA talks about the triple aim of reform: increasing access to care, reducing costs and improving quality. This law fundamentally changes the face of health care, where the pharmacy becomes more than just a place where you pick up medications. Now, you can get services there,” Roth said.
“This law speaks to increased access, reduced costs and improved quality.”
Pharmacist Karl Hess, who is helping to write protocol recommendations for state regulators, said the new law makes it easier to address questions promptly.
“Probably the biggest advantage now is the ordering of laboratory tests. If I’m uncertain about somebody’s antibody status for hepatitis A, I can order those labs,” he said. “Having that authority in consultation with the primary care provider, I think that’s an advantage.”
Mildred Keagy, who visited Hess recently for a yellow fever inoculation prior to a trip to South Africa, said she’s glad doctors remain involved in routine health care.
“If they’re able to diagnose something in the pharmacy, I could see them changing my prescription,” she said. “But if they couldn’t diagnose it, I don’t know that that would be a good idea.”
California’s new standard has drawn national attention. Shortly after Gov. Jerry Brown signed SB 493 in October, the “National
Law Journal” published a column by New Jersey health care attorney Frank Ciesla that questioned how letting non-physicians assume some of a physician’s tasks might influence medical malpractice law.
In a telephone interview, Ciesla predicted the law could undermine patients’ health.
“(Pharmacists) don’t go through four years of medical school and then three to five years of a residency program that gives you a certain level of knowledge,” he said.
“If the pharmacist makes a mistake, will we be able to hold the pharmacist to the same standard as we hold the physician?”
Ciesla questioned leaving scope of practice decisions to state legislators as lawmakers try to anticipate increased demand for medical services under the ACA. Such an approach, he said, “is helter-skelter.”
As for California, Roth said neither medical nor malpractice rules will change.
“The standard of care is the standard of care. It won’t be different for doctors and pharmacists,” he said.
“If you look at this in its totality, what the pharmacists will be doing at the community level is not a lot greater than what pharmacists have been doing in a hospital setting for a number of years.”
State Sen. Ed Hernandez (D-West Covina), who introduced SB 493, also said pharmacists are fully capable of fulfilling the roles assigned to them under the legislation.
He said skeptics made similar arguments when the state legislature expanded optometrists’ scope of practice in 2000. Optometrists’ malpractice rates shot up. But a couple years later, when none of the frightening predictions were born out, those rates plummeted, Hernandez said.
“I anticipate the same thing is going to happen with pharmacies as well,” he said.
Susan Hoagland, executive vice president of the California Academy of Family Physicians, said the law satisfied her members’ concerns about communication between physician, pharmacist and patient.
“I think what we want to do is monitor very carefully how the regulations come out and monitor very carefully what the performance is under the new system, and if anything has to be adjusted, that it be done,” she said.
The California Medical Assn. lobbied hard against Hernandez’ proposed expansion to what nurse practitioners can do. But in a written statement, CMA president Richard Thorp offered qualified support for the new rules governing pharmacists.
“Allowing pharmacists to independently administer vaccines with additional training may help increase public health for families and communities that don’t currently have that access,” the statement reads.