The New Ballgame: Will Pharmacists Be Able to Play?

Lowell J. Anderson

Originally published in the "Minnesota Pharmacist," the journal of the Minnesota Pharmacists Association

The health professions have prided themselves in their willingness to work with each other in the interest of their patients. As those of us who have practice experience know, it has not always been as smooth as we would like. But, we made it work.

In 2008 the Minnesota Governor signed a health-reform act that seeks to create meaningful, transformative health reform. The law incorporates models that will change the way we deliver and pay for health care, with the goal of improving quality, reducing costs and promoting more consumer engagement in health-care choices.

An important part of this law is the Health Care Home. “A health care home is a redesign of primary care, allowing providers, patients and families to work in partnership to improve the health and quality of life. Health care homes aim to improve the patient experience by centering care around the patient and family, improving access to care, and coordinating care between providers and community resources. Health care homes also represent one type of payment reform because providers will be reimbursed for care coordination and recertified based on outcomes. Certification standards for health care homes were created through a stakeholder process.”1 The credentialing of the first eleven of these was announced in August.2 3

The Academic Health Center at the University (the six colleges: medicine, pharmacy, nursing, dentistry, veterinary medicine and public health) this year initiated a program called “1Health.” This program will bring together the entering students from each of the six colleges to participate in an interprofessional experience to develop interprofessional competencies in professionalism & ethics, teamwork and communication. The goal is to prepare the student to participate in an interprofessional team such as that envisioned in the Health Home concept that is part of both the state and federal reformation.

For pharmacists, as for all health practitioners, the goal must be inclusion in the health homes and accountable care organizations (ACO) as full and equal participants. The challenge will be that Rule 47644 defines the teams as “the participant, the personal clinician or local trade area clinician, and other member of the health care home team.“ Pharmacists are not included by rule, but neither are we excluded by rule. Therefore, the burden is clearly on us as individual practitioners in a given market, as well as for us as a profession.

Having said all that, the “800 pound gorilla in the room” is the unanswered question of whether or not the Minnesota pharmacy practice act allows pharmacists to practice in such an environment?

Our practice act, as with all the other Minnesota health professions’ acts were originally written in 1927. To put that view of the world into perspective, 1927 was the year that Charles Lindbergh made the first solo flight across the Atlantic Ocean.

The way the world works has changed since 1927!

Certainly the practice acts have been updated, but the updates are still based on the original 1927 vision of what each profession should do. We have all come a long way from only physicians diagnosing and treating, nursing “taking care of bed-sores and emptying bed pans, and pharmacists counting and pouring!

Pharmacy is unique in the health profession in that we are qualified to provide clinical services and, in addition, we are assigned as principal responsibility for the custody and management of the physical medication product. Because our practice act was written when the Spirit of St. Louis was the only airplane that flew the Atlantic, it is primarily focused on product management.

In January of 2009 the “Health Workforce Shortage Study Report” was submitted by the Minnesota Department of Health to the Minnesota Legislature. That report stated:

The workforce challenge for health care homes is to recruit appropriately trained providers across several professions, and combine them in the workplace in ways that improve care and control costs. This care model will allow all qualified primary care professionals to practice at the top of their education and capacity, use each profession for the tasks which they are uniquely qualified to perform and reduce tasks that do not make the best use of each professional on the team.5

The Report identified a set of competencies and skills considered a requirement for the practice of primary care

Health Workforce Shortage Study Work Group Primary Care Core Competencies Ability to:

• Conduct physical exams – simple and comprehensive 
• Order labs and other diagnostic tests, interpret results 
• Diagnose complex and multiple issues 
• Refer and consult – integrate and coordinate specialty care 
• Treat and/or prescribe, including knowing what is not indicated 
• Use/integrate evidence-based guidelines into care 
• Consider longitudinal care and make adjustments as appropriate 
• Monitor and manage medication 
• Advise patient on primary prevention/health promotion 
• Assess patient’s psychosocial needs, lifestyle, and values 
• Relate/communicate with patients/families.6

The Report noted that these competencies and skills are characteristic of Minnesota’s primary care professionals – physicians, advanced practice registered nurses, and physician assistants. It further noted that pharmacists, while limited in diagnoses or prescribing treatment, provide an integral primary care role in monitoring and managing patient medications. It recognized the collaborative practice opportunities between pharmacists and dentists, optometrists, physicians, podiatrists and veterinarians; but noted that pharmacist are not currently allowed to sign prescriptions while working under a protocol or under a medication management agreement.

In addressing the barriers to effective primary care practice the Report noted:

a number of barriers that interfere with effective delivery of primary care and prevent full utilization of primary care physicians, advanced practice registered nurses, physician assistants, and pharmacists practicing collaboratively in a primary care or health care home setting. The barriers identified fall primarily into several categories: 
• Supervision, collaboration and management 
• Restrictions on care delivery 
• Reimbursements and payment 
• Institutional 
• Cultural7

The Report made several assumptions that address changing the scope of practice:

• The purpose of regulation – public protection – should have top priority in scope of practice decisions, rather than professional self-interest. 
• Changes in scope of practice are inherent in our current healthcare system. 
• Collaboration between health care providers should be the professional norm. 
• Overlap among professions is necessary. 
• Practice acts should require licensees to demonstrate that they have the requisite training and competence to provide a service.

The Report noted that there are 164 statutes and rules citations that apply directly to pharmacists, suggesting a thorough review for identification of potential issues. Some barriers that specifically apply to pharmacy are, which need resolution are:

And finally, the report made ten recommendations that relate to the practice acts of the primary care health professions. Those that relate to pharmacy directly are:

4. Allow pharmacists to sign legally valid prescriptions pursuant to protocol implemented by practitioners (M.S. 151.37 subd. 2).

5. Permit advanced practice registered nurses and physician assistants to enter into collaborative practice agreements with pharmacists under protocol (M.S. 151.01, subd. 23 and 27).

6. Ensure that any statutory or regulatory modifications supersede obsolete wording in related statutes and elsewhere to ensure the broadest application, if appropriate.

7. Complete a review of all applicable and related statutes and rules to ensure that they are not in conflict with any changes implemented as a result of these recommendations.

8. Ensure that Minnesota’s health care home learning collaboratives are required to address health professional cultural issues, collaborative team roles and team skill-building.

10. Continue an advisory process with health licensing boards, professional associations and higher education to formalize collaboration and encourage interdisciplinary practice among health professionals, examine further policy changes required for effective care delivery, and respond to changes in the health care environment as health care reform moves forward.8

In summary, there should be no doubt that the way each of the professions deliver care will change significantly and these changes have already begun in Minnesota as well as nationally. Pharmacy will not be exempt from those changes and each pharmacist will need to pay attention to developments in community, state and nation.

The case I have attempted to make in this article is that it is recognized that pharmacists do, and will continue to be an important part of the delivery of health care in Minnesota and the United States. But, the ongoing contribution of our services in a meaningful way will to a large part depend on significant revisions of our Pharmacy Practice Act that will allow pharmacists to practice at the limit of their education.

Pharmacists cannot expect to fully participate in the changes that are occurring in American health-care delivery changes if we are restricted by the limitations in the current Practice Act.

Lowell J. Anderson, D.Sc., FAPhA, practiced in community pharmacy for most of his career. He is a former president of MPhA, Mn Board of Pharmacy and APhA. In addition he has held positions in the Accrediting Council on Pharmacy Education, National Association of Board of Pharmacy and the United States Pharmacopeia. Currently he is Co-director of the Center for Leading Healthcare Change, University of Minnesota and co-editor of the International Pharmacy Journal. He is a Remington Medalist.

2 Minnesota Department of Health, New Release 17 August 2010 lists:
• Christopher J. Wenner, M.D., Cold Springs
• Mayo Health System-Austin Medical Center
• Lakewood Health System-Staples Clinic
• Lakewood Health System-Browerville Clinic
• Lakewood Health System-Eagle Bend Clinic
• Lakewood Health System-Pillager Clinic
• Lakewood Health System-Motley Clinic
• Park Nicollet-Minneapolis Pediatric Clinic
• Park Nicollet-St. Louis Park Internal Medicine Clinic
• Park Nicollet-St. Louis Park Family Medicine Clinic
• Park Nicollet-St. Louis Park Pediatric Clinic

4 Minnesota Administrative Rules, Department of Health, CHAPTER 4764, Health Care Homes

5 Health Workforce Shortage Study Report: Report to the Minnesota Legislature 2009, January 15, 2009
6 Health Workforce Shortage Study Report, Op cit: p2
7 ibid, p4
8 Health Workforce Shortage Study Report, Op cit, p5